Kate Johnson

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

A national quality improvement initiative significantly improved several aspects of care for diabetes, asthma, and hypertension at community health centers, but had no impact on intermediate outcomes, according to a recent study.

“The substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods,” wrote Dr. Bruce E. Landon of Harvard Medical School, Boston, and colleagues (N. Engl. J. Med. 2007;356:921–34). “There is still much to learn about the tools and methods for quality improvement and their potential effectiveness.”

The study compared the quality of care at 44 community health centers before and after their participation in the quality-improvement Health Disparities Collaboratives. This initiative, sponsored by the Health Resources and Services Administration, the Agency for Healthcare Research and Quality, and the Commonwealth Fund, was designed to improve care at community health centers, a particularly relevant target because of their “prominent role in providing care for members of minority groups and other disadvantaged populations,” the authors noted. Since 1998, about two-thirds of community health centers (645) have participated in the collaboratives, but to date there has been no evaluation of their effect, they wrote.

The 44 intervention centers enrolled in the quality-improvement collaborative were matched with 20 control centers which had never participated in a quality-improvement collaborative. In addition, 40 of the 44 intervention centers also served as internal controls. Sequential, random samples of patients with diabetes, asthma, or hypertension were selected during the 1-year period before the intervention and the 1-year period after its completion. A total of 9,658 patients with one of the three conditions were selected: 3,392 with asthma; 2,904 with diabetes; and 3,362 with hypertension. Percentage scores for overall quality of care and composite scores for prevention and screening, disease monitoring and treatment, and outcomes were then calculated.

The study found that overall, when considering all three conditions, the intervention centers improved their care 4.9% above internal controls and 4.5% above external controls. In the composite score for prevention and screening, intervention centers also improved 6.2% more than internal controls and 4.5% more than external controls. And intervention centers also improved significantly more than controls in the composite score for disease monitoring and treatment (5.9% over external controls and 5.5% over internal ones).

When results were divided according to the three conditions, the overall trend was evident in centers focusing on asthma and diabetes, but not in those focusing on hypertension.

With regard to specific measures within the centers, the percentage of patients receiving antiinflammatory medication for persistent asthma, the percentage of patients with an asthma management plan, the percentage of diabetes patients with two or more assessments of glycated hemoglobin levels, and the percentage of patients advised about smoking all increased more in the intervention centers, compared with the control centers.

The authors offered several explanations for the lack of effect with respect to intermediate outcomes, including that many of the processes of care that were studied are linked to longer-term outcomes. In addition, “intermediate outcomes may require more intensive interventions in order to overcome environmental factors that pose particular challenges for patients treated at community health centers,” they noted.

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON

HOUSTON — Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

“There is only one case report of this leading to urinary retention,” she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. “That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that.”

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of “absent vagina” because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. “The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis,” she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

“I really think it's important to try and avoid surgery,” she said in an interview. “It is such a big deal to take these children to the operating room, and so often the problem recurs anyway.”

The success rates for estrogen medical therapy range from 50% to 100%, she said. “This works for thin adhesions but not thick or recurrent ones.” Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2–4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

It's important to try and avoid surgery. It is such a big deal to take these children to the OR. DR. BERENSON

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain, but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

“The conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues reported that all four studies were consistent regarding their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient, said Dr. Borenstein, during the interview.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain, but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

“The conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues reported that all four studies were consistent regarding their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient, said Dr. Borenstein, during the interview.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain, but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

“The conclusion [of the AAN report] is that these injections are not overwhelmingly therapeutic, and I would say that is fair—they don't cure this problem—but they help certain patients, and I think when all is said and done, you have a better chance of helping someone [with epidural steroid injections] than harming them,” Dr. David Borenstein, a Washington rheumatologist who specializes in low back pain, said during an interview.

“When it comes down to the clinical situation, I think what's important is the risk benefit ratio,” said Dr. Borenstein, also of George Washington University, Washington.

The guidelines were drafted by the academy's (AAN's) Therapeutics and Technology Assessment Subcommittee and are based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues reported that all four studies were consistent regarding their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient, said Dr. Borenstein, during the interview.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

The authors noted that current data on the use of epidural steroid injections to treat cervical radicular pain are inadequate to make recommendations.

The number of U.S. children receiving preventive dental care has risen, but minority children from low-income families remain the least likely group of children to receive it, according to a study.

The report was published shortly after a Maryland boy on Medicaid died because of complications ultimately related to lack of preventive dental care.

Among those children at high risk, having a personal doctor and being enrolled in the State Children's Health Insurance Program (for a subgroup of children) were factors associated with receiving preventive dental care, according to the study.

“We still have a long way to go before we can say that all U.S. children are receiving the preventive dental care that they need,” wrote Dr. Charlotte W. Lewis of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:544–53). They suggested that increasing the availability of dental insurance should be a priority in addressing this issue.

