Sharon Worcester

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS – Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), said Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

She concluded that more time within pregnancy prevention intervention programs should be spent teaching that pregnancy is likely to make the achievement of career goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

Pneumococcal Vaccine Safety

Receiving three or more doses of pneumococcal polysaccharide vaccine does not appear to increase the risk of serious adverse events, a retrospective study has shown.

Only 1 of 179 persons who received three or more doses of 23-valent pneumococcal polysaccharide vaccine, and 4 of 181 controls who received one or two doses, had a medically attended adverse event, reported Frances J. Walker and colleagues at the Centers for Disease Control and Prevention, Atlanta.

Adverse events included tachycardia and arm redness, tenderness, rash, or swelling. No severe adverse events occurred, the investigators noted (Clin. Infect. Dis. 2005;40:1730–5).

The findings are important because data on the safety and effectiveness of revaccination have been lacking, and routine revaccination is therefore not generally recommended, except in certain high-risk patients, the investigators reported. However, pneumococcal antibody levels have been shown to decline to prevaccination levels within 6–10 years after vaccination.

Dengue Infection

A total of 77 cases of travel-associated dengue infection were confirmed in the United States from 2001 to 2004, according to the CDC.

Commonly reported symptoms of the infection included fever, headache, myalgias, chills, and rash. Additionally, 25% of patients had at least one hemorrhagic symptom, 16% had elevated liver transaminase levels, and 27% required hospitalization; one of the hospitalized patients died (MMWR 2005;54:556–8).

Travel destinations of affected patients in the 2 weeks prior to the onset of the illness included a Caribbean island (30% of patients), a Pacific island (21%), Asia (17%), Central America (15%), South America (15%), and Africa (2%).

Mosquito repellant, protective clothing, and remaining in well-screened or air-conditioned areas can help prevent infection. Health care workers should consider dengue in patients presenting with fever and a recent history of travel to tropical and subtropical areas. Patients should receive supportive treatment, with only acetaminophen for pain and fever, and should be monitored for dengue hemorrhagic fever with provision of fluids as necessary, according to the CDC.

Purpura Fulminans

Five recent cases of purpura fulminans associated with Staphylococcus aureus strains that produce high levels of superantigens suggest that this is a newly emerging clinical entity, Gary R. Kravitz, M.D., an infectious disease specialist in group practice in St. Paul, Minn., and his colleagues reported.

These patients represent the first known cases of purpura fulminans directly associated with S. aureus strains that produce high levels of toxic shock syndrome toxin-1, S. enterotoxin serotype B, or S. enterotoxin serotype C. One patient had a methicillin-resistant strain, and only two of the five patients survived, the investigators reported (Clin. Infect. Dis. 2005;40:941–4).

The clinical presentations were identical to those for patients with fulminant meningococcemia, which is much more common. Patients presenting with purpura fulminans should receive antibiotic therapy active against Neisseria meningitidis and streptococci, as well as methicillin-resistant S. aureus, the investigators advised.

Early administration of activated protein C to minimize purpuric skin injury may be indicated, as well as intravenous immunoglobulin therapy (which contains significant antibodies against the causative exotoxins), they noted.

Spread of HIV

The CDC estimates that 63% of new cases of HIV infection are in men who have sex with men, 50% are in blacks, 32% are in whites, and 16% are in Hispanics.

A recent report based on data from 5 cities (Baltimore, Los Angeles, Miami, New York, and San Francisco) of 17 participating in the National HIV Behavioral Surveillance System further suggested that 25% of the 1,767 surveyed men who have sex with men have HIV, and 48% of those were unaware of their infection (MMWR 2005;54:597–601).

Men under 30 years who are nonwhite and not living in San Francisco accounted for the highest proportion of those who were unaware of their HIV status, according to the report, which was presented at the 2005 National HIV Prevention Conference in Atlanta.

Men who have sex with men should be encouraged to have HIV testing at least annually, and prevention programs should focus on reaching those who are unaware of their HIV status, the report concluded. Men who have sex with men were more likely to be tested for HIV during the previous year if a health professional they visited had recommended such testing.

Pneumococcal Vaccine Safety

Receiving three or more doses of pneumococcal polysaccharide vaccine does not appear to increase the risk of serious adverse events, a retrospective study has shown.

Only 1 of 179 persons who received three or more doses of 23-valent pneumococcal polysaccharide vaccine, and 4 of 181 controls who received one or two doses, had a medically attended adverse event, reported Frances J. Walker and colleagues at the Centers for Disease Control and Prevention, Atlanta.

Adverse events included tachycardia and arm redness, tenderness, rash, or swelling. No severe adverse events occurred, the investigators noted (Clin. Infect. Dis. 2005;40:1730–5).

The findings are important because data on the safety and effectiveness of revaccination have been lacking, and routine revaccination is therefore not generally recommended, except in certain high-risk patients, the investigators reported. However, pneumococcal antibody levels have been shown to decline to prevaccination levels within 6–10 years after vaccination.

Dengue Infection

A total of 77 cases of travel-associated dengue infection were confirmed in the United States from 2001 to 2004, according to the CDC.

Commonly reported symptoms of the infection included fever, headache, myalgias, chills, and rash. Additionally, 25% of patients had at least one hemorrhagic symptom, 16% had elevated liver transaminase levels, and 27% required hospitalization; one of the hospitalized patients died (MMWR 2005;54:556–8).

Travel destinations of affected patients in the 2 weeks prior to the onset of the illness included a Caribbean island (30% of patients), a Pacific island (21%), Asia (17%), Central America (15%), South America (15%), and Africa (2%).

