Michele G. Sullivan

Teen births hit a 70-year low in 2010, probably due to a combination of increased abstinence and the use of more effective contraception.

The birth rate for U.S. teenage females in 2010 – the most recent year with full data – was 34 per 1,000, Crystal Pirtle Tyler, Ph.D., and her associates wrote in the May 4 issue of Morbidity and Mortality Report. That translates to a total of about 368,000 pregnancies that year – a 44% decline from 1990 (MMWR Morb. Mortal. Wkly. Rep. 2012;61:297-301).

A significant increase in sexual abstinence is a larger driver of that change, wrote Dr. Tyler and her associates at the National Center for Chronic Disease Prevention and Health Promotion. "During 2006-2010, more than half of female teens had never had sex, reflecting a 16% increase relative to the 1995 estimate."

Dr. Tyler and her colleagues extracted their data from three cycles of the National Survey of Family Growth (1995, 2002, and 2006-2010). The in-person survey addresses health issues in people aged 15-44 years.

The survey stratifies birth control methods into highly effective (long-acting reversible contraception); moderately effective (only condoms); and less effective (withdrawal, periodic abstinence, rhythm method, emergency contraception, diaphragm, female condom, foam, jelly, cervical cap, sponge, suppository, or insert).

Overall, 57% of teen females aged 15-19 years reported never having engaged in vaginal intercourse, a significant increase compared with 49% in 1995. There were intragroup differences in the proportion of abstinent teens in terms of race and ethnicity, with a 34% increase among black girls and a 29% increase among Hispanic girls, compared with a 15% increase among white girls.

Age also significantly impacted abstinence – 73% of teen girls aged 15-17 years compared with 36% aged 18-19 years reported never having had vaginal intercourse.

During the 2006-2010 era, 60% of teenage girls reported using highly effective contraception. This represented a 34% increase among whites, a 19% increase among Hispanics, and a 4% increase among blacks.

There were still disparities in the use of these methods, however. During 2006-2010, the highly effective methods were used by 66% of whites, 46% of Hispanics, and 54% of blacks.

There was also a 43% decrease in the use of moderately effective methods and a 27% decrease in less effective methods, compared with 1995.

There were changes in the proportion of teenage girls using no birth control. Compared with 1995, there was a 19% decrease among whites, but a 20% increase among blacks.

Again, Dr. Tyler noted, age was a factor. Teens aged 15-17 years had increased rates of highly effective methods compared with 1995 (56% vs. 46%). The rate for those aged 18-19 years increased from 48% in 1995 to 62% during 2006-2010.

Among the younger teens, rates of nonuse declined relative to 1995 (from 24% to 19%), but stayed steady for older teens at 16%-17%.

Parents, schools, communities, and health care providers all can contribute to furthering the decline in teen pregnancy, according to an accompanying editorial. "Ways to reduce barriers to decrease teen pregnancy include encouraging teens to delay sexual debut, offering teens convenient [health care provider practice] hours, culturally competent and confidential counseling and services, and low-cost or free services and methods."

Health care providers also should know that no contraceptive method is contraindicated for teens solely on the basis of age, according to the editorial.

As a federal employee, Dr. Tyler had no financial disclosures.

Teen births hit a 70-year low in 2010, probably due to a combination of increased abstinence and the use of more effective contraception.

The birth rate for U.S. teenage females in 2010 – the most recent year with full data – was 34 per 1,000, Crystal Pirtle Tyler, Ph.D., and her associates wrote in the May 4 issue of Morbidity and Mortality Report. That translates to a total of about 368,000 pregnancies that year – a 44% decline from 1990 (MMWR Morb. Mortal. Wkly. Rep. 2012;61:297-301).

A significant increase in sexual abstinence is a larger driver of that change, wrote Dr. Tyler and her associates at the National Center for Chronic Disease Prevention and Health Promotion. "During 2006-2010, more than half of female teens had never had sex, reflecting a 16% increase relative to the 1995 estimate."

Dr. Tyler and her colleagues extracted their data from three cycles of the National Survey of Family Growth (1995, 2002, and 2006-2010). The in-person survey addresses health issues in people aged 15-44 years.

The survey stratifies birth control methods into highly effective (long-acting reversible contraception); moderately effective (only condoms); and less effective (withdrawal, periodic abstinence, rhythm method, emergency contraception, diaphragm, female condom, foam, jelly, cervical cap, sponge, suppository, or insert).

Overall, 57% of teen females aged 15-19 years reported never having engaged in vaginal intercourse, a significant increase compared with 49% in 1995. There were intragroup differences in the proportion of abstinent teens in terms of race and ethnicity, with a 34% increase among black girls and a 29% increase among Hispanic girls, compared with a 15% increase among white girls.

Age also significantly impacted abstinence – 73% of teen girls aged 15-17 years compared with 36% aged 18-19 years reported never having had vaginal intercourse.

During the 2006-2010 era, 60% of teenage girls reported using highly effective contraception. This represented a 34% increase among whites, a 19% increase among Hispanics, and a 4% increase among blacks.

There were still disparities in the use of these methods, however. During 2006-2010, the highly effective methods were used by 66% of whites, 46% of Hispanics, and 54% of blacks.

There was also a 43% decrease in the use of moderately effective methods and a 27% decrease in less effective methods, compared with 1995.

There were changes in the proportion of teenage girls using no birth control. Compared with 1995, there was a 19% decrease among whites, but a 20% increase among blacks.

Again, Dr. Tyler noted, age was a factor. Teens aged 15-17 years had increased rates of highly effective methods compared with 1995 (56% vs. 46%). The rate for those aged 18-19 years increased from 48% in 1995 to 62% during 2006-2010.

Among the younger teens, rates of nonuse declined relative to 1995 (from 24% to 19%), but stayed steady for older teens at 16%-17%.

Parents, schools, communities, and health care providers all can contribute to furthering the decline in teen pregnancy, according to an accompanying editorial. "Ways to reduce barriers to decrease teen pregnancy include encouraging teens to delay sexual debut, offering teens convenient [health care provider practice] hours, culturally competent and confidential counseling and services, and low-cost or free services and methods."

Health care providers also should know that no contraceptive method is contraindicated for teens solely on the basis of age, according to the editorial.

As a federal employee, Dr. Tyler had no financial disclosures.

Teen births hit a 70-year low in 2010, probably due to a combination of increased abstinence and the use of more effective contraception.

The birth rate for U.S. teenage females in 2010 – the most recent year with full data – was 34 per 1,000, Crystal Pirtle Tyler, Ph.D., and her associates wrote in the May 4 issue of Morbidity and Mortality Report. That translates to a total of about 368,000 pregnancies that year – a 44% decline from 1990 (MMWR Morb. Mortal. Wkly. Rep. 2012;61:297-301).

A significant increase in sexual abstinence is a larger driver of that change, wrote Dr. Tyler and her associates at the National Center for Chronic Disease Prevention and Health Promotion. "During 2006-2010, more than half of female teens had never had sex, reflecting a 16% increase relative to the 1995 estimate."

Dr. Tyler and her colleagues extracted their data from three cycles of the National Survey of Family Growth (1995, 2002, and 2006-2010). The in-person survey addresses health issues in people aged 15-44 years.

The survey stratifies birth control methods into highly effective (long-acting reversible contraception); moderately effective (only condoms); and less effective (withdrawal, periodic abstinence, rhythm method, emergency contraception, diaphragm, female condom, foam, jelly, cervical cap, sponge, suppository, or insert).

Overall, 57% of teen females aged 15-19 years reported never having engaged in vaginal intercourse, a significant increase compared with 49% in 1995. There were intragroup differences in the proportion of abstinent teens in terms of race and ethnicity, with a 34% increase among black girls and a 29% increase among Hispanic girls, compared with a 15% increase among white girls.

Age also significantly impacted abstinence – 73% of teen girls aged 15-17 years compared with 36% aged 18-19 years reported never having had vaginal intercourse.

During the 2006-2010 era, 60% of teenage girls reported using highly effective contraception. This represented a 34% increase among whites, a 19% increase among Hispanics, and a 4% increase among blacks.

There were still disparities in the use of these methods, however. During 2006-2010, the highly effective methods were used by 66% of whites, 46% of Hispanics, and 54% of blacks.

There was also a 43% decrease in the use of moderately effective methods and a 27% decrease in less effective methods, compared with 1995.

There were changes in the proportion of teenage girls using no birth control. Compared with 1995, there was a 19% decrease among whites, but a 20% increase among blacks.

Again, Dr. Tyler noted, age was a factor. Teens aged 15-17 years had increased rates of highly effective methods compared with 1995 (56% vs. 46%). The rate for those aged 18-19 years increased from 48% in 1995 to 62% during 2006-2010.

Among the younger teens, rates of nonuse declined relative to 1995 (from 24% to 19%), but stayed steady for older teens at 16%-17%.

Parents, schools, communities, and health care providers all can contribute to furthering the decline in teen pregnancy, according to an accompanying editorial. "Ways to reduce barriers to decrease teen pregnancy include encouraging teens to delay sexual debut, offering teens convenient [health care provider practice] hours, culturally competent and confidential counseling and services, and low-cost or free services and methods."

Health care providers also should know that no contraceptive method is contraindicated for teens solely on the basis of age, according to the editorial.

As a federal employee, Dr. Tyler had no financial disclosures.

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

BOSTON – For about half of children with type 2 diabetes, metformin alone is not enough to produce durable glycemic control, a study has shown.

The TODAY trial found that 52% of children failed monotherapy – many by 11 months, Dr. Phil Zeitler said at the annual meeting of the Pediatric Academic Societies.

And although the addition of rosiglitazone to metformin did improve results, the take-home message about monotherapy is clear, he said: Many young people with type 2 diabetes are going to need multiple medications, or insulin, within a few years of diagnosis.

"Metformin is not as good a medicine as we all thought it was. This is a much more rapid loss of control than we see in adults, in which metformin failure is about 6%-10% per year. And while the addition of rosiglitazone reduced the loss of glycemic control by 23%, the time to failure was unchanged," said Dr. Zeitler, a lead investigator in the Treatment Options for Type 2 Diabetes in Adolescents and Youth trial.

The study’s third arm – a combination of metformin and lifestyle modification – was not significantly different than either monotherapy or dual therapy. Patients using the combination of nutritional and activity counseling plus medication did lose significantly more weight than did those in the medication-only arms, but that did not translate into a longer period of glycemic control.

The study was simultaneously publishedin the online edition of the New England Journal of Medicine (2012 April 29 [doi:10.1056/NEJMoa1109333]).

The 60-month trial started 699 patients aged 10-17 years on 2,000 mg/day metformin; this treatment was continued until hemoglobin A_1c stabilized at 8%. The group was then randomized to one of the three treatment arms. The primary end point was time to the failure of glycemic control, defined as an HbA_1c level of at least 8% for 6 months, or sustained metabolic decompensation that required insulin treatment.

Overall, nearly half of the cohort (46%) failed to maintain glycemic control; the median time to failure was 11 months. However, compared with the combination therapy group, significantly more of those taking metformin alone failed glycemic control (52% vs. 39%). The failure rate in the lifestyle intervention group was 47% – not significantly different from that for metformin monotherapy or combination therapy.

Physiology rather than compliance probably drove the differences, said Dr. Zeitler, head of pediatric endocrinology at the Children’s Hospital Colorado, Aurora.

"There was no reason to suspect that differences [in any of the results] were due to lack of adherence," he said. "In fact, if we look at a comparison of those who failed compared to those who did not, adherence was generally better in those who failed, which might have reflected the efforts of the sites to enforce adherence as the HbA_1C levels began to rise."

However, Dr. Zeitler said, the results differed significantly between sexes and racial/ethnic groups. For girls, metformin plus rosiglitazone was significantly better than monotherapy or the combination of metformin and lifestyle modification. For boys, the combination of metformin and lifestyle changes was significantly better than for the other groups.

"Metformin is not as good a medicine as we all thought it was."

"While we saw distinct gender differences in the response, we can only speculate about the reasons behind that," Dr. Zeitler said.

Blacks responded especially poorly to metformin alone, he said, "such that by 12 months, almost 50% had failed treatment. We saw increased [statistically significant] efficacy with the addition of either rosiglitazone or lifestyle changes."

Among Hispanics, there were no statistically significant differences between any of the treatment arms, although Dr. Zeitler said that lifestyle intervention tended to be less effective than drug therapy.

Among whites, there was no difference between metformin and metformin with lifestyle changes. These patients had a better response with the addition of rosiglitazone, but it was not statistically significant, he said.