The study included data from 2003 on 102,353 children involved in the National Survey of Children's Health, and was weighted to represent 72.7 million children nationally. It found that in 2003, 72% of all children and 62.5% of low-income children (those at or below 200% of the federal poverty level [FPL]) reported a preventive dental care visit in the previous year. Almost 23% of children lacked dental insurance, compared with almost 9% who lacked health insurance.

The numbers of children receiving preventive dental care are higher than previously reported, and exceed the Healthy People 2010 goal of 57% of low-income children receiving a preventive dental care visit in the previous year, according to the authors.

But children who are at highest risk for dental problems are still those who are least likely to receive preventive care, they wrote.

“Certain groups continue to be underrepresented,” the researchers noted. “These include children who are young, who are black or multiracial, lack dental insurance, lack a personal doctor, are under 400% of the FPL … live in nonmetropolitan areas or states, or are foreign born.” After the researchers controlled for other variables, Hispanic and white children had a similar likelihood of receiving care, but black children had lower odds that persisted even after adjustment for income and insurance status, Dr. Lewis and her associates reported.

The picture painted by the study is a familiar one for Laurie Norris, a lawyer at the Baltimore-based Public Justice Center who tried between September 2006 and January 2007 to help the family of a 12-year-old Maryland boy who died in February after an infection from an abscessed tooth spread to his brain. There is “terrible access” to dental care for underprivileged children in Maryland, Ms. Norris said in an interview. “I made 26 calls and was unable to find a dentist contracted to the family's dental plan (Medicaid) in their geographic area.”

In examining factors influencing access to dental care, the study showed that income eligibility for State Children's Health Insurance Program (SCHIP) policies was associated with preventive dental health visits by “near-poor” children. (Near-poor was defined as 1− to 5-year-old children living at 133%–199% of the FPL, or children older than 5 years living at 100%–199% of the FPL.) Near-poor children in states with the broadest income eligibility for SCHIP dental care had a 24% higher likelihood of a preventive dental visit compared with children in states with limited or no eligibility for SCHIP dental services, reported the authors. Yet, “even in the best states, near-poor children lag substantially behind their higher income counterparts.”

Near-poor children were of primary interest “because they were the intended target of SCHIP/Medicaid expansions,” they noted.

The findings bear consideration “as we evaluate current SCHIP performance and contemplate potential revisions in anticipation of SCHIP legislative renewal in 2007,” Dr. Lewis and her associates noted.

There are “layers of barriers” built into the Medicaid and SCHIP systems in Maryland, and probably many other states, said Ms. Norris. But she is not convinced that access problems stem from government underfunding.

“I think it could be a structural problem. The system is too complex for parents to navigate and there aren't enough dentists in the system,” she said.

“The state is paying money to managed care programs to provide care, but that care is not being provided. The list of providers in the network looks good on paper, but when you go looking for them they are just not there. The money is padding the profits of the private plans,” she contended.

Although reasons for poor access to preventive dental care may be debated, the study identified that one positive influence on access to dental care was having a personal doctor.

“This is the first time to our knowledge that such an association has been recognized for the U.S. pediatric population as a whole,” wrote Dr. Lewis and her associates.

They noted several possible explanations for this, including the fact that families with a regular doctor “may have values and attributes that also lead them to seek preventive dental care,” or that physicians play an important role in referring patients and reinforcing the importance of dental care.

“By whatever mechanism,” they wrote, “there exists a link between having a personal doctor and receiving preventive dental care that deserves additional attention and study.”

The number of U.S. children receiving preventive dental care has risen, but minority children from low-income families remain the least likely group of children to receive it, according to a study.

The report was published shortly after a Maryland boy on Medicaid died because of complications ultimately related to lack of preventive dental care.

Among those children at high risk, having a personal doctor and being enrolled in the State Children's Health Insurance Program (for a subgroup of children) were factors associated with receiving preventive dental care, according to the study.

“We still have a long way to go before we can say that all U.S. children are receiving the preventive dental care that they need,” wrote Dr. Charlotte W. Lewis of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:544–53). They suggested that increasing the availability of dental insurance should be a priority in addressing this issue.

The study included data from 2003 on 102,353 children involved in the National Survey of Children's Health, and was weighted to represent 72.7 million children nationally. It found that in 2003, 72% of all children and 62.5% of low-income children (those at or below 200% of the federal poverty level [FPL]) reported a preventive dental care visit in the previous year. Almost 23% of children lacked dental insurance, compared with almost 9% who lacked health insurance.

The numbers of children receiving preventive dental care are higher than previously reported, and exceed the Healthy People 2010 goal of 57% of low-income children receiving a preventive dental care visit in the previous year, according to the authors.

But children who are at highest risk for dental problems are still those who are least likely to receive preventive care, they wrote.