Mosquito repellant, protective clothing, and remaining in well-screened or air-conditioned areas can help prevent infection. Health care workers should consider dengue in patients presenting with fever and a recent history of travel to tropical and subtropical areas. Patients should receive supportive treatment, with only acetaminophen for pain and fever, and should be monitored for dengue hemorrhagic fever with provision of fluids as necessary, according to the CDC.

Purpura Fulminans

Five recent cases of purpura fulminans associated with Staphylococcus aureus strains that produce high levels of superantigens suggest that this is a newly emerging clinical entity, Gary R. Kravitz, M.D., an infectious disease specialist in group practice in St. Paul, Minn., and his colleagues reported.

These patients represent the first known cases of purpura fulminans directly associated with S. aureus strains that produce high levels of toxic shock syndrome toxin-1, S. enterotoxin serotype B, or S. enterotoxin serotype C. One patient had a methicillin-resistant strain, and only two of the five patients survived, the investigators reported (Clin. Infect. Dis. 2005;40:941–4).

The clinical presentations were identical to those for patients with fulminant meningococcemia, which is much more common. Patients presenting with purpura fulminans should receive antibiotic therapy active against Neisseria meningitidis and streptococci, as well as methicillin-resistant S. aureus, the investigators advised.

Early administration of activated protein C to minimize purpuric skin injury may be indicated, as well as intravenous immunoglobulin therapy (which contains significant antibodies against the causative exotoxins), they noted.

Spread of HIV

The CDC estimates that 63% of new cases of HIV infection are in men who have sex with men, 50% are in blacks, 32% are in whites, and 16% are in Hispanics.

A recent report based on data from 5 cities (Baltimore, Los Angeles, Miami, New York, and San Francisco) of 17 participating in the National HIV Behavioral Surveillance System further suggested that 25% of the 1,767 surveyed men who have sex with men have HIV, and 48% of those were unaware of their infection (MMWR 2005;54:597–601).

Men under 30 years who are nonwhite and not living in San Francisco accounted for the highest proportion of those who were unaware of their HIV status, according to the report, which was presented at the 2005 National HIV Prevention Conference in Atlanta.

Men who have sex with men should be encouraged to have HIV testing at least annually, and prevention programs should focus on reaching those who are unaware of their HIV status, the report concluded. Men who have sex with men were more likely to be tested for HIV during the previous year if a health professional they visited had recommended such testing.

Pneumococcal Vaccine Safety

Receiving three or more doses of pneumococcal polysaccharide vaccine does not appear to increase the risk of serious adverse events, a retrospective study has shown.

Only 1 of 179 persons who received three or more doses of 23-valent pneumococcal polysaccharide vaccine, and 4 of 181 controls who received one or two doses, had a medically attended adverse event, reported Frances J. Walker and colleagues at the Centers for Disease Control and Prevention, Atlanta.

Adverse events included tachycardia and arm redness, tenderness, rash, or swelling. No severe adverse events occurred, the investigators noted (Clin. Infect. Dis. 2005;40:1730–5).

The findings are important because data on the safety and effectiveness of revaccination have been lacking, and routine revaccination is therefore not generally recommended, except in certain high-risk patients, the investigators reported. However, pneumococcal antibody levels have been shown to decline to prevaccination levels within 6–10 years after vaccination.

Dengue Infection

A total of 77 cases of travel-associated dengue infection were confirmed in the United States from 2001 to 2004, according to the CDC.

Commonly reported symptoms of the infection included fever, headache, myalgias, chills, and rash. Additionally, 25% of patients had at least one hemorrhagic symptom, 16% had elevated liver transaminase levels, and 27% required hospitalization; one of the hospitalized patients died (MMWR 2005;54:556–8).

Travel destinations of affected patients in the 2 weeks prior to the onset of the illness included a Caribbean island (30% of patients), a Pacific island (21%), Asia (17%), Central America (15%), South America (15%), and Africa (2%).

Mosquito repellant, protective clothing, and remaining in well-screened or air-conditioned areas can help prevent infection. Health care workers should consider dengue in patients presenting with fever and a recent history of travel to tropical and subtropical areas. Patients should receive supportive treatment, with only acetaminophen for pain and fever, and should be monitored for dengue hemorrhagic fever with provision of fluids as necessary, according to the CDC.

Purpura Fulminans

Five recent cases of purpura fulminans associated with Staphylococcus aureus strains that produce high levels of superantigens suggest that this is a newly emerging clinical entity, Gary R. Kravitz, M.D., an infectious disease specialist in group practice in St. Paul, Minn., and his colleagues reported.

These patients represent the first known cases of purpura fulminans directly associated with S. aureus strains that produce high levels of toxic shock syndrome toxin-1, S. enterotoxin serotype B, or S. enterotoxin serotype C. One patient had a methicillin-resistant strain, and only two of the five patients survived, the investigators reported (Clin. Infect. Dis. 2005;40:941–4).

The clinical presentations were identical to those for patients with fulminant meningococcemia, which is much more common. Patients presenting with purpura fulminans should receive antibiotic therapy active against Neisseria meningitidis and streptococci, as well as methicillin-resistant S. aureus, the investigators advised.

Early administration of activated protein C to minimize purpuric skin injury may be indicated, as well as intravenous immunoglobulin therapy (which contains significant antibodies against the causative exotoxins), they noted.

Spread of HIV

The CDC estimates that 63% of new cases of HIV infection are in men who have sex with men, 50% are in blacks, 32% are in whites, and 16% are in Hispanics.

A recent report based on data from 5 cities (Baltimore, Los Angeles, Miami, New York, and San Francisco