"These very distinct differences in gender and ethnicity suggest that there is something biologic going on here. But we need to analyze a variety of things that could also be factors, including adherence, socioeconomic status, site location, depression, and other things. We do have those data, and those analyses will be forthcoming," Dr. Zeitler said.

Despite the benefit rosiglitazone conferred to some patients, it can’t be recommended as an add-on therapy for young people with type 2 diabetes, he said in an interview. "It’s been shown to increase cardiovascular events in adults, although we don’t know how it would affect young people who are typically more cardiovascularly healthy."

TODAY made it clear that metformin alone isn’t enough for about half of these young patients. However, Dr. Zeitler said, this glass is not just half-empty.

"Half of the youngsters do seem to maintain long-term control irrespective of treatment, and this is something we don’t want to lose sight of," he said. "This suggests there are two cohorts of patients: One that will continue to do well on monotherapy, and one that will fail very rapidly. If we could predict who those children will be at the time of diagnosis, that could have a substantial effect on our choice of treatment."

The study was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Zeitler said he had no relevant financial disclosures. However, several of the coauthors did note financial relationships with various pharmaceutical companies, including Daiichi-Sankyo, Merck, Bristol-Meyers-Squibb, Jenny Craig/Nestle, and Medtronic.

BOSTON – For about half of children with type 2 diabetes, metformin alone is not enough to produce durable glycemic control, a study has shown.

The TODAY trial found that 52% of children failed monotherapy – many by 11 months, Dr. Phil Zeitler said at the annual meeting of the Pediatric Academic Societies.

And although the addition of rosiglitazone to metformin did improve results, the take-home message about monotherapy is clear, he said: Many young people with type 2 diabetes are going to need multiple medications, or insulin, within a few years of diagnosis.

"Metformin is not as good a medicine as we all thought it was. This is a much more rapid loss of control than we see in adults, in which metformin failure is about 6%-10% per year. And while the addition of rosiglitazone reduced the loss of glycemic control by 23%, the time to failure was unchanged," said Dr. Zeitler, a lead investigator in the Treatment Options for Type 2 Diabetes in Adolescents and Youth trial.

The study’s third arm – a combination of metformin and lifestyle modification – was not significantly different than either monotherapy or dual therapy. Patients using the combination of nutritional and activity counseling plus medication did lose significantly more weight than did those in the medication-only arms, but that did not translate into a longer period of glycemic control.

The study was simultaneously publishedin the online edition of the New England Journal of Medicine (2012 April 29 [doi:10.1056/NEJMoa1109333]).

The 60-month trial started 699 patients aged 10-17 years on 2,000 mg/day metformin; this treatment was continued until hemoglobin A_1c stabilized at 8%. The group was then randomized to one of the three treatment arms. The primary end point was time to the failure of glycemic control, defined as an HbA_1c level of at least 8% for 6 months, or sustained metabolic decompensation that required insulin treatment.

Overall, nearly half of the cohort (46%) failed to maintain glycemic control; the median time to failure was 11 months. However, compared with the combination therapy group, significantly more of those taking metformin alone failed glycemic control (52% vs. 39%). The failure rate in the lifestyle intervention group was 47% – not significantly different from that for metformin monotherapy or combination therapy.

Physiology rather than compliance probably drove the differences, said Dr. Zeitler, head of pediatric endocrinology at the Children’s Hospital Colorado, Aurora.

"There was no reason to suspect that differences [in any of the results] were due to lack of adherence," he said. "In fact, if we look at a comparison of those who failed compared to those who did not, adherence was generally better in those who failed, which might have reflected the efforts of the sites to enforce adherence as the HbA_1C levels began to rise."

However, Dr. Zeitler said, the results differed significantly between sexes and racial/ethnic groups. For girls, metformin plus rosiglitazone was significantly better than monotherapy or the combination of metformin and lifestyle modification. For boys, the combination of metformin and lifestyle changes was significantly better than for the other groups.

"Metformin is not as good a medicine as we all thought it was."

"While we saw distinct gender differences in the response, we can only speculate about the reasons behind that," Dr. Zeitler said.

Blacks responded especially poorly to metformin alone, he said, "such that by 12 months, almost 50% had failed treatment. We saw increased [statistically significant] efficacy with the addition of either rosiglitazone or lifestyle changes."

Among Hispanics, there were no statistically significant differences between any of the treatment arms, although Dr. Zeitler said that lifestyle intervention tended to be less effective than drug therapy.

Among whites, there was no difference between metformin and metformin with lifestyle changes. These patients had a better response with the addition of rosiglitazone, but it was not statistically significant, he said.

"These very distinct differences in gender and ethnicity suggest that there is something biologic going on here. But we need to analyze a variety of things that could also be factors, including adherence, socioeconomic status, site location, depression, and other things. We do have those data, and those analyses will be forthcoming," Dr. Zeitler said.

Despite the benefit rosiglitazone conferred to some patients, it can’t be recommended as an add-on therapy for young people with type 2 diabetes, he said in an interview. "It’s been shown to increase cardiovascular events in adults, although we don’t know how it would affect young people who are typically more cardiovascularly healthy."

TODAY made it clear that metformin alone isn’t enough for about half of these young patients. However, Dr. Zeitler said, this glass is not just half-empty.

"Half of the youngsters do seem to maintain long-term control irrespective of treatment, and this is something we don’t want to lose sight of," he said. "This suggests there are two cohorts of patients: One that will continue to do well on monotherapy, and one that will fail very rapidly. If we could predict who those children will be at the time of diagnosis, that could have a substantial effect on our choice of treatment."

The study was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Zeitler said he had no relevant financial disclosures. However, several of the coauthors did note financial relationships with various pharmaceutical companies, including Daiichi-Sankyo, Merck, Bristol-Meyers-Squibb, Jenny Craig/Nestle, and Medtronic.

BOSTON – For about half of children with type 2 diabetes, metformin alone is not enough to produce durable glycemic control, a study has shown.

The TODAY trial found that 52% of children failed monotherapy – many by 11 months, Dr. Phil Zeitler said at the annual meeting of the Pediatric Academic Societies.

And although the addition of rosiglitazone to metformin did improve results, the take-home message about monotherapy is clear, he said: Many young people with type 2 diabetes are going to need multiple medications, or insulin, within a few years of diagnosis.

"Metformin is not as good a medicine as we all thought it was. This is a much more rapid loss of control than we see in adults, in which metformin failure is about 6%-10% per year. And while the addition of rosiglitazone reduced the loss of glycemic control by 23%, the time to failure was unchanged," said Dr. Zeitler, a lead investigator in the Treatment Options for Type 2 Diabetes in Adolescents and Youth trial.

The study’s third arm – a combination of metformin and lifestyle modification – was not significantly different than either monotherapy or dual therapy. Patients using the combination of nutritional and activity counseling plus medication did lose significantly more weight than did those in the medication-only arms, but that did not translate into a longer period of glycemic control.

The study was simultaneously publishedin the online edition of the New England Journal of Medicine (2012 April 29 [doi:10.1056/NEJMoa1109333]).

The 60-month trial started 699 patients aged 10-17 years on 2,000 mg/day metformin; this treatment was continued until hemoglobin A_1c stabilized at 8%. The group was then randomized to one of the three treatment arms. The primary end point was time to the failure of glycemic control, defined as an HbA_1c level of at least 8% for 6 months, or sustained metabolic decompensation that required insulin treatment.

Overall, nearly half of the cohort (46%) failed to maintain glycemic control; the median time to failure was 11 months. However, compared with the combination therapy group, significantly more of those taking metformin alone failed glycemic control (52% vs. 39%). The failure rate in the lifestyle intervention group was 47% – not significantly different from that for metformin monotherapy or combination therapy.

Physiology rather than compliance probably drove the differences, said Dr. Zeitler, head of pediatric endocrinology at the Children’s Hospital Colorado, Aurora.

"There was no reason to suspect that differences [in any of the results] were due to lack of adherence," he said. "In fact, if we look at a comparison of those who failed compared to those who did not, adherence was generally better in those who failed, which might have reflected the efforts of the sites to enforce adherence as the HbA_1C levels began to rise."

However, Dr. Zeitler said, the results differed significantly between sexes and racial/ethnic groups. For girls, metformin plus rosiglitazone was significantly better than monotherapy or the combination of metformin and lifestyle modification. For boys, the combination of metformin and lifestyle changes was significantly better than for the other groups.

"Metformin is not as good a medicine as we all thought it was."

"While we saw distinct gender differences in the response, we can only speculate about the reasons behind that," Dr. Zeitler said.

Blacks responded especially poorly to metformin alone, he said, "such that by 12 months, almost 50% had failed treatment. We saw increased [statistically significant] efficacy with the addition of either rosiglitazone or lifestyle changes."

Among Hispanics, there were no statistically significant differences between any of the treatment arms, although Dr. Zeitler said that lifestyle intervention tended to be less effective than drug therapy.

Among whites, there was no difference between metformin and metformin with lifestyle changes. These patients had a better response with the addition of rosiglitazone, but it was not statistically significant, he said.

"These very distinct differences in gender and ethnicity suggest that there is something biologic going on here. But we need to analyze a variety of things that could also be factors, including adherence, socioeconomic status, site location, depression, and other things. We do have those data, and those analyses will be forthcoming," Dr. Zeitler said.

Despite the benefit rosiglitazone conferred to some patients, it can’t be recommended as an add-on therapy for young people with type 2 diabetes, he said in an interview. "It’s been shown to increase cardiovascular events in adults, although we don’t know how it would affect young people who are typically more cardiovascularly healthy."

TODAY made it clear that metformin alone isn’t enough for about half of these young patients. However, Dr. Zeitler said, this glass is not just half-empty.

"Half of the youngsters do seem to maintain long-term control irrespective of treatment, and this is something we don’t want to lose sight of," he said. "This suggests there are two cohorts of patients: One that will continue to do well on monotherapy, and one that will fail very rapidly. If we could predict who those children will be at the time of diagnosis, that could have a substantial effect on our choice of treatment."

The study was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Zeitler said he had no relevant financial disclosures. However, several of the coauthors did note financial relationships with various pharmaceutical companies, including Daiichi-Sankyo, Merck, Bristol-Meyers-Squibb, Jenny Craig/Nestle, and Medtronic.

The American Lung Association has thrown its weight behind low-dose CT screening of heavy smokers who meet criteria set forth in the National Lung Screening Trial.

The group emphasized that it does not recommend universal screening at this time, and that it believes chest x-rays should not be used for lung cancer screening. It only recommends low-dose computed axial tomography screening – and only for current or past smokers aged 55-74 years, who have smoked at least 30 pack-years and have no history of lung cancer.

"For those who chose to undergo the screening process, smoking cessation should be continuously emphasized as it remains the best method of reducing lung cancer risk," according to an interim report outlining the new guidance.

The document comes from a seven-member Lung Cancer Screening Committee formed to assess the American Lung Association (ALA)’s position in light of the National Lung Screening Trial (NLST) results – the study was the first to show a screening program could reduce lung cancer deaths. The panel’s charge was to review current evidence about lung cancer screening that would, "offer the best possible guidance to the public and those suffering from lung disease."

The NLST randomized subjects at risk of lung cancer to three annual screenings with either low-dose CT or single-view posteroanterior chest x-rays. Investigators reported that low-dose CT was associated with a 20% decrease in mortality compared with chest x-rays. The false positive rate was 96%, however (N. Engl. J. Med. 2011;365:395-409).

Since the results were announced, the National Comprehensive Cancer Network (NCCN) has similarly endorsed screening of high-risk smokers, and the International Association for the Study of Lung Cancer (IASLC) has urged physicians to discuss screening with patients who smoke. Many other groups have yet to take a stand, however.

Although the landmark trial found solid evidence supporting annual screens in the population studied, the ALA noted it also raised many "personal and public health issues": among them, what to do about false positive results, the physical and emotional risks of screening and any resultant invasive procedures, cost implications, and equitable access to the CT procedure. The ALA task force sought to provide some guidance around these questions.

"Our hope is that this report will serve ALA well in its mission to guide the public on this very important personal and public health issue," noted committee chair Dr. Jonathan M Samet, professor and Flora L. Thornton Chair, of the department of preventive medicine at the University of Southern California, Los Angeles, and coauthors.

"We believe that the report and the educational materials that stem from it will be invaluable to the tens of millions of people at risk for lung cancer."

Also among the key points in the interim report are:

• Providers should continue to stress that smoking cessation is the most important way to reduce the risk of lung cancer.