“Certain groups continue to be underrepresented,” the researchers noted. “These include children who are young, who are black or multiracial, lack dental insurance, lack a personal doctor, are under 400% of the FPL … live in nonmetropolitan areas or states, or are foreign born.” After the researchers controlled for other variables, Hispanic and white children had a similar likelihood of receiving care, but black children had lower odds that persisted even after adjustment for income and insurance status, Dr. Lewis and her associates reported.

The picture painted by the study is a familiar one for Laurie Norris, a lawyer at the Baltimore-based Public Justice Center who tried between September 2006 and January 2007 to help the family of a 12-year-old Maryland boy who died in February after an infection from an abscessed tooth spread to his brain. There is “terrible access” to dental care for underprivileged children in Maryland, Ms. Norris said in an interview. “I made 26 calls and was unable to find a dentist contracted to the family's dental plan (Medicaid) in their geographic area.”

In examining factors influencing access to dental care, the study showed that income eligibility for State Children's Health Insurance Program (SCHIP) policies was associated with preventive dental health visits by “near-poor” children. (Near-poor was defined as 1− to 5-year-old children living at 133%–199% of the FPL, or children older than 5 years living at 100%–199% of the FPL.) Near-poor children in states with the broadest income eligibility for SCHIP dental care had a 24% higher likelihood of a preventive dental visit compared with children in states with limited or no eligibility for SCHIP dental services, reported the authors. Yet, “even in the best states, near-poor children lag substantially behind their higher income counterparts.”

Near-poor children were of primary interest “because they were the intended target of SCHIP/Medicaid expansions,” they noted.

The findings bear consideration “as we evaluate current SCHIP performance and contemplate potential revisions in anticipation of SCHIP legislative renewal in 2007,” Dr. Lewis and her associates noted.

There are “layers of barriers” built into the Medicaid and SCHIP systems in Maryland, and probably many other states, said Ms. Norris. But she is not convinced that access problems stem from government underfunding.

“I think it could be a structural problem. The system is too complex for parents to navigate and there aren't enough dentists in the system,” she said.

“The state is paying money to managed care programs to provide care, but that care is not being provided. The list of providers in the network looks good on paper, but when you go looking for them they are just not there. The money is padding the profits of the private plans,” she contended.

Although reasons for poor access to preventive dental care may be debated, the study identified that one positive influence on access to dental care was having a personal doctor.

“This is the first time to our knowledge that such an association has been recognized for the U.S. pediatric population as a whole,” wrote Dr. Lewis and her associates.

They noted several possible explanations for this, including the fact that families with a regular doctor “may have values and attributes that also lead them to seek preventive dental care,” or that physicians play an important role in referring patients and reinforcing the importance of dental care.

“By whatever mechanism,” they wrote, “there exists a link between having a personal doctor and receiving preventive dental care that deserves additional attention and study.”

The number of U.S. children receiving preventive dental care has risen, but minority children from low-income families remain the least likely group of children to receive it, according to a study.

The report was published shortly after a Maryland boy on Medicaid died because of complications ultimately related to lack of preventive dental care.

Among those children at high risk, having a personal doctor and being enrolled in the State Children's Health Insurance Program (for a subgroup of children) were factors associated with receiving preventive dental care, according to the study.

“We still have a long way to go before we can say that all U.S. children are receiving the preventive dental care that they need,” wrote Dr. Charlotte W. Lewis of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:544–53). They suggested that increasing the availability of dental insurance should be a priority in addressing this issue.

The study included data from 2003 on 102,353 children involved in the National Survey of Children's Health, and was weighted to represent 72.7 million children nationally. It found that in 2003, 72% of all children and 62.5% of low-income children (those at or below 200% of the federal poverty level [FPL]) reported a preventive dental care visit in the previous year. Almost 23% of children lacked dental insurance, compared with almost 9% who lacked health insurance.

The numbers of children receiving preventive dental care are higher than previously reported, and exceed the Healthy People 2010 goal of 57% of low-income children receiving a preventive dental care visit in the previous year, according to the authors.

But children who are at highest risk for dental problems are still those who are least likely to receive preventive care, they wrote.

“Certain groups continue to be underrepresented,” the researchers noted. “These include children who are young, who are black or multiracial, lack dental insurance, lack a personal doctor, are under 400% of the FPL … live in nonmetropolitan areas or states, or are foreign born.” After the researchers controlled for other variables, Hispanic and white children had a similar likelihood of receiving care, but black children had lower odds that persisted even after adjustment for income and insurance status, Dr. Lewis and her associates reported.

The picture painted by the study is a familiar one for Laurie Norris, a lawyer at the Baltimore-based Public Justice Center who tried between September 2006 and January 2007 to help the family of a 12-year-old Maryland boy who died in February after an infection from an abscessed tooth spread to his brain. There is “terrible access” to dental care for underprivileged children in Maryland, Ms. Norris said in an interview. “I made 26 calls and was unable to find a dentist contracted to the family's dental plan (Medicaid) in their geographic area.”

In examining factors influencing access to dental care, the study showed that income eligibility for State Children's Health Insurance Program (SCHIP) policies was associated with preventive dental health visits by “near-poor” children. (Near-poor was defined as 1− to 5-year-old children living at 133%–199% of the FPL, or children older than 5 years living at 100%–199% of the FPL.) Near-poor children in states with the broadest income eligibility for SCHIP dental care had a 24% higher likelihood of a preventive dental visit compared with children in states with limited or no eligibility for SCHIP dental services, reported the authors. Yet, “even in the best states, near-poor children lag substantially behind their higher income counterparts.”

Near-poor children were of primary interest “because they were the intended target of SCHIP/Medicaid expansions,” they noted.

The findings bear consideration “as we evaluate current SCHIP performance and contemplate potential revisions in anticipation of SCHIP legislative renewal in 2007,” Dr. Lewis and her associates noted.

There are “layers of barriers” built into the Medicaid and SCHIP systems in Maryland, and probably many other states, said Ms. Norris. But she is not convinced that access problems stem from government underfunding.

“I think it could be a structural problem. The system is too complex for parents to navigate and there aren't enough dentists in the system,” she said.

“The state is paying money to managed care programs to provide care, but that care is not being provided. The list of providers in the network looks good on paper, but when you go looking for them they are just not there. The money is padding the profits of the private plans,” she contended.

Although reasons for poor access to preventive dental care may be debated, the study identified that one positive influence on access to dental care was having a personal doctor.

“This is the first time to our knowledge that such an association has been recognized for the U.S. pediatric population as a whole,” wrote Dr. Lewis and her associates.

They noted several possible explanations for this, including the fact that families with a regular doctor “may have values and attributes that also lead them to seek preventive dental care,” or that physicians play an important role in referring patients and reinforcing the importance of dental care.

“By whatever mechanism,” they wrote, “there exists a link between having a personal doctor and receiving preventive dental care that deserves additional attention and study.”

The risks of prolonged acute otitis media in children who are not initially treated with antibiotics are two times higher if the patients are aged younger than 2 years and have acute bilateral infection, compared with older children who have unilateral infection, according to a meta-analysis.

“Clinicians can use these features … to inform parents more explicitly about the expected course of their child's AOM [acute otitis media] and to explain which features should prompt parents to contact their clinician for reexamination of the child,” wrote Maroeska M. Rovers, Ph.D., of the Julius Center for Health Sciences and Primary Care, and Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands, and colleagues (Pediatrics 2007;119; 579–85).

The meta-analysis included six randomized, controlled trials of children aged 6 months to 12 years with AOM who were randomized to antibiotic therapy or observation (either placebo or no treatment). Only the 824 patients in the observation arms were included in the analysis. The primary outcome was a prolonged infection defined as fever and/or pain at 3–7 days, and the predictors analyzed were age, gender, season, having been breast-fed or not, presence or absence of recurrent AOM, and baseline symptoms of fever, pain, bilateral AOM, otorrhea, and appearance of tympanic membrane (bulging, redness, perforation).

Of the 824 children, 303 (37%) had fever and/or pain at 3–7 days.

The absolute risks of pain and/or fever at follow-up were highest for children aged under 2 years with bilateral infection (55%) and lowest for those aged 2 years or older with unilateral infection (25%).

The risks of prolonged acute otitis media in children who are not initially treated with antibiotics are two times higher if the patients are aged younger than 2 years and have acute bilateral infection, compared with older children who have unilateral infection, according to a meta-analysis.

“Clinicians can use these features … to inform parents more explicitly about the expected course of their child's AOM [acute otitis media] and to explain which features should prompt parents to contact their clinician for reexamination of the child,” wrote Maroeska M. Rovers, Ph.D., of the Julius Center for Health Sciences and Primary Care, and Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands, and colleagues (Pediatrics 2007;119; 579–85).

The meta-analysis included six randomized, controlled trials of children aged 6 months to 12 years with AOM who were randomized to antibiotic therapy or observation (either placebo or no treatment). Only the 824 patients in the observation arms were included in the analysis. The primary outcome was a prolonged infection defined as fever and/or pain at 3–7 days, and the predictors analyzed were age, gender, season, having been breast-fed or not, presence or absence of recurrent AOM, and baseline symptoms of fever, pain, bilateral AOM, otorrhea, and appearance of tympanic membrane (bulging, redness, perforation).

Of the 824 children, 303 (37%) had fever and/or pain at 3–7 days.

The absolute risks of pain and/or fever at follow-up were highest for children aged under 2 years with bilateral infection (55%) and lowest for those aged 2 years or older with unilateral infection (25%).

The risks of prolonged acute otitis media in children who are not initially treated with antibiotics are two times higher if the patients are aged younger than 2 years and have acute bilateral infection, compared with older children who have unilateral infection, according to a meta-analysis.