• ALA should produce a patient-focused toolkit that discusses the risks and benefits of screening, including the physical risks of any invasive diagnostic procedure, and the costs – both financial and emotional – of any false-positive result. The toolkit should have information to help patients with chronic lung disease and their health providers to have a detailed discussion about the risks of any subsequent invasive testing.

• Since low-dose CT screening is not currently covered by Medicare or private insurance, it should not be used to recruit patients. Doing so would focus care on financially advantaged patients over financially disadvantaged. Hospitals and screening centers should ethically promote the procedure with full disclosure of the risks, costs, and benefits.

• ALA should "strongly advocate" for screening to be linked to "best practice" multidisciplinary clinical teams that can provide complete follow-up for any positive finding.

The group has also created separate "FAQ" sheets for patients and for physicians to help them discuss screening in an objective, accurate manner.

Dr. Samet said he has no relevant conflicts of interest.

The American Lung Association has thrown its weight behind low-dose CT screening of heavy smokers who meet criteria set forth in the National Lung Screening Trial.

The group emphasized that it does not recommend universal screening at this time, and that it believes chest x-rays should not be used for lung cancer screening. It only recommends low-dose computed axial tomography screening – and only for current or past smokers aged 55-74 years, who have smoked at least 30 pack-years and have no history of lung cancer.

"For those who chose to undergo the screening process, smoking cessation should be continuously emphasized as it remains the best method of reducing lung cancer risk," according to an interim report outlining the new guidance.

The document comes from a seven-member Lung Cancer Screening Committee formed to assess the American Lung Association (ALA)’s position in light of the National Lung Screening Trial (NLST) results – the study was the first to show a screening program could reduce lung cancer deaths. The panel’s charge was to review current evidence about lung cancer screening that would, "offer the best possible guidance to the public and those suffering from lung disease."

The NLST randomized subjects at risk of lung cancer to three annual screenings with either low-dose CT or single-view posteroanterior chest x-rays. Investigators reported that low-dose CT was associated with a 20% decrease in mortality compared with chest x-rays. The false positive rate was 96%, however (N. Engl. J. Med. 2011;365:395-409).

Since the results were announced, the National Comprehensive Cancer Network (NCCN) has similarly endorsed screening of high-risk smokers, and the International Association for the Study of Lung Cancer (IASLC) has urged physicians to discuss screening with patients who smoke. Many other groups have yet to take a stand, however.

Although the landmark trial found solid evidence supporting annual screens in the population studied, the ALA noted it also raised many "personal and public health issues": among them, what to do about false positive results, the physical and emotional risks of screening and any resultant invasive procedures, cost implications, and equitable access to the CT procedure. The ALA task force sought to provide some guidance around these questions.

"Our hope is that this report will serve ALA well in its mission to guide the public on this very important personal and public health issue," noted committee chair Dr. Jonathan M Samet, professor and Flora L. Thornton Chair, of the department of preventive medicine at the University of Southern California, Los Angeles, and coauthors.

"We believe that the report and the educational materials that stem from it will be invaluable to the tens of millions of people at risk for lung cancer."

Also among the key points in the interim report are:

• Providers should continue to stress that smoking cessation is the most important way to reduce the risk of lung cancer.

• ALA should produce a patient-focused toolkit that discusses the risks and benefits of screening, including the physical risks of any invasive diagnostic procedure, and the costs – both financial and emotional – of any false-positive result. The toolkit should have information to help patients with chronic lung disease and their health providers to have a detailed discussion about the risks of any subsequent invasive testing.

• Since low-dose CT screening is not currently covered by Medicare or private insurance, it should not be used to recruit patients. Doing so would focus care on financially advantaged patients over financially disadvantaged. Hospitals and screening centers should ethically promote the procedure with full disclosure of the risks, costs, and benefits.

• ALA should "strongly advocate" for screening to be linked to "best practice" multidisciplinary clinical teams that can provide complete follow-up for any positive finding.

The group has also created separate "FAQ" sheets for patients and for physicians to help them discuss screening in an objective, accurate manner.

Dr. Samet said he has no relevant conflicts of interest.

The American Lung Association has thrown its weight behind low-dose CT screening of heavy smokers who meet criteria set forth in the National Lung Screening Trial.

The group emphasized that it does not recommend universal screening at this time, and that it believes chest x-rays should not be used for lung cancer screening. It only recommends low-dose computed axial tomography screening – and only for current or past smokers aged 55-74 years, who have smoked at least 30 pack-years and have no history of lung cancer.

"For those who chose to undergo the screening process, smoking cessation should be continuously emphasized as it remains the best method of reducing lung cancer risk," according to an interim report outlining the new guidance.

The document comes from a seven-member Lung Cancer Screening Committee formed to assess the American Lung Association (ALA)’s position in light of the National Lung Screening Trial (NLST) results – the study was the first to show a screening program could reduce lung cancer deaths. The panel’s charge was to review current evidence about lung cancer screening that would, "offer the best possible guidance to the public and those suffering from lung disease."

The NLST randomized subjects at risk of lung cancer to three annual screenings with either low-dose CT or single-view posteroanterior chest x-rays. Investigators reported that low-dose CT was associated with a 20% decrease in mortality compared with chest x-rays. The false positive rate was 96%, however (N. Engl. J. Med. 2011;365:395-409).

Since the results were announced, the National Comprehensive Cancer Network (NCCN) has similarly endorsed screening of high-risk smokers, and the International Association for the Study of Lung Cancer (IASLC) has urged physicians to discuss screening with patients who smoke. Many other groups have yet to take a stand, however.

Although the landmark trial found solid evidence supporting annual screens in the population studied, the ALA noted it also raised many "personal and public health issues": among them, what to do about false positive results, the physical and emotional risks of screening and any resultant invasive procedures, cost implications, and equitable access to the CT procedure. The ALA task force sought to provide some guidance around these questions.

"Our hope is that this report will serve ALA well in its mission to guide the public on this very important personal and public health issue," noted committee chair Dr. Jonathan M Samet, professor and Flora L. Thornton Chair, of the department of preventive medicine at the University of Southern California, Los Angeles, and coauthors.

"We believe that the report and the educational materials that stem from it will be invaluable to the tens of millions of people at risk for lung cancer."

Also among the key points in the interim report are:

• Providers should continue to stress that smoking cessation is the most important way to reduce the risk of lung cancer.

• ALA should produce a patient-focused toolkit that discusses the risks and benefits of screening, including the physical risks of any invasive diagnostic procedure, and the costs – both financial and emotional – of any false-positive result. The toolkit should have information to help patients with chronic lung disease and their health providers to have a detailed discussion about the risks of any subsequent invasive testing.

• Since low-dose CT screening is not currently covered by Medicare or private insurance, it should not be used to recruit patients. Doing so would focus care on financially advantaged patients over financially disadvantaged. Hospitals and screening centers should ethically promote the procedure with full disclosure of the risks, costs, and benefits.

• ALA should "strongly advocate" for screening to be linked to "best practice" multidisciplinary clinical teams that can provide complete follow-up for any positive finding.

The group has also created separate "FAQ" sheets for patients and for physicians to help them discuss screening in an objective, accurate manner.

Dr. Samet said he has no relevant conflicts of interest.

Patients with rheumatic disease who take anti-tumor necrosis factor drugs are four times more likely to develop mycobacterial diseases than patients not taking the drugs, and up to 14 times more likely to die from those diseases.

Anti-TNF drugs were associated with significantly increased risks for tuberculosis and nontuberculous mycobacterial disease, Dr. Kevin Winthrop and colleagues reported in the April 20 online edition of the Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2012 April 20 [doi:10.1136/annrheumdis-2011-200690]). Because most of the deaths in their retrospective study occurred in patients with nontubercular mycobacterial (NTM) disease, physicians should consider anti-TNF agents carefully in such patients, they said.

"It is currently unclear if patients with active NTM disease can safely receive anti-TNF therapy," wrote Dr. Winthrop of the Oregon Health and Science University, Portland, and his coauthors. "These cases [in this study] and the reports of others, suggest patients with NTM disease should discontinue anti-TNF therapy."

The investigators extracted their data from a large health care database, identifying 8,418 patients who took anti-TNF medications from 2000-2008. Most of these subjects had a diagnosis of rheumatoid arthritis (61%); 64% were female and 61% white.

There were 16 cases of tuberculosis and 18 cases of NTM that developed after the initiation of therapy. Among the TB cases, 69% (11) were pulmonary and 25% (4) extrapulmonary. Disease location was unknown in one patient. Rheumatoid arthritis was the most common diagnosis in this group (75%; 12 patients); one patient had Crohn’s disease, one had ulcerative colitis, and three had psoriasis. Their median age was 57 years.

Tuberculosis developed a median of 670 days after beginning the drug, but the time of onset varied widely (1-3,181 days). At the time of diagnosis, nine (44%) were taking prednisone and four (25%) were taking methotrexate; most (63%) were taking anti-TNF drugs.

Three patients (19%) died during the study period, with a median time of 74 days between disease onset and death.

Of the NTM cases, 67% (12) were pulmonary and four (22%) extrapulmonary; disease location was unknown in two patients. All of the patents had rheumatoid arthritis. Three (15%) also had psoriasis and two (11%) ankylosing spondylitis. Their median age was 68 years.

The median onset of disease was 1,027 days after beginning therapy (range 77-2,832). At the time of diagnosis nine (50%) were taking prednisone and two (11%) were taking methotrexate; most (83%) were also taking anti-TNF drugs.

Seven of this group (39%) died during the study period, with a median time of 569 days (range 21-2,127 days) between disease onset and death.

Both tuberculosis and NTM were more common in anti-TNF exposed patients than in the general population. In exposed patients, the investigators calculated a rate of 105 NTM cases and 56 tuberculosis cases per 100,000 persons per year, compared to 3 and 4 per 100,000 respectively in the general population. Incidence of both diseases was highest among those taking monoclonal antibodies (123 tuberculosis and 168 NTM cases per 100,000). Etanercept was associated with the lowest incidence – 17 tuberculosis and 35 NTM cases per 100,000.

Compared to non-infected anti-TNF users, those with tuberculosis were less likely to be white and significantly more likely to have diabetes or chronic renal disease. Those with NTM were significantly older, and more likely to be white, have gastroesophageal reflux disease, or chronic lung disease.

All of those with NTM had a diagnosis of rheumatoid arthritis, compared to 60% of uninfected anti-TNF users. NTM patients were four times more likely to have used infliximab than the uninfected group (67% vs. 33%; odds ratio, 4.0).

The investigators also stratified findings by age. In an analysis of patients 50 years and older, they found a significant association between NTM and a rheumatoid arthritis diagnosis. "All seven of the observed NTM case deaths were in this group," they noted. "NTM disease rates were substantially higher in this ... subset."

The finding of more NTM than tuberculosis cases is "not surprising," the authors wrote, "Given the low prevalence of tuberculosis in the U.S. and given that tuberculosis screening guidelines have been well-publicized in the last 5 years, making it likely that tuberculosis cases were averted in our study population."

Nevertheless, the study highlights the importance of identifying risk factors for both diseases in patients taking anti-TNF medications.

"These include chronic renal disease and diabetes mellitus for tuberculosis and chronic lung disease for NTM. These associations are important for physicians to recognize when considering anti-TNF therapy use."

The study was funded by a grant from UCB Pharmaceuticals. Dr. Winthrop has received grant money from the company as advisory board remuneration from Amgen, Genentech, and Oxford Immunotec. Coauthors also reported a number of disclosures, including links to UCB.

Patients with rheumatic disease who take anti-tumor necrosis factor drugs are four times more likely to develop mycobacterial diseases than patients not taking the drugs, and up to 14 times more likely to die from those diseases.

Anti-TNF drugs were associated with significantly increased risks for tuberculosis and nontuberculous mycobacterial disease, Dr. Kevin Winthrop and colleagues reported in the April 20 online edition of the Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2012 April 20 [doi:10.1136/annrheumdis-2011-200690]). Because most of the deaths in their retrospective study occurred in patients with nontubercular mycobacterial (NTM) disease, physicians should consider anti-TNF agents carefully in such patients, they said.

"It is currently unclear if patients with active NTM disease can safely receive anti-TNF therapy," wrote Dr. Winthrop of the Oregon Health and Science University, Portland, and his coauthors. "These cases [in this study] and the reports of others, suggest patients with NTM disease should discontinue anti-TNF therapy."

The investigators extracted their data from a large health care database, identifying 8,418 patients who took anti-TNF medications from 2000-2008. Most of these subjects had a diagnosis of rheumatoid arthritis (61%); 64% were female and 61% white.

There were 16 cases of tuberculosis and 18 cases of NTM that developed after the initiation of therapy. Among the TB cases, 69% (11) were pulmonary and 25% (4) extrapulmonary. Disease location was unknown in one patient. Rheumatoid arthritis was the most common diagnosis in this group (75%; 12 patients); one patient had Crohn’s disease, one had ulcerative colitis, and three had psoriasis. Their median age was 57 years.

Tuberculosis developed a median of 670 days after beginning the drug, but the time of onset varied widely (1-3,181 days). At the time of diagnosis, nine (44%) were taking prednisone and four (25%) were taking methotrexate; most (63%) were taking anti-TNF drugs.

Three patients (19%) died during the study period, with a median time of 74 days between disease onset and death.

Of the NTM cases, 67% (12) were pulmonary and four (22%) extrapulmonary; disease location was unknown in two patients. All of the patents had rheumatoid arthritis. Three (15%) also had psoriasis and two (11%) ankylosing spondylitis. Their median age was 68 years.

The median onset of disease was 1,027 days after beginning therapy (range 77-2,832). At the time of diagnosis nine (50%) were taking prednisone and two (11%) were taking methotrexate; most (83%) were also taking anti-TNF drugs.

Seven of this group (39%) died during the study period, with a median time of 569 days (range 21-2,127 days) between disease onset and death.

Both tuberculosis and NTM were more common in anti-TNF exposed patients than in the general population. In exposed patients, the investigators calculated a rate of 105 NTM cases and 56 tuberculosis cases per 100,000 persons per year, compared to 3 and 4 per 100,000 respectively in the general population. Incidence of both diseases was highest among those taking monoclonal antibodies (123 tuberculosis and 168 NTM cases per 100,000). Etanercept was associated with the lowest incidence – 17 tuberculosis and 35 NTM cases per 100,000.

Compared to non-infected anti-TNF users, those with tuberculosis were less likely to be white and significantly more likely to have diabetes or chronic renal disease. Those with NTM were significantly older, and more likely to be white, have gastroesophageal reflux disease, or chronic lung disease.

All of those with NTM had a diagnosis of rheumatoid arthritis, compared to 60% of uninfected anti-TNF users. NTM patients were four times more likely to have used infliximab than the uninfected group (67% vs. 33%; odds ratio, 4.0).

The investigators also stratified findings by age. In an analysis of patients 50 years and older, they found a significant association between NTM and a rheumatoid arthritis diagnosis. "All seven of the observed NTM case deaths were in this group," they noted. "NTM disease rates were substantially higher in this ... subset."

The finding of more NTM than tuberculosis cases is "not surprising," the authors wrote, "Given the low prevalence of tuberculosis in the U.S. and given that tuberculosis screening guidelines have been well-publicized in the last 5 years, making it likely that tuberculosis cases were averted in our study population."

Nevertheless, the study highlights the importance of identifying risk factors for both diseases in patients taking anti-TNF medications.

"These include chronic renal disease and diabetes mellitus for tuberculosis and chronic lung disease for NTM. These associations are important for physicians to recognize when considering anti-TNF therapy use."

The study was funded by a grant from UCB Pharmaceuticals. Dr. Winthrop has received grant money from the company as advisory board remuneration from Amgen, Genentech, and Oxford Immunotec. Coauthors also reported a number of disclosures, including links to UCB.

Patients with rheumatic disease who take anti-tumor necrosis factor drugs are four times more likely to develop mycobacterial diseases than patients not taking the drugs, and up to 14 times more likely to die from those diseases.

Anti-TNF drugs were associated with significantly increased risks for tuberculosis and nontuberculous mycobacterial disease, Dr. Kevin Winthrop and colleagues reported in the April 20 online edition of the Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2012 April 20 [doi:10.1136/annrheumdis-2011-200690]). Because most of the deaths in their retrospective study occurred in patients with nontubercular mycobacterial (NTM) disease, physicians should consider anti-TNF agents carefully in such patients, they said.

"It is currently unclear if patients with active NTM disease can safely receive anti-TNF therapy," wrote Dr. Winthrop of the Oregon Health and Science University, Portland, and his coauthors. "These cases [in this study] and the reports of others, suggest patients with NTM disease should discontinue anti-TNF therapy."

The investigators extracted their data from a large health care database, identifying 8,418 patients who took anti-TNF medications from 2000-2008. Most of these subjects had a diagnosis of rheumatoid arthritis (61%); 64% were female and 61% white.

There were 16 cases of tuberculosis and 18 cases of NTM that developed after the initiation of therapy. Among the TB cases, 69% (11) were pulmonary and 25% (4) extrapulmonary. Disease location was unknown in one patient. Rheumatoid arthritis was the most common diagnosis in this group (75%; 12 patients); one patient had Crohn’s disease, one had ulcerative colitis, and three had psoriasis. Their median age was 57 years.

Tuberculosis developed a median of 670 days after beginning the drug, but the time of onset varied widely (1-3,181 days). At the time of diagnosis, nine (44%) were taking prednisone and four (25%) were taking methotrexate; most (63%) were taking anti-TNF drugs.

Three patients (19%) died during the study period, with a median time of 74 days between disease onset and death.

Of the NTM cases, 67% (12) were pulmonary and four (22%) extrapulmonary; disease location was unknown in two patients. All of the patents had rheumatoid arthritis. Three (15%) also had psoriasis and two (11%) ankylosing spondylitis. Their median age was 68 years.

The median onset of disease was 1,027 days after beginning therapy (range 77-2,832). At the time of diagnosis nine (50%) were taking prednisone and two (11%) were taking methotrexate; most (83%) were also taking anti-TNF drugs.

Seven of this group (39%) died during the study period, with a median time of 569 days (range 21-2,127 days) between disease onset and death.

Both tuberculosis and NTM were more common in anti-TNF exposed patients than in the general population. In exposed patients, the investigators calculated a rate of 105 NTM cases and 56 tuberculosis cases per 100,000 persons per year, compared to 3 and 4 per 100,000 respectively in the general population. Incidence of both diseases was highest among those taking monoclonal antibodies (123 tuberculosis and 168 NTM cases per 100,000). Etanercept was associated with the lowest incidence – 17 tuberculosis and 35 NTM cases per 100,000.

Compared to non-infected anti-TNF users, those with tuberculosis were less likely to be white and significantly more likely to have diabetes or chronic renal disease. Those with NTM were significantly older, and more likely to be white, have gastroesophageal reflux disease, or chronic lung disease.

All of those with NTM had a diagnosis of rheumatoid arthritis, compared to 60% of uninfected anti-TNF users. NTM patients were four times more likely to have used infliximab than the uninfected group (67% vs. 33%; odds ratio, 4.0).

The investigators also stratified findings by age. In an analysis of patients 50 years and older, they found a significant association between NTM and a rheumatoid arthritis diagnosis. "All seven of the observed NTM case deaths were in this group," they noted. "NTM disease rates were substantially higher in this ... subset."

The finding of more NTM than tuberculosis cases is "not surprising," the authors wrote, "Given the low prevalence of tuberculosis in the U.S. and given that tuberculosis screening guidelines have been well-publicized in the last 5 years, making it likely that tuberculosis cases were averted in our study population."

Nevertheless, the study highlights the importance of identifying risk factors for both diseases in patients taking anti-TNF medications.

"These include chronic renal disease and diabetes mellitus for tuberculosis and chronic lung disease for NTM. These associations are important for physicians to recognize when considering anti-TNF therapy use."

The study was funded by a grant from UCB Pharmaceuticals. Dr. Winthrop has received grant money from the company as advisory board remuneration from Amgen, Genentech, and Oxford Immunotec. Coauthors also reported a number of disclosures, including links to UCB.

Results from new studies of the investigational imaging agents florbetaben and flutemetamol indicate that they may help to support a diagnosis of Alzheimer’s disease or rule it out, with the potential to improve both clinical management and research.

Comparisons of the radioactive imaging agents against the diagnostic standard of histopathology at autopsy in two studies, as well as against the results of brain biopsy in another, showed that the compounds have high sensitivity and specificity for detecting the presence of beta-amyloid plaques.

In a phase III trial, 204 patients from Japan, Australia, France, and the United States underwent PET imaging with florbetaben. The study group included 194 individuals with dementia and 10 healthy volunteers. All of the participants were near the end of life.

Patients underwent both MR and PET imaging 90-110 minutes after an intravenous infusion of florbetaben. The investigators coregistered the MRI and PET scans to more precisely track beta-amyloid deposits in each of the brain regions examined – the first time such a technique has been employed in amyloid imaging studies, said Dr. Marwan N. Sabbagh, lead author and the director of Banner Sun Health Research Institute in Sun City, Ariz.

The investigators then compared the imaging results with postmortem findings in 31 of the patients whose brains came to autopsy, for a total of 186 brain regions. They analyzed another 60 regions from the 10 participants without dementia whose brains also were autopsied. Three readers who analyzed the imaging data and three neuropathologists who scored the autopsy results were blinded to all clinical and autopsy data. They evaluated the presence of beta-amyloid plaques in six prespecified brain regions.

In the six brain regions, florbetaben detected beta-amyloid with an overall sensitivity of 77% and a specificity of 94%. Visual scoring of the entire brain for the presence of beta-amyloid plaques concurred with the autopsy results with 100% sensitivity and 92% specificity.

The inter-reader agreement for the presence of beta-amyloid plaques on imaging within each brain "was almost perfect, with a kappa value of 0.88," said one of the coauthors of the study, Dr. Cornelia Reininger, global clinical leader of the florbetaben development program at Bayer Pharma AG, in an interview. "This is important because a robust and reliable method for assessing the PET scans is also a prerequisite for approval of tracers of this type."

"These results confirm that florbetaben is able to detect beta-amyloid plaques in the brain during life with great accuracy and is a suitable biomarker," Dr. Sabbagh said in a written statement. "This is an easy, non-invasive way to assist an Alzheimer’s diagnosis at an early stage. Also exciting is the possibility of using florbetaben as tool in future therapeutic clinical research studies where therapy goals focus on reducing levels of beta-amyloid in the brain.

With a half-life of 10 hours, florbetaben could be much more clinically useful than the first amyloid imaging agent developed, Pittsburgh Compound B, which has a 20-minute half-life, making it much more difficult to obtain quality images in anything but a research setting.

(Bayer recently sold the rights to florbetaben and other in vivo imaging agents to Piramal Imaging SA, based in India. Piramal said it will seek Food and Drug Administration approval for florbetaben by the end of the year.)

Two separate studies of flutemetamol suggest that the drug not only binds strongly to beta-amyloid plaques, but that such binding also correlates with cognitive status.

Dr. David Wolk, assistant director of the Penn Memory Center at the University of Pennsylvania, Philadelphia, and his colleagues analyzed the results of flutemetamol PET imaging in 180 patients who were near the end of life and 49 patients who had a presumed diagnosis of normal pressure hydrocephalus (NPH).

NPH is a form of dementia characterized by enlarged cerebral ventricles, a specific gait imbalance, and urinary incontinence, Dr. Wolk said in an interview. "It also turns out that a significant proportion of these patients seem to have evidence of concomitant Alzheimer’s pathology. It’s thought that these are either coexistent diagnoses or that the NPH was an incorrect diagnosis and the patient actually has Alzheimer’s."

Placement of a cerebrospinal fluid shunt into a brain ventricle is the typical NPH treatment and, in true cases, can actually reverse some of the symptoms. Many neurosurgeons who perform the procedure take a biopsy of the tissue removed, and it was these samples that allowed Dr. Wolk and his associates to conduct their study.

In patients with suspected NPH, the investigators compared biopsy histopathology to PET scans of flutemetamol beta-amyloid binding. For the 69 end-of-life subjects who eventually came to autopsy, the investigators compared brain histopathology with the results of imaging.

Compared against autopsy results, five readers of the PET scans who were blinded to clinical data reported an overall sensitivity and specificity of 86% and 92%, respectively. In comparison against biopsy, the sensitivity and specificity of flutemetamol imaging by three separate readers who were blinded to clinical data were 93% and 100%.

The results not only confirm flutemetamol’s proclivity for beta-amyloid plaques, but also suggest the possibility that imaging could someday improve diagnostic accuracy and help pinpoint treatment decisions.

"In a prior study, we found that people with NPH and concomitant Alzheimer’s have a poor response to shunting," Dr. Wolk said. "If a patient gets a shunt and doesn’t get better, we typically do another shunt. But in someone who also has Alzheimer’s, we would be less inclined to do another procedure."