“Clinicians can use these features … to inform parents more explicitly about the expected course of their child's AOM [acute otitis media] and to explain which features should prompt parents to contact their clinician for reexamination of the child,” wrote Maroeska M. Rovers, Ph.D., of the Julius Center for Health Sciences and Primary Care, and Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands, and colleagues (Pediatrics 2007;119; 579–85).

The meta-analysis included six randomized, controlled trials of children aged 6 months to 12 years with AOM who were randomized to antibiotic therapy or observation (either placebo or no treatment). Only the 824 patients in the observation arms were included in the analysis. The primary outcome was a prolonged infection defined as fever and/or pain at 3–7 days, and the predictors analyzed were age, gender, season, having been breast-fed or not, presence or absence of recurrent AOM, and baseline symptoms of fever, pain, bilateral AOM, otorrhea, and appearance of tympanic membrane (bulging, redness, perforation).

Of the 824 children, 303 (37%) had fever and/or pain at 3–7 days.

The absolute risks of pain and/or fever at follow-up were highest for children aged under 2 years with bilateral infection (55%) and lowest for those aged 2 years or older with unilateral infection (25%).

Preterm infants vaccinated against measles, mumps, rubella, and varicella at age 15 months mount adequate antibody responses similar to those of term infants, according to study findings.

“These findings support the prevailing recommendations for immunization of the preterm infant at the chronological age appropriate for a term infant,” concluded Dr. Carl T. D'Angio of the University of Rochester (N.Y.) and his colleagues (Pediatrics 2007;119;574–9).

They noted that whereas few data previously have existed on these particular vaccines in preterm infants, limited data on other vaccines—such as inactivated influenza, Haemophilus influenzae type b booster, tetanus, diphtheria, and polio—have suggested diminished responses in preterm compared with term infants. “The relatively robust responses in preterm infants in this study may be explained in part by the specific vaccine antigens studied,” they noted. “Live viral vaccines, such as MMR [measles, mumps, rubella] and varicella, often are highly immunogenic.”

The study included 16 term infants, aged 37 weeks or older, and 16 preterm infants younger than 29 weeks. All infants were immunized with MMR and varicella vaccines between the ages of 14.4 and 16 months. Blood specimens were obtained before and again 3–6 weeks after immunization. Measles antibody was measured by plaque reduction neutralization assay; mumps and rubella immunoglobulin G (IgG) titers were measured by enzyme-linked fluorescent immunoassay; and varicella IgG was measured using a glycoprotein enzyme-linked immunosorbent assay.

Before vaccination, all patients in both groups were seronegative for measles-neutralizing antibody, and all had measles titers of more than 120 mIU/mL after vaccination, reported the authors. Varicella titers were similar in both groups before and after vaccination; mumps and rubella titers were similar in both groups after vaccination, but lower in preterm than in term infants before vaccination. “This is consistent with lower transplacental antibody transfer in the preterm infants, because the most likely source of detectable prevaccine antibodies would be maternal,” they explained.

Preterm infants vaccinated against measles, mumps, rubella, and varicella at age 15 months mount adequate antibody responses similar to those of term infants, according to study findings.

“These findings support the prevailing recommendations for immunization of the preterm infant at the chronological age appropriate for a term infant,” concluded Dr. Carl T. D'Angio of the University of Rochester (N.Y.) and his colleagues (Pediatrics 2007;119;574–9).

They noted that whereas few data previously have existed on these particular vaccines in preterm infants, limited data on other vaccines—such as inactivated influenza, Haemophilus influenzae type b booster, tetanus, diphtheria, and polio—have suggested diminished responses in preterm compared with term infants. “The relatively robust responses in preterm infants in this study may be explained in part by the specific vaccine antigens studied,” they noted. “Live viral vaccines, such as MMR [measles, mumps, rubella] and varicella, often are highly immunogenic.”

The study included 16 term infants, aged 37 weeks or older, and 16 preterm infants younger than 29 weeks. All infants were immunized with MMR and varicella vaccines between the ages of 14.4 and 16 months. Blood specimens were obtained before and again 3–6 weeks after immunization. Measles antibody was measured by plaque reduction neutralization assay; mumps and rubella immunoglobulin G (IgG) titers were measured by enzyme-linked fluorescent immunoassay; and varicella IgG was measured using a glycoprotein enzyme-linked immunosorbent assay.

Before vaccination, all patients in both groups were seronegative for measles-neutralizing antibody, and all had measles titers of more than 120 mIU/mL after vaccination, reported the authors. Varicella titers were similar in both groups before and after vaccination; mumps and rubella titers were similar in both groups after vaccination, but lower in preterm than in term infants before vaccination. “This is consistent with lower transplacental antibody transfer in the preterm infants, because the most likely source of detectable prevaccine antibodies would be maternal,” they explained.

Preterm infants vaccinated against measles, mumps, rubella, and varicella at age 15 months mount adequate antibody responses similar to those of term infants, according to study findings.

“These findings support the prevailing recommendations for immunization of the preterm infant at the chronological age appropriate for a term infant,” concluded Dr. Carl T. D'Angio of the University of Rochester (N.Y.) and his colleagues (Pediatrics 2007;119;574–9).

They noted that whereas few data previously have existed on these particular vaccines in preterm infants, limited data on other vaccines—such as inactivated influenza, Haemophilus influenzae type b booster, tetanus, diphtheria, and polio—have suggested diminished responses in preterm compared with term infants. “The relatively robust responses in preterm infants in this study may be explained in part by the specific vaccine antigens studied,” they noted. “Live viral vaccines, such as MMR [measles, mumps, rubella] and varicella, often are highly immunogenic.”

The study included 16 term infants, aged 37 weeks or older, and 16 preterm infants younger than 29 weeks. All infants were immunized with MMR and varicella vaccines between the ages of 14.4 and 16 months. Blood specimens were obtained before and again 3–6 weeks after immunization. Measles antibody was measured by plaque reduction neutralization assay; mumps and rubella immunoglobulin G (IgG) titers were measured by enzyme-linked fluorescent immunoassay; and varicella IgG was measured using a glycoprotein enzyme-linked immunosorbent assay.

Before vaccination, all patients in both groups were seronegative for measles-neutralizing antibody, and all had measles titers of more than 120 mIU/mL after vaccination, reported the authors. Varicella titers were similar in both groups before and after vaccination; mumps and rubella titers were similar in both groups after vaccination, but lower in preterm than in term infants before vaccination. “This is consistent with lower transplacental antibody transfer in the preterm infants, because the most likely source of detectable prevaccine antibodies would be maternal,” they explained.

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid, Sunnyvale, Calif.)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, said Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics. “It is not intended that this test would be the sole determinant. It is an adjunctive test.” he said in an interview.

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial Gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said in a written statement.

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid, Sunnyvale, Calif.)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, said Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics. “It is not intended that this test would be the sole determinant. It is an adjunctive test.” he said in an interview.

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial Gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said in a written statement.

The first rapid test for viral meningitis has been cleared for marketing by the Food and Drug Administration.

The Xpert EV test (Cepheid, Sunnyvale, Calif.)—which was released in Europe last summer—can help identify viral meningitis within 2.5 hours instead of the current 3–7 days, thus helping physicians to distinguish quickly between the viral and bacterial forms of the infection, according to the FDA.

“Since bacterial meningitis can be deadly within as little as 2 days, patients who have viral meningitis are frequently treated with antibiotics as a safeguard,” said Dr. Daniel G. Schultz, director of the FDA's Center for Devices and Radiological Health, in a written statement. By using the rapid test, physicians can reduce this unnecessary antibiotic treatment, he noted.

The Xpert EV test uses reverse-transcription real-time polymerase chain reaction to detect enterovirus, which is responsible for 85%–95% of viral meningitis, in cerebrospinal fluid (CSF). However, the test should not be used in isolation, said Dr. Steven Gutman, director of the FDA's Office of In Vitro Diagnostics. “It is not intended that this test would be the sole determinant. It is an adjunctive test.” he said in an interview.

Indeed, according to the company, the test is designed to be used in conjunction “with standard CSF tests [such as] bacterial Gram stain, bacterial culture, CSF glucose, CSF-blood glucose ratio, CSF protein concentrations, and CSF leukocyte counts.” It “fills a clinical testing void,” because it is a fully automated test, thereby allowing “round-the-clock” testing, Cepheid said in a written statement.

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

While for some patients, vulvar signs may be the first presentation of Crohn's, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

While for some patients, vulvar signs may be the first presentation of Crohn's, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

HOUSTON — Women with Crohn's disease can sometimes present with knifelike vulvar ulcers that are very specific to the disorder and may be its only manifestation, according to several experts who spoke at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.

“There are three things in the vulvar or perianal area that might make you think of unrecognized Crohn's: knifelike ulcerations, vulvar edema that has no other cause, or fistula around the anus,” said Dr. Libby Edwards, a dermatologist in private practice in Charlotte, N.C. “It has been said that vulvar Crohn's is rare, but it is not. It's uncommon but it's not rare. I see it several times a year, and most gynecologists will see it without necessarily recognizing what it is,” she said in an interview.

While for some patients, vulvar signs may be the first presentation of Crohn's, this tends to be the exception, said Dr. Hope K. Haefner, professor of obstetrics and gynecology at the University of Michigan and director of the university's Center for Vulvar Diseases in Ann Arbor.

“There is the rare patient who doesn't have any gastrointestinal symptoms and might develop them later, but usually the majority already have a diagnosis of gastrointestinal Crohn's and are seeking gynecologic care for their vulvar symptoms,” she said in an interview. In her opinion, perianal fistulae may be the most common of the three gynecologic manifestations of Crohn's. “I see them every couple of months, in children and in the elderly—there's a big age range,” she said.