In a separate study of 11 community-dwelling older adults, Dustin Hammers, Ph.D., and his colleagues compared the relationship between flutemetamol uptake and cognitive status. All of the participants (eight women and three men with a mean age of 76 years) had a prior complaint of memory loss.

In these subjects, flutemetamol uptake was significantly related to several cognitive domains, including auditory delayed memory, processing speed, mental flexibility, and semantic fluency. Cognitive performance worsened with greater uptake of flutemetamol.

"Flutemetamol uptake was highly related to worse cognitive performance on tasks traditionally impaired in patients with Alzheimer’s disease, but not in others," said Dr. Hammers, a neuropsychologist at the University of Utah’s Center for Alzheimer’s Care, Imaging, and Research in Salt Lake City.

"What we found really interesting is that this was a population of normal, elderly adults who had no cognitive problems except for a prior complaint of some memory issue," he said in an interview. "The results clearly fall in the direction of what we would expect to see in Alzheimer’s, although clearly they were in a preclinical state."

The florbetaben study was sponsored by Bayer Pharma AG. Dr. Sabbagh said that he had no financial disclosures. Dr. Wolk’s study was sponsored by GE Healthcare. He has received personal compensation from the company for consulting activities. GE Healthcare partly sponsored Dr. Hammer’s study. Dr. Hammer had no financial disclosures.

Results from new studies of the investigational imaging agents florbetaben and flutemetamol indicate that they may help to support a diagnosis of Alzheimer’s disease or rule it out, with the potential to improve both clinical management and research.

Comparisons of the radioactive imaging agents against the diagnostic standard of histopathology at autopsy in two studies, as well as against the results of brain biopsy in another, showed that the compounds have high sensitivity and specificity for detecting the presence of beta-amyloid plaques.

In a phase III trial, 204 patients from Japan, Australia, France, and the United States underwent PET imaging with florbetaben. The study group included 194 individuals with dementia and 10 healthy volunteers. All of the participants were near the end of life.

Patients underwent both MR and PET imaging 90-110 minutes after an intravenous infusion of florbetaben. The investigators coregistered the MRI and PET scans to more precisely track beta-amyloid deposits in each of the brain regions examined – the first time such a technique has been employed in amyloid imaging studies, said Dr. Marwan N. Sabbagh, lead author and the director of Banner Sun Health Research Institute in Sun City, Ariz.

The investigators then compared the imaging results with postmortem findings in 31 of the patients whose brains came to autopsy, for a total of 186 brain regions. They analyzed another 60 regions from the 10 participants without dementia whose brains also were autopsied. Three readers who analyzed the imaging data and three neuropathologists who scored the autopsy results were blinded to all clinical and autopsy data. They evaluated the presence of beta-amyloid plaques in six prespecified brain regions.

In the six brain regions, florbetaben detected beta-amyloid with an overall sensitivity of 77% and a specificity of 94%. Visual scoring of the entire brain for the presence of beta-amyloid plaques concurred with the autopsy results with 100% sensitivity and 92% specificity.

The inter-reader agreement for the presence of beta-amyloid plaques on imaging within each brain "was almost perfect, with a kappa value of 0.88," said one of the coauthors of the study, Dr. Cornelia Reininger, global clinical leader of the florbetaben development program at Bayer Pharma AG, in an interview. "This is important because a robust and reliable method for assessing the PET scans is also a prerequisite for approval of tracers of this type."

"These results confirm that florbetaben is able to detect beta-amyloid plaques in the brain during life with great accuracy and is a suitable biomarker," Dr. Sabbagh said in a written statement. "This is an easy, non-invasive way to assist an Alzheimer’s diagnosis at an early stage. Also exciting is the possibility of using florbetaben as tool in future therapeutic clinical research studies where therapy goals focus on reducing levels of beta-amyloid in the brain.

With a half-life of 10 hours, florbetaben could be much more clinically useful than the first amyloid imaging agent developed, Pittsburgh Compound B, which has a 20-minute half-life, making it much more difficult to obtain quality images in anything but a research setting.

(Bayer recently sold the rights to florbetaben and other in vivo imaging agents to Piramal Imaging SA, based in India. Piramal said it will seek Food and Drug Administration approval for florbetaben by the end of the year.)

Two separate studies of flutemetamol suggest that the drug not only binds strongly to beta-amyloid plaques, but that such binding also correlates with cognitive status.

Dr. David Wolk, assistant director of the Penn Memory Center at the University of Pennsylvania, Philadelphia, and his colleagues analyzed the results of flutemetamol PET imaging in 180 patients who were near the end of life and 49 patients who had a presumed diagnosis of normal pressure hydrocephalus (NPH).

NPH is a form of dementia characterized by enlarged cerebral ventricles, a specific gait imbalance, and urinary incontinence, Dr. Wolk said in an interview. "It also turns out that a significant proportion of these patients seem to have evidence of concomitant Alzheimer’s pathology. It’s thought that these are either coexistent diagnoses or that the NPH was an incorrect diagnosis and the patient actually has Alzheimer’s."

Placement of a cerebrospinal fluid shunt into a brain ventricle is the typical NPH treatment and, in true cases, can actually reverse some of the symptoms. Many neurosurgeons who perform the procedure take a biopsy of the tissue removed, and it was these samples that allowed Dr. Wolk and his associates to conduct their study.

In patients with suspected NPH, the investigators compared biopsy histopathology to PET scans of flutemetamol beta-amyloid binding. For the 69 end-of-life subjects who eventually came to autopsy, the investigators compared brain histopathology with the results of imaging.

Compared against autopsy results, five readers of the PET scans who were blinded to clinical data reported an overall sensitivity and specificity of 86% and 92%, respectively. In comparison against biopsy, the sensitivity and specificity of flutemetamol imaging by three separate readers who were blinded to clinical data were 93% and 100%.

The results not only confirm flutemetamol’s proclivity for beta-amyloid plaques, but also suggest the possibility that imaging could someday improve diagnostic accuracy and help pinpoint treatment decisions.

"In a prior study, we found that people with NPH and concomitant Alzheimer’s have a poor response to shunting," Dr. Wolk said. "If a patient gets a shunt and doesn’t get better, we typically do another shunt. But in someone who also has Alzheimer’s, we would be less inclined to do another procedure."

In a separate study of 11 community-dwelling older adults, Dustin Hammers, Ph.D., and his colleagues compared the relationship between flutemetamol uptake and cognitive status. All of the participants (eight women and three men with a mean age of 76 years) had a prior complaint of memory loss.

In these subjects, flutemetamol uptake was significantly related to several cognitive domains, including auditory delayed memory, processing speed, mental flexibility, and semantic fluency. Cognitive performance worsened with greater uptake of flutemetamol.

"Flutemetamol uptake was highly related to worse cognitive performance on tasks traditionally impaired in patients with Alzheimer’s disease, but not in others," said Dr. Hammers, a neuropsychologist at the University of Utah’s Center for Alzheimer’s Care, Imaging, and Research in Salt Lake City.

"What we found really interesting is that this was a population of normal, elderly adults who had no cognitive problems except for a prior complaint of some memory issue," he said in an interview. "The results clearly fall in the direction of what we would expect to see in Alzheimer’s, although clearly they were in a preclinical state."

The florbetaben study was sponsored by Bayer Pharma AG. Dr. Sabbagh said that he had no financial disclosures. Dr. Wolk’s study was sponsored by GE Healthcare. He has received personal compensation from the company for consulting activities. GE Healthcare partly sponsored Dr. Hammer’s study. Dr. Hammer had no financial disclosures.

Results from new studies of the investigational imaging agents florbetaben and flutemetamol indicate that they may help to support a diagnosis of Alzheimer’s disease or rule it out, with the potential to improve both clinical management and research.

Comparisons of the radioactive imaging agents against the diagnostic standard of histopathology at autopsy in two studies, as well as against the results of brain biopsy in another, showed that the compounds have high sensitivity and specificity for detecting the presence of beta-amyloid plaques.

In a phase III trial, 204 patients from Japan, Australia, France, and the United States underwent PET imaging with florbetaben. The study group included 194 individuals with dementia and 10 healthy volunteers. All of the participants were near the end of life.

Patients underwent both MR and PET imaging 90-110 minutes after an intravenous infusion of florbetaben. The investigators coregistered the MRI and PET scans to more precisely track beta-amyloid deposits in each of the brain regions examined – the first time such a technique has been employed in amyloid imaging studies, said Dr. Marwan N. Sabbagh, lead author and the director of Banner Sun Health Research Institute in Sun City, Ariz.

The investigators then compared the imaging results with postmortem findings in 31 of the patients whose brains came to autopsy, for a total of 186 brain regions. They analyzed another 60 regions from the 10 participants without dementia whose brains also were autopsied. Three readers who analyzed the imaging data and three neuropathologists who scored the autopsy results were blinded to all clinical and autopsy data. They evaluated the presence of beta-amyloid plaques in six prespecified brain regions.

In the six brain regions, florbetaben detected beta-amyloid with an overall sensitivity of 77% and a specificity of 94%. Visual scoring of the entire brain for the presence of beta-amyloid plaques concurred with the autopsy results with 100% sensitivity and 92% specificity.

The inter-reader agreement for the presence of beta-amyloid plaques on imaging within each brain "was almost perfect, with a kappa value of 0.88," said one of the coauthors of the study, Dr. Cornelia Reininger, global clinical leader of the florbetaben development program at Bayer Pharma AG, in an interview. "This is important because a robust and reliable method for assessing the PET scans is also a prerequisite for approval of tracers of this type."

"These results confirm that florbetaben is able to detect beta-amyloid plaques in the brain during life with great accuracy and is a suitable biomarker," Dr. Sabbagh said in a written statement. "This is an easy, non-invasive way to assist an Alzheimer’s diagnosis at an early stage. Also exciting is the possibility of using florbetaben as tool in future therapeutic clinical research studies where therapy goals focus on reducing levels of beta-amyloid in the brain.

With a half-life of 10 hours, florbetaben could be much more clinically useful than the first amyloid imaging agent developed, Pittsburgh Compound B, which has a 20-minute half-life, making it much more difficult to obtain quality images in anything but a research setting.

(Bayer recently sold the rights to florbetaben and other in vivo imaging agents to Piramal Imaging SA, based in India. Piramal said it will seek Food and Drug Administration approval for florbetaben by the end of the year.)

Two separate studies of flutemetamol suggest that the drug not only binds strongly to beta-amyloid plaques, but that such binding also correlates with cognitive status.

Dr. David Wolk, assistant director of the Penn Memory Center at the University of Pennsylvania, Philadelphia, and his colleagues analyzed the results of flutemetamol PET imaging in 180 patients who were near the end of life and 49 patients who had a presumed diagnosis of normal pressure hydrocephalus (NPH).

NPH is a form of dementia characterized by enlarged cerebral ventricles, a specific gait imbalance, and urinary incontinence, Dr. Wolk said in an interview. "It also turns out that a significant proportion of these patients seem to have evidence of concomitant Alzheimer’s pathology. It’s thought that these are either coexistent diagnoses or that the NPH was an incorrect diagnosis and the patient actually has Alzheimer’s."

Placement of a cerebrospinal fluid shunt into a brain ventricle is the typical NPH treatment and, in true cases, can actually reverse some of the symptoms. Many neurosurgeons who perform the procedure take a biopsy of the tissue removed, and it was these samples that allowed Dr. Wolk and his associates to conduct their study.

In patients with suspected NPH, the investigators compared biopsy histopathology to PET scans of flutemetamol beta-amyloid binding. For the 69 end-of-life subjects who eventually came to autopsy, the investigators compared brain histopathology with the results of imaging.

Compared against autopsy results, five readers of the PET scans who were blinded to clinical data reported an overall sensitivity and specificity of 86% and 92%, respectively. In comparison against biopsy, the sensitivity and specificity of flutemetamol imaging by three separate readers who were blinded to clinical data were 93% and 100%.

The results not only confirm flutemetamol’s proclivity for beta-amyloid plaques, but also suggest the possibility that imaging could someday improve diagnostic accuracy and help pinpoint treatment decisions.

"In a prior study, we found that people with NPH and concomitant Alzheimer’s have a poor response to shunting," Dr. Wolk said. "If a patient gets a shunt and doesn’t get better, we typically do another shunt. But in someone who also has Alzheimer’s, we would be less inclined to do another procedure."

In a separate study of 11 community-dwelling older adults, Dustin Hammers, Ph.D., and his colleagues compared the relationship between flutemetamol uptake and cognitive status. All of the participants (eight women and three men with a mean age of 76 years) had a prior complaint of memory loss.

In these subjects, flutemetamol uptake was significantly related to several cognitive domains, including auditory delayed memory, processing speed, mental flexibility, and semantic fluency. Cognitive performance worsened with greater uptake of flutemetamol.

"Flutemetamol uptake was highly related to worse cognitive performance on tasks traditionally impaired in patients with Alzheimer’s disease, but not in others," said Dr. Hammers, a neuropsychologist at the University of Utah’s Center for Alzheimer’s Care, Imaging, and Research in Salt Lake City.

"What we found really interesting is that this was a population of normal, elderly adults who had no cognitive problems except for a prior complaint of some memory issue," he said in an interview. "The results clearly fall in the direction of what we would expect to see in Alzheimer’s, although clearly they were in a preclinical state."

The florbetaben study was sponsored by Bayer Pharma AG. Dr. Sabbagh said that he had no financial disclosures. Dr. Wolk’s study was sponsored by GE Healthcare. He has received personal compensation from the company for consulting activities. GE Healthcare partly sponsored Dr. Hammer’s study. Dr. Hammer had no financial disclosures.

When a child with autism arrives at the emergency department, the approach to care should be as individualized as the treatment itself.

The ED itself is almost a caricature of everything that can tip the delicate behavioral balance for children on the autism spectrum: bright lights, loud noises, and scurrying strangers who want to get close with dangerous-looking implements. Combine that sensory onslaught with the pain of an injury or illness, and the result can be a bomb that threatens the child’s optimal care at least, and the safety of staff at worst.

"When you are caring for a child with autism, you are a stranger in a strange land," said Dr. Thomas Chun, an emergency physician at the Hasbro Children’s Hospital, Providence, R.I. "You don’t know who you are to them, or who they are, or where they are," on the autism spectrum.

A core trait of autism is hypo- or hyperreactivity to stimuli, according to Dr. Joseph Horrigan, a child psychiatrist who is head of medical research for the advocacy group, Autism Speaks. "The hyperreactivity can be really challenging for many children with autism and their medical caregivers. In conjunction with this, it’s not at all unusual for these children to have anxiety, so there is a very low threshold for catastrophic stress responses, particularly if there is some sort of intellectual disability, or no decent method of communication."

Absence of social reciprocity is another unifying characteristic of autism, Dr. Chun said at a meeting sponsored by the American College of Emergency Physicians. But that characteristic can be expressed in a multitude of ways, from completely withdrawn and silent, to parroting adult speech, to full-blown violence. "It’s an incredibly wide spectrum, and in order to help that child, you need to know" where he or she falls on that spectrum. In this maze, the parents should be your most-trusted guides, he said.

"They have been dealing with this the child’s entire life. They know what calms and bothers him. They know the cognitive level, the best ways to communicate, what scares and how to soothe. It’s always worthwhile to take the time to ask them how they think their child will react to the situation."

In a perfect world, parents will have incorporated desensitization into their teaching about how a doctor’s or dentist’s visit will go. But as emergency physicians know all too well, the world is far from perfect. And when an emergency arises, there’s usually little time for parents to rehearse a trip to the ED – which means the physician is responsible for at least some destressing.

"Systematic desensitization can be very helpful here. Walk in, say hi, talk to the parents, and then walk out for a while. Let the parents play with the stethoscope and have them introduce it to the child," Dr. Chun advised. Although this approach takes some time, that delay could be nothing compared with the time consumed by a full-blown encounter with a stressed-out, uncooperative child. "I’m betting that a lot of the things we spend time on actually decrease time spent with that patient in the long run."

Interventions like these work best if everyone in the ED is on the same page, Dr. Chun said. His hospital instituted a 16-hour training program designed to decrease the need for patient restraint, and the injuries incurred during restraint. The program helped prevent or minimize incidents by teaching de-escalation techniques and avoidance of power struggles; it also included a debriefing component. In the year after implementing the program, the hospital saw an 83% decrease in patient injury due to restraint.

Practically Speaking

It’s one thing to intellectualize what interventions should look like, and entirely another to put them into action. Fortunately, said Dr. Horrigan, many of the more useful modifications are both easy and inexpensive.

Because overstimulation is a key component in troublesome interactions, one easy and very effective intervention is simply to reduce it, Dr. Horrigan said.

"Simply find a quiet place" to examine and treat the child in the parents’ company, he said in an interview. "A bay with a curtain in the ED is really not a good fit for a child with autism."

"When you are caring for a child with autism, you are a stranger in a strange land."

A private exam room is optimal; facilities that don’t have that luxury can make good use of a quiet family waiting room. Dim the ambient lighting, he said, and use a procedure lamp instead of glaring overhead fixtures.

Dr. Chun said some children enjoy the feeling of pressure all around their bodies. A weighted blanket is one way to achieve this, but a radiologist’s apron or a beanbag chair can be just as effective. If the child brings in a beloved toy or blanket from home, keep it close at hand to take full advantage of its soothing properties.

"Some children like light pressure," Dr. Chun noted. "For these, an electric foot massager or even a paint roller can be a good idea. Some like rocking, so we have a rocking chair with a small weighted blanket."

Say What?

Communication deficit is a universal manifestation of autism spectrum disorders. Children with autism tend to think in pictures or symbols rather than words. Many make use of adaptive communication tools at home, and it’s a good idea to have a few types of these in the ED.

A picture book with images of hospital personnel and procedures can be very helpful. An effective and virtually free method is to take photographs of the treatment bays, medical tools, and people with whom the child might interact; showing the child these is a good way to help her understand what to expect, Dr. Chun said.

"Go through the ED and take a bunch of pictures, laminate them, and you have an instant communication system. You can prepare a child for almost any procedure this way."

Even if there isn’t much reciprocal communication, most children with autism are taking in spoken language, so be sure to talk them through their experience, giving them descriptions of medical tools and devices, how they’re going to be used, and what procedures might feel like.

Pragmatic Procedures

Trust is the basis for any successful medical treatment, but trust is something children with autism don’t readily give, said Dr. Alan Rosenblatt, a neurodevelopmental pediatrician practicing in Skokie, Ill.

"Some of this will have to be done at a distance because some of these children don’t want to be touched by strangers," he said in an interview. "Only after a certain level of trust is established can that be done. You must be very careful about intruding too quickly and too intensely into the child’s personal space."

Fingers and toes are a good place to start the exam, he said. "That’s one of the tricks I use. I start at the periphery – away from the trunk and face – and slowly move more centrally so that they’re not overwhelmed all at once. Even with this approach, certain kids are so overwhelmed by anxiety that there is going to be resistance when you touch any part of them."

Drawing blood can be particularly troublesome. The Autism Treatment Network, part of Autism Speaks, offers a free guide to effective phlebotomy technique in children with autism. The pamphlet briefly explains how distraction, relaxation, and picture communication can improve results for everyone involved.

(The publication is available online.)

The Center for Autism and Related Disabilities, an autism support center affiliated with the University of Miami, also provides a "tip pamphlet" for EDs. "Autism and the Hospital Emergency Room" includes background information on autism, as well as lots of practical tips on making an ED more "autism friendly," Dr. Horrigan said.

Managing Medications

Children with autism don’t always react predictably to medications, especially anesthetics and psychotropic drugs, Dr. Horrigan said.

"A bay with a curtain in the ED is really not a good fit for a child with autism."

The small-dose benzodiazepine that might help a normally developing child relax could send an autistic child over the edge. "These individuals can have unique, idiosyncratic responses to medicines. Some of the medications a ‘normal’ child would get could provoke serious adverse reactions in a child with autism – especially a younger child."

Topical anesthetics, if appropriate, are usually a better choice for these children. Systemic medications must be handled very carefully – even antihistamines can provoke serious agitation and even violence.

On the other hand, some children with autism are so withdrawn that they may not express anxiety or pain, he said. But this doesn’t mean forgoing medication on the assumption that withholding it might actually be less stressful than giving it.

"Medications can and should be used in the same way as they are used on anyone else, to improve comfort and alleviate distress," Dr. Horrigan said. "But we must be thoughtful about the drug selection and dose. It requires a more sophisticated approach."

Generally, the rule should be to start with a lower test dose than usual, observe its effect and any reactions, and then increase the dose. Again, the parent is the provider’s best guide. "It’s critical to get as much medical history as possible about any past adverse reaction," he said.

For very agitated children, an atypical antipsychotic may be helpful. Risperidone and aripiprazole are the only two approved for use in children with autism spectrum disorders. Both are available in oral dissolvable tablets.

Oral ketamine – alone or in conjunction with midazolam – is a possibility for the combative child, Dr. Chun noted. "It’s not evidence based, but some say that it should be a first-line drug," for these cases.

A Matter of Time

Autism is on the rise in the United States, according to a new report from the Centers for Disease Control and Prevention (MMWR 2012;61[SS-3]:1-19). The report estimated a 78% increase in cases from 2002-2008. The report suggests that one in every 88 children has some form of autism spectrum disorder.

"Emergency physicians are going to be seeing more and more children with autism. That is a fact. This is not a rare disorder we’re talking about. It’s out there, the prevalence is growing, and you’re going to see it" in the emergency department, Dr. Horrigan said.

None of the physicians interviewed for this article reported any relevant financial conflicts.

When a child with autism arrives at the emergency department, the approach to care should be as individualized as the treatment itself.

The ED itself is almost a caricature of everything that can tip the delicate behavioral balance for children on the autism spectrum: bright lights, loud noises, and scurrying strangers who want to get close with dangerous-looking implements. Combine that sensory onslaught with the pain of an injury or illness, and the result can be a bomb that threatens the child’s optimal care at least, and the safety of staff at worst.

"When you are caring for a child with autism, you are a stranger in a strange land," said Dr. Thomas Chun, an emergency physician at the Hasbro Children’s Hospital, Providence, R.I. "You don’t know who you are to them, or who they are, or where they are," on the autism spectrum.

A core trait of autism is hypo- or hyperreactivity to stimuli, according to Dr. Joseph Horrigan, a child psychiatrist who is head of medical research for the advocacy group, Autism Speaks. "The hyperreactivity can be really challenging for many children with autism and their medical caregivers. In conjunction with this, it’s not at all unusual for these children to have anxiety, so there is a very low threshold for catastrophic stress responses, particularly if there is some sort of intellectual disability, or no decent method of communication."

Absence of social reciprocity is another unifying characteristic of autism, Dr. Chun said at a meeting sponsored by the American College of Emergency Physicians. But that characteristic can be expressed in a multitude of ways, from completely withdrawn and silent, to parroting adult speech, to full-blown violence. "It’s an incredibly wide spectrum, and in order to help that child, you need to know" where he or she falls on that spectrum. In this maze, the parents should be your most-trusted guides, he said.

"They have been dealing with this the child’s entire life. They know what calms and bothers him. They know the cognitive level, the best ways to communicate, what scares and how to soothe. It’s always worthwhile to take the time to ask them how they think their child will react to the situation."

In a perfect world, parents will have incorporated desensitization into their teaching about how a doctor’s or dentist’s visit will go. But as emergency physicians know all too well, the world is far from perfect. And when an emergency arises, there’s usually little time for parents to rehearse a trip to the ED – which means the physician is responsible for at least some destressing.

"Systematic desensitization can be very helpful here. Walk in, say hi, talk to the parents, and then walk out for a while. Let the parents play with the stethoscope and have them introduce it to the child," Dr. Chun advised. Although this approach takes some time, that delay could be nothing compared with the time consumed by a full-blown encounter with a stressed-out, uncooperative child. "I’m betting that a lot of the things we spend time on actually decrease time spent with that patient in the long run."

Interventions like these work best if everyone in the ED is on the same page, Dr. Chun said. His hospital instituted a 16-hour training program designed to decrease the need for patient restraint, and the injuries incurred during restraint. The program helped prevent or minimize incidents by teaching de-escalation techniques and avoidance of power struggles; it also included a debriefing component. In the year after implementing the program, the hospital saw an 83% decrease in patient injury due to restraint.

Practically Speaking

It’s one thing to intellectualize what interventions should look like, and entirely another to put them into action. Fortunately, said Dr. Horrigan, many of the more useful modifications are both easy and inexpensive.

Because overstimulation is a key component in troublesome interactions, one easy and very effective intervention is simply to reduce it, Dr. Horrigan said.

"Simply find a quiet place" to examine and treat the child in the parents’ company, he said in an interview. "A bay with a curtain in the ED is really not a good fit for a child with autism."

"When you are caring for a child with autism, you are a stranger in a strange land."

A private exam room is optimal; facilities that don’t have that luxury can make good use of a quiet family waiting room. Dim the ambient lighting, he said, and use a procedure lamp instead of glaring overhead fixtures.

Dr. Chun said some children enjoy the feeling of pressure all around their bodies. A weighted blanket is one way to achieve this, but a radiologist’s apron or a beanbag chair can be just as effective. If the child brings in a beloved toy or blanket from home, keep it close at hand to take full advantage of its soothing properties.

"Some children like light pressure," Dr. Chun noted. "For these, an electric foot massager or even a paint roller can be a good idea. Some like rocking, so we have a rocking chair with a small weighted blanket."

Say What?

Communication deficit is a universal manifestation of autism spectrum disorders. Children with autism tend to think in pictures or symbols rather than words. Many make use of adaptive communication tools at home, and it’s a good idea to have a few types of these in the ED.

A picture book with images of hospital personnel and procedures can be very helpful. An effective and virtually free method is to take photographs of the treatment bays, medical tools, and people with whom the child might interact; showing the child these is a good way to help her understand what to expect, Dr. Chun said.

"Go through the ED and take a bunch of pictures, laminate them, and you have an instant communication system. You can prepare a child for almost any procedure this way."

Even if there isn’t much reciprocal communication, most children with autism are taking in spoken language, so be sure to talk them through their experience, giving them descriptions of medical tools and devices, how they’re going to be used, and what procedures might feel like.

Pragmatic Procedures

Trust is the basis for any successful medical treatment, but trust is something children with autism don’t readily give, said Dr. Alan Rosenblatt, a neurodevelopmental pediatrician practicing in Skokie, Ill.

"Some of this will have to be done at a distance because some of these children don’t want to be touched by strangers," he said in an interview. "Only after a certain level of trust is established can that be done. You must be very careful about intruding too quickly and too intensely into the child’s personal space."

Fingers and toes are a good place to start the exam, he said. "That’s one of the tricks I use. I start at the periphery – away from the trunk and face – and slowly move more centrally so that they’re not overwhelmed all at once. Even with this approach, certain kids are so overwhelmed by anxiety that there is going to be resistance when you touch any part of them."

Drawing blood can be particularly troublesome. The Autism Treatment Network, part of Autism Speaks, offers a free guide to effective phlebotomy technique in children with autism. The pamphlet briefly explains how distraction, relaxation, and picture communication can improve results for everyone involved.

(The publication is available online.)

The Center for Autism and Related Disabilities, an autism support center affiliated with the University of Miami, also provides a "tip pamphlet" for EDs. "Autism and the Hospital Emergency Room" includes background information on autism, as well as lots of practical tips on making an ED more "autism friendly," Dr. Horrigan said.

Managing Medications

Children with autism don’t always react predictably to medications, especially anesthetics and psychotropic drugs, Dr. Horrigan said.

"A bay with a curtain in the ED is really not a good fit for a child with autism."

The small-dose benzodiazepine that might help a normally developing child relax could send an autistic child over the edge. "These individuals can have unique, idiosyncratic responses to medicines. Some of the medications a ‘normal’ child would get could provoke serious adverse reactions in a child with autism – especially a younger child."

Topical anesthetics, if appropriate, are usually a better choice for these children. Systemic medications must be handled very carefully – even antihistamines can provoke serious agitation and even violence.

On the other hand, some children with autism are so withdrawn that they may not express anxiety or pain, he said. But this doesn’t mean forgoing medication on the assumption that withholding it might actually be less stressful than giving it.

"Medications can and should be used in the same way as they are used on anyone else, to improve comfort and alleviate distress," Dr. Horrigan said. "But we must be thoughtful about the drug selection and dose. It requires a more sophisticated approach."

Generally, the rule should be to start with a lower test dose than usual, observe its effect and any reactions, and then increase the dose. Again, the parent is the provider’s best guide. "It’s critical to get as much medical history as possible about any past adverse reaction," he said.

For very agitated children, an atypical antipsychotic may be helpful. Risperidone and aripiprazole are the only two approved for use in children with autism spectrum disorders. Both are available in oral dissolvable tablets.

Oral ketamine – alone or in conjunction with midazolam – is a possibility for the combative child, Dr. Chun noted. "It’s not evidence based, but some say that it should be a first-line drug," for these cases.

A Matter of Time

Autism is on the rise in the United States, according to a new report from the Centers for Disease Control and Prevention (MMWR 2012;61[SS-3]:1-19). The report estimated a 78% increase in cases from 2002-2008. The report suggests that one in every 88 children has some form of autism spectrum disorder.

"Emergency physicians are going to be seeing more and more children with autism. That is a fact. This is not a rare disorder we’re talking about. It’s out there, the prevalence is growing, and you’re going to see it" in the emergency department, Dr. Horrigan said.

None of the physicians interviewed for this article reported any relevant financial conflicts.

When a child with autism arrives at the emergency department, the approach to care should be as individualized as the treatment itself.

The ED itself is almost a caricature of everything that can tip the delicate behavioral balance for children on the autism spectrum: bright lights, loud noises, and scurrying strangers who want to get close with dangerous-looking implements. Combine that sensory onslaught with the pain of an injury or illness, and the result can be a bomb that threatens the child’s optimal care at least, and the safety of staff at worst.

"When you are caring for a child with autism, you are a stranger in a strange land," said Dr. Thomas Chun, an emergency physician at the Hasbro Children’s Hospital, Providence, R.I. "You don’t know who you are to them, or who they are, or where they are," on the autism spectrum.

A core trait of autism is hypo- or hyperreactivity to stimuli, according to Dr. Joseph Horrigan, a child psychiatrist who is head of medical research for the advocacy group, Autism Speaks. "The hyperreactivity can be really challenging for many children with autism and their medical caregivers. In conjunction with this, it’s not at all unusual for these children to have anxiety, so there is a very low threshold for catastrophic stress responses, particularly if there is some sort of intellectual disability, or no decent method of communication."

Absence of social reciprocity is another unifying characteristic of autism, Dr. Chun said at a meeting sponsored by the American College of Emergency Physicians. But that characteristic can be expressed in a multitude of ways, from completely withdrawn and silent, to parroting adult speech, to full-blown violence. "It’s an incredibly wide spectrum, and in order to help that child, you need to know" where he or she falls on that spectrum. In this maze, the parents should be your most-trusted guides, he said.

"They have been dealing with this the child’s entire life. They know what calms and bothers him. They know the cognitive level, the best ways to communicate, what scares and how to soothe. It’s always worthwhile to take the time to ask them how they think their child will react to the situation."

In a perfect world, parents will have incorporated desensitization into their teaching about how a doctor’s or dentist’s visit will go. But as emergency physicians know all too well, the world is far from perfect. And when an emergency arises, there’s usually little time for parents to rehearse a trip to the ED – which means the physician is responsible for at least some destressing.

"Systematic desensitization can be very helpful here. Walk in, say hi, talk to the parents, and then walk out for a while. Let the parents play with the stethoscope and have them introduce it to the child," Dr. Chun advised. Although this approach takes some time, that delay could be nothing compared with the time consumed by a full-blown encounter with a stressed-out, uncooperative child. "I’m betting that a lot of the things we spend time on actually decrease time spent with that patient in the long run."

Interventions like these work best if everyone in the ED is on the same page, Dr. Chun said. His hospital instituted a 16-hour training program designed to decrease the need for patient restraint, and the injuries incurred during restraint. The program helped prevent or minimize incidents by teaching de-escalation techniques and avoidance of power struggles; it also included a debriefing component. In the year after implementing the program, the hospital saw an 83% decrease in patient injury due to restraint.

Practically Speaking

It’s one thing to intellectualize what interventions should look like, and entirely another to put them into action. Fortunately, said Dr. Horrigan, many of the more useful modifications are both easy and inexpensive.

Because overstimulation is a key component in troublesome interactions, one easy and very effective intervention is simply to reduce it, Dr. Horrigan said.

"Simply find a quiet place" to examine and treat the child in the parents’ company, he said in an interview. "A bay with a curtain in the ED is really not a good fit for a child with autism."

"When you are caring for a child with autism, you are a stranger in a strange land."

A private exam room is optimal; facilities that don’t have that luxury can make good use of a quiet family waiting room. Dim the ambient lighting, he said, and use a procedure lamp instead of glaring overhead fixtures.

Dr. Chun said some children enjoy the feeling of pressure all around their bodies. A weighted blanket is one way to achieve this, but a radiologist’s apron or a beanbag chair can be just as effective. If the child brings in a beloved toy or blanket from home, keep it close at hand to take full advantage of its soothing properties.

"Some children like light pressure," Dr. Chun noted. "For these, an electric foot massager or even a paint roller can be a good idea. Some like rocking, so we have a rocking chair with a small weighted blanket."

Say What?

Communication deficit is a universal manifestation of autism spectrum disorders. Children with autism tend to think in pictures or symbols rather than words. Many make use of adaptive communication tools at home, and it’s a good idea to have a few types of these in the ED.

A picture book with images of hospital personnel and procedures can be very helpful. An effective and virtually free method is to take photographs of the treatment bays, medical tools, and people with whom the child might interact; showing the child these is a good way to help her understand what to expect, Dr. Chun said.

"Go through the ED and take a bunch of pictures, laminate them, and you have an instant communication system. You can prepare a child for almost any procedure this way."

Even if there isn’t much reciprocal communication, most children with autism are taking in spoken language, so be sure to talk them through their experience, giving them descriptions of medical tools and devices, how they’re going to be used, and what procedures might feel like.

Pragmatic Procedures

Trust is the basis for any successful medical treatment, but trust is something children with autism don’t readily give, said Dr. Alan Rosenblatt, a neurodevelopmental pediatrician practicing in Skokie, Ill.

"Some of this will have to be done at a distance because some of these children don’t want to be touched by strangers," he said in an interview. "Only after a certain level of trust is established can that be done. You must be very careful about intruding too quickly and too intensely into the child’s personal space."

Fingers and toes are a good place to start the exam, he said. "That’s one of the tricks I use. I start at the periphery – away from the trunk and face – and slowly move more centrally so that they’re not overwhelmed all at once. Even with this approach, certain kids are so overwhelmed by anxiety that there is going to be resistance when you touch any part of them."

Drawing blood can be particularly troublesome. The Autism Treatment Network, part of Autism Speaks, offers a free guide to effective phlebotomy technique in children with autism. The pamphlet briefly explains how distraction, relaxation, and picture communication can improve results for everyone involved.

(The publication is available online.)

The Center for Autism and Related Disabilities, an autism support center affiliated with the University of Miami, also provides a "tip pamphlet" for EDs. "Autism and the Hospital Emergency Room" includes background information on autism, as well as lots of practical tips on making an ED more "autism friendly," Dr. Horrigan said.

Managing Medications

Children with autism don’t always react predictably to medications, especially anesthetics and psychotropic drugs, Dr. Horrigan said.

"A bay with a curtain in the ED is really not a good fit for a child with autism."

The small-dose benzodiazepine that might help a normally developing child relax could send an autistic child over the edge. "These individuals can have unique, idiosyncratic responses to medicines. Some of the medications a ‘normal’ child would get could provoke serious adverse reactions in a child with autism – especially a younger child."

Topical anesthetics, if appropriate, are usually a better choice for these children. Systemic medications must be handled very carefully – even antihistamines can provoke serious agitation and even violence.

On the other hand, some children with autism are so withdrawn that they may not express anxiety or pain, he said. But this doesn’t mean forgoing medication on the assumption that withholding it might actually be less stressful than giving it.

"Medications can and should be used in the same way as they are used on anyone else, to improve comfort and alleviate distress," Dr. Horrigan said. "But we must be thoughtful about the drug selection and dose. It requires a more sophisticated approach."

Generally, the rule should be to start with a lower test dose than usual, observe its effect and any reactions, and then increase the dose. Again, the parent is the provider’s best guide. "It’s critical to get as much medical history as possible about any past adverse reaction," he said.

For very agitated children, an atypical antipsychotic may be helpful. Risperidone and aripiprazole are the only two approved for use in children with autism spectrum disorders. Both are available in oral dissolvable tablets.

Oral ketamine – alone or in conjunction with midazolam – is a possibility for the combative child, Dr. Chun noted. "It’s not evidence based, but some say that it should be a first-line drug," for these cases.

A Matter of Time

Autism is on the rise in the United States, according to a new report from the Centers for Disease Control and Prevention (MMWR 2012;61[SS-3]:1-19). The report estimated a 78% increase in cases from 2002-2008. The report suggests that one in every 88 children has some form of autism spectrum disorder.

"Emergency physicians are going to be seeing more and more children with autism. That is a fact. This is not a rare disorder we’re talking about. It’s out there, the prevalence is growing, and you’re going to see it" in the emergency department, Dr. Horrigan said.

None of the physicians interviewed for this article reported any relevant financial conflicts.

NATIONAL HARBOR, MD. – A headache may hurt, but for most children, it’s nothing more serious than a pain.

The vast majority of pediatric headaches are not caused by space-occupying lesions in the brain, Dr. Marc DiSabella said at a meeting sponsored by the American College of Emergency Physicians. Even in the context of an abnormal neurologic exam, "only 4% have a space-occupying lesion, and most of them will also have an abnormal neurologic exam. So if you have a normal exam in a child with headache, that is a very reassuring thing."

Nevertheless, severe headaches can significantly impair almost every aspect of a child’s life, said Dr. DiSabella, a neurologist at Children’s National Medical Center, Washington, D.C. And treating headache is as much an art as a science; a good treatment plan includes behavioral strategies, daily preventive medications, and a choice of rescue therapies. Rescue treatments must be used cautiously so that they don’t provoke dependence or escalate the headaches into rebound.

When diagnosing the headache type, pay attention to the child’s clues.

"Tension-type [headache] is probably everything that migraine is not," he said. "Tension headaches are usually bilateral, pressing, nonpulsating pain. Activity does not worsen it, and rest doesn’t make it better."

Migraines, on the other hand, have some specific diagnostic criteria. According to the American Academy of Neurology, a migraine has at least two of these hallmark symptoms: unilateral or bilateral pain, moderate to severe pain, pounding or throbbing pain, and associated nausea, vomiting, photophobia, or phonophobia.

"I ask the child what makes the headache better. If they say they usually want to go into their bedroom and sleep, that is a big clue that it’s a migraine."

A family history of migraine makes the diagnosis even more likely. "Three-quarters of children with migraine have a parent with migraine."

Dr. DiSabella said he images only about 10% of his pediatric headache patients. Indications for MRI include:

• Migraines that are situated behind the ears. "Migraines are generated from the trigeminal nerve, and anything behind the ears can be bad news," he said.

• Abnormal neurologic exam or abnormal gait.

• New-onset headache.

• Migraine in the setting of no family history. "You really have to probe into the family history to get this information, though, and that might not be feasible in the ED."

• Headache with a substantial period of confusion or disorientation.

• Headache that is painful enough to wake the child from sleep (this is different from a child waking up in the morning with a headache).

• Headache accompanied by seizures.

Treatment is aimed at reducing the duration, intensity, and frequency of the headache, but medication should be used conservatively. "We want to moderate medication intake and improve quality of life. Migraineurs want the headache to go away, so medication overuse is very common. If patients are using rescue medication 15 or more days per month, they are at risk of developing daily migraines or a chronic background headache. Low regular use of these medications is much worse than high doses for a short period of time," Dr. DiSabella said.

Even ibuprofen and acetaminophen can cause a rebound headache. If a child already has medication overuse headache, recovery can take up to 6 weeks after starting a preventive regimen.

When a child with headache arrives in the emergency department, pain relief is the immediate goal. A non-oral route can be helpful with children. "Our emergency protocol is intravenous fluids plus Toradol [ketorolac] and Compazine [prochlorperazine]." Hydration is also key to headache relief. "I give them a sports drink in the ED. They like it, it’s noncaffeinated, and it does provide some electrolytes."

A combination of ketorolac and prochlorperazine is a very effective strategy, reaching 95% efficacy for pain relief. If the prochlorperazine strategy doesn’t work, intravenous valproic acid is worth a try. A 2005 study found that 39% of adolescents experienced pain relief after the first infusion of IV valproic acid and 57% after the second infusion (Headache 2005;45:899-903). "The faster you push it, the better it works," Dr. DiSabella said.

"How good are narcotics? Well, I don’t use them at all. They really result in a lot of overuse and abuse, and it’s my experience that patients get ‘wimpier’ every time they take one. The 7 out of 10 [pain] headaches will start to feel like a 10."

After stabilizing the pain, counseling is in order. "A three-tiered approach is the way to go – behavioral, prevention, and abortive. You can get a headache treatment plan worked up just like an asthma treatment plan."

Sample plans, including a patient information and instruction form and a medication chart, are available on the American Headache Society website. The group also provides an educational handout for parents.

Dr. DiSabella had no financial conflicts.

NATIONAL HARBOR, MD. – A headache may hurt, but for most children, it’s nothing more serious than a pain.

The vast majority of pediatric headaches are not caused by space-occupying lesions in the brain, Dr. Marc DiSabella said at a meeting sponsored by the American College of Emergency Physicians. Even in the context of an abnormal neurologic exam, "only 4% have a space-occupying lesion, and most of them will also have an abnormal neurologic exam. So if you have a normal exam in a child with headache, that is a very reassuring thing."

Nevertheless, severe headaches can significantly impair almost every aspect of a child’s life, said Dr. DiSabella, a neurologist at Children’s National Medical Center, Washington, D.C. And treating headache is as much an art as a science; a good treatment plan includes behavioral strategies, daily preventive medications, and a choice of rescue therapies. Rescue treatments must be used cautiously so that they don’t provoke dependence or escalate the headaches into rebound.

When diagnosing the headache type, pay attention to the child’s clues.

"Tension-type [headache] is probably everything that migraine is not," he said. "Tension headaches are usually bilateral, pressing, nonpulsating pain. Activity does not worsen it, and rest doesn’t make it better."

Migraines, on the other hand, have some specific diagnostic criteria. According to the American Academy of Neurology, a migraine has at least two of these hallmark symptoms: unilateral or bilateral pain, moderate to severe pain, pounding or throbbing pain, and associated nausea, vomiting, photophobia, or phonophobia.

"I ask the child what makes the headache better. If they say they usually want to go into their bedroom and sleep, that is a big clue that it’s a migraine."

A family history of migraine makes the diagnosis even more likely. "Three-quarters of children with migraine have a parent with migraine."

Dr. DiSabella said he images only about 10% of his pediatric headache patients. Indications for MRI include:

• Migraines that are situated behind the ears. "Migraines are generated from the trigeminal nerve, and anything behind the ears can be bad news," he said.

• Abnormal neurologic exam or abnormal gait.

• New-onset headache.

• Migraine in the setting of no family history. "You really have to probe into the family history to get this information, though, and that might not be feasible in the ED."

• Headache with a substantial period of confusion or disorientation.

• Headache that is painful enough to wake the child from sleep (this is different from a child waking up in the morning with a headache).

• Headache accompanied by seizures.

Treatment is aimed at reducing the duration, intensity, and frequency of the headache, but medication should be used conservatively. "We want to moderate medication intake and improve quality of life. Migraineurs want the headache to go away, so medication overuse is very common. If patients are using rescue medication 15 or more days per month, they are at risk of developing daily migraines or a chronic background headache. Low regular use of these medications is much worse than high doses for a short period of time," Dr. DiSabella said.

Even ibuprofen and acetaminophen can cause a rebound headache. If a child already has medication overuse headache, recovery can take up to 6 weeks after starting a preventive regimen.

When a child with headache arrives in the emergency department, pain relief is the immediate goal. A non-oral route can be helpful with children. "Our emergency protocol is intravenous fluids plus Toradol [ketorolac] and Compazine [prochlorperazine]." Hydration is also key to headache relief. "I give them a sports drink in the ED. They like it, it’s noncaffeinated, and it does provide some electrolytes."

A combination of ketorolac and prochlorperazine is a very effective strategy, reaching 95% efficacy for pain relief. If the prochlorperazine strategy doesn’t work, intravenous valproic acid is worth a try. A 2005 study found that 39% of adolescents experienced pain relief after the first infusion of IV valproic acid and 57% after the second infusion (Headache 2005;45:899-903). "The faster you push it, the better it works," Dr. DiSabella said.

"How good are narcotics? Well, I don’t use them at all. They really result in a lot of overuse and abuse, and it’s my experience that patients get ‘wimpier’ every time they take one. The 7 out of 10 [pain] headaches will start to feel like a 10."

After stabilizing the pain, counseling is in order. "A three-tiered approach is the way to go – behavioral, prevention, and abortive. You can get a headache treatment plan worked up just like an asthma treatment plan."

Sample plans, including a patient information and instruction form and a medication chart, are available on the American Headache Society website. The group also provides an educational handout for parents.

Dr. DiSabella had no financial conflicts.

NATIONAL HARBOR, MD. – A headache may hurt, but for most children, it’s nothing more serious than a pain.

The vast majority of pediatric headaches are not caused by space-occupying lesions in the brain, Dr. Marc DiSabella said at a meeting sponsored by the American College of Emergency Physicians. Even in the context of an abnormal neurologic exam, "only 4% have a space-occupying lesion, and most of them will also have an abnormal neurologic exam. So if you have a normal exam in a child with headache, that is a very reassuring thing."

Nevertheless, severe headaches can significantly impair almost every aspect of a child’s life, said Dr. DiSabella, a neurologist at Children’s National Medical Center, Washington, D.C. And treating headache is as much an art as a science; a good treatment plan includes behavioral strategies, daily preventive medications, and a choice of rescue therapies. Rescue treatments must be used cautiously so that they don’t provoke dependence or escalate the headaches into rebound.

When diagnosing the headache type, pay attention to the child’s clues.

"Tension-type [headache] is probably everything that migraine is not," he said. "Tension headaches are usually bilateral, pressing, nonpulsating pain. Activity does not worsen it, and rest doesn’t make it better."

Migraines, on the other hand, have some specific diagnostic criteria. According to the American Academy of Neurology, a migraine has at least two of these hallmark symptoms: unilateral or bilateral pain, moderate to severe pain, pounding or throbbing pain, and associated nausea, vomiting, photophobia, or phonophobia.

"I ask the child what makes the headache better. If they say they usually want to go into their bedroom and sleep, that is a big clue that it’s a migraine."

A family history of migraine makes the diagnosis even more likely. "Three-quarters of children with migraine have a parent with migraine."

Dr. DiSabella said he images only about 10% of his pediatric headache patients. Indications for MRI include:

• Migraines that are situated behind the ears. "Migraines are generated from the trigeminal nerve, and anything behind the ears can be bad news," he said.

• Abnormal neurologic exam or abnormal gait.

• New-onset headache.

• Migraine in the setting of no family history. "You really have to probe into the family history to get this information, though, and that might not be feasible in the ED."

• Headache with a substantial period of confusion or disorientation.

• Headache that is painful enough to wake the child from sleep (this is different from a child waking up in the morning with a headache).

• Headache accompanied by seizures.

Treatment is aimed at reducing the duration, intensity, and frequency of the headache, but medication should be used conservatively. "We want to moderate medication intake and improve quality of life. Migraineurs want the headache to go away, so medication overuse is very common. If patients are using rescue medication 15 or more days per month, they are at risk of developing daily migraines or a chronic background headache. Low regular use of these medications is much worse than high doses for a short period of time," Dr. DiSabella said.

Even ibuprofen and acetaminophen can cause a rebound headache. If a child already has medication overuse headache, recovery can take up to 6 weeks after starting a preventive regimen.

When a child with headache arrives in the emergency department, pain relief is the immediate goal. A non-oral route can be helpful with children. "Our emergency protocol is intravenous fluids plus Toradol [ketorolac] and Compazine [prochlorperazine]." Hydration is also key to headache relief. "I give them a sports drink in the ED. They like it, it’s noncaffeinated, and it does provide some electrolytes."

A combination of ketorolac and prochlorperazine is a very effective strategy, reaching 95% efficacy for pain relief. If the prochlorperazine strategy doesn’t work, intravenous valproic acid is worth a try. A 2005 study found that 39% of adolescents experienced pain relief after the first infusion of IV valproic acid and 57% after the second infusion (Headache 2005;45:899-903). "The faster you push it, the better it works," Dr. DiSabella said.

"How good are narcotics? Well, I don’t use them at all. They really result in a lot of overuse and abuse, and it’s my experience that patients get ‘wimpier’ every time they take one. The 7 out of 10 [pain] headaches will start to feel like a 10."

After stabilizing the pain, counseling is in order. "A three-tiered approach is the way to go – behavioral, prevention, and abortive. You can get a headache treatment plan worked up just like an asthma treatment plan."

Sample plans, including a patient information and instruction form and a medication chart, are available on the American Headache Society website. The group also provides an educational handout for parents.

Dr. DiSabella had no financial conflicts.