Vulvar and perianal Crohn's is a marker for severe disease that needs to be aggressively treated systemically, said Dr. Edwards, also of the department of dermatology at the University of North Carolina at Chapel Hill. “First of all, if [these patients] don't have an aggressive gastroenterologist, they really need one,” she said, adding that aggressive systemic treatment for Crohn's might relieve some vulvar symptoms. But, she said, patients also need local vulvar care. “These patients get secondary infections, and when they do, they need oral antibiotics—maybe even on a long-term basis if they have open, draining sores.” In addition, both oral antibiotics and immunosuppressive therapy for Crohn's can make patients susceptible to yeast infections, which may require weekly antifungal therapy, she said.

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”

Epidural steroid injections may provide some short-term pain relief in radicular lumbosacral pain but they are not recommended for long-term relief, improvement of function, or reducing the need for surgery, according to new guidelines from the American Academy of Neurology.

The guidelines were drafted by the AAN's Therapeutics and Technology Assessment Subcommittee, based on a literature review (Neurology 2007;68:723–9).

From an initial 37 studies that were identified, only 4 met the committee's predetermined inclusion criteria of being randomized, double-blinded, and placebo or active-controlled with a clear case definition and clear pain-relief outcomes using a standardized measure, wrote lead author Dr. Carmel Armon, chief of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University in Boston.

Dr. Armon and colleagues said all four studies were consistent in their findings on epidural steroid injection for radicular lumbosacral pain relief. The findings concluded that when compared with a control group, the injections proved “no efficacy at 24 hours, some efficacy at 2–6 weeks, no difference or rebound worsening at 3 months and 6 months, and no difference at 1 year.”

“While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful,” Dr. Armon wrote. The clinically meaningful effect is usually defined as 15 mm on a 100-mm visual analog pain scale, according to the guidelines.

Reported complications of epidural steroid injections are usually minor and transient—most frequently a headache, they reported. Major complications are rare and include aseptic meningitis, arachnoiditis, bacterial meningitis, epidural abscess, and conus medullaris syndrome.

“I think the risk-benefit ratio [is important],” Dr. David Borenstein, clinical professor of rheumatology at George Washington University and a rheumatologist specializing in low back pain, said in an interview. “People should consider exercises and oral therapies first, but if they're not getting better, this relatively noninvasive type of procedure, compared to surgical intervention, would be worthwhile to consider in the appropriate patient.”

“Epidural steroid injections are likely overused,” said Dr. J. D. Bartleson, a neurologist at the spine center of the Mayo Clinic in Rochester, Minn. “There is bias that they are extremely helpful, which is not borne out by the data,” he said in an interview. “I hope neurologists … will gain a better understanding of the modest help that epidural injections can provide.”

NEW YORK — Symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, but debate about the necessity of diagnosing and treating asymptomatic disease was lively at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, while below the waterline is a spectrum of asymptomatic disease, which includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, which was cosponsored by the AGA Institute.

Reducing Long-Term Risk

A gluten-free diet can dramatically reduce or eliminate symptoms, and this treatment has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease—even its asymptomatic form. However, new research suggests that these long-term risks might be lower than previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers did reveal a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Interestingly, breast cancers were 70% less common in the celiac population. “This is a pretty robust and intriguing finding for which I have no explanation,” Dr. West said.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said. “One way to look at it is to say that in an untreated group the risks could be much higher. The other way of looking at it is to say that people with undetected celiac may have less severe disease and therefore perhaps less risk,” he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested, although this is still widely debated.

The Psychological Toll

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said. Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, according to research by Dr. Claes Hallert of Linköping (Sweden) University.

“We used to say celiac was a very treatable disorder, but that is not entirely true,” he said in an interview. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression.”

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking, as well as restrictions on food choice and extra work involved in food preparation (J. Hum. Nutr. Diet. 2005;18:171–80).

Such barriers might be important contributors to noncompliance with the diet, suggested Dr. Carolina Ciacci, whose research showed that anger is the predominant emotion in roughly 40% of diagnosed patients (Dig. Dis. Sci. 2002;47:2082–7). Between 45% and 75% of patients report strict adherence to the diet, she said.

NEW YORK — Symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, but debate about the necessity of diagnosing and treating asymptomatic disease was lively at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, while below the waterline is a spectrum of asymptomatic disease, which includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, which was cosponsored by the AGA Institute.

Reducing Long-Term Risk

A gluten-free diet can dramatically reduce or eliminate symptoms, and this treatment has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease—even its asymptomatic form. However, new research suggests that these long-term risks might be lower than previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers did reveal a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Interestingly, breast cancers were 70% less common in the celiac population. “This is a pretty robust and intriguing finding for which I have no explanation,” Dr. West said.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said. “One way to look at it is to say that in an untreated group the risks could be much higher. The other way of looking at it is to say that people with undetected celiac may have less severe disease and therefore perhaps less risk,” he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested, although this is still widely debated.

The Psychological Toll

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said. Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, according to research by Dr. Claes Hallert of Linköping (Sweden) University.

“We used to say celiac was a very treatable disorder, but that is not entirely true,” he said in an interview. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression.”

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking, as well as restrictions on food choice and extra work involved in food preparation (J. Hum. Nutr. Diet. 2005;18:171–80).

Such barriers might be important contributors to noncompliance with the diet, suggested Dr. Carolina Ciacci, whose research showed that anger is the predominant emotion in roughly 40% of diagnosed patients (Dig. Dis. Sci. 2002;47:2082–7). Between 45% and 75% of patients report strict adherence to the diet, she said.

NEW YORK — Symptomatic celiac disease is a clear indication for treatment with a gluten-free diet, but debate about the necessity of diagnosing and treating asymptomatic disease was lively at an international symposium on celiac disease.

“If we are going to diagnose this disease [in asymptomatic people], we have to be certain it will be of benefit,” said Dr. Richard Logan of the University of Nottingham (England).

Experts believe that diagnosed, symptomatic celiac disease represents only the tip of the iceberg of gluten sensitivity, while below the waterline is a spectrum of asymptomatic disease, which includes people with positive serology and histology (silent disease), as well as those with positive serology but negative histology (latent disease).

Such asymptomatic patients are often diagnosed during family screening, because it is now recognized that genetic predisposition plays an important role in the development of the disorder; almost all celiac patients carry the DQ2 or DQ8 genes.

But the uncertain clinical benefit of labeling asymptomatic individuals and prescribing them a lifelong gluten-free diet should be carefully weighed against the potential psychological and economic risks, warned several experts at the meeting, which was cosponsored by the AGA Institute.

Reducing Long-Term Risk

A gluten-free diet can dramatically reduce or eliminate symptoms, and this treatment has also been considered protective against the increased risks of malignancy and osteoporosis that have been associated with celiac disease—even its asymptomatic form. However, new research suggests that these long-term risks might be lower than previously believed, said Dr. Joe West of the University of Nottingham (England).

His study of almost 5,000 treated celiac patients and more than 23,000 controls revealed a 30% increase in overall malignancies among the celiac patients (BMJ 2004;329:716–9), but a closer analysis revealed a detection bias in that most cancers were diagnosed in the first year after the celiac diagnosis.

After controlling for this phenomenon, the difference in overall cancer rate between the two groups was no longer significant. However, further analysis of individual cancers did reveal a fivefold increase in non-Hodgkin's lymphoma among the celiac patients, and a 40-fold increase in small bowel lymphoma (Aliment. Pharmacol. Ther. 2004;20:769–75). Interestingly, breast cancers were 70% less common in the celiac population. “This is a pretty robust and intriguing finding for which I have no explanation,” Dr. West said.

His research also found a 30% increase in osteoporosis among celiac patients, with a twofold increase in hip fracture; however, the absolute risk remained small. These results were restricted to diagnosed celiac patients who were being treated with a gluten-free diet, and therefore their relevance for undiagnosed, untreated individuals is not clear, he said. “One way to look at it is to say that in an untreated group the risks could be much higher. The other way of looking at it is to say that people with undetected celiac may have less severe disease and therefore perhaps less risk,” he said.

Another argument for screening and treating asymptomatic celiac disease comes from evidence that it might progress to overt disease with continued gluten exposure, other experts said. Early treatment with a gluten-free diet could halt the progression from latent to silent and then to symptomatic disease, they suggested, although this is still widely debated.

The Psychological Toll

But the psychological price of a lifelong gluten-free diet is often underappreciated by physicians who prescribe it, Dr. Logan said. A recent survey of patients diagnosed with celiac disease revealed that one-third felt the gluten-free diet greatly reduced their enjoyment of food, and a quarter were not entirely pleased to have been diagnosed, he said. Despite experiencing relief of symptoms, many celiac patients (particularly women) on a gluten-free diet report a reduced quality of life, according to research by Dr. Claes Hallert of Linköping (Sweden) University.

“We used to say celiac was a very treatable disorder, but that is not entirely true,” he said in an interview. “Many patients react psychologically to the restrictive diet—there are social problems, societal problems, problems at work, problems with travel—and this may lead to depression.”

In a study of 40 celiac patients, his research group identified 195 situational dilemmas faced by patients dealing with a gluten-free diet. Specific emotions that were identified included isolation, shame, fear of gluten, and worry about inconveniencing others. Patients also reported unwanted visibility, neglect, disclosure avoidance, and risk-taking, as well as restrictions on food choice and extra work involved in food preparation (J. Hum. Nutr. Diet. 2005;18:171–80).

Such barriers might be important contributors to noncompliance with the diet, suggested Dr. Carolina Ciacci, whose research showed that anger is the predominant emotion in roughly 40% of diagnosed patients (Dig. Dis. Sci. 2002;47:2082–7). Between 45% and 75% of patients report strict adherence to the diet, she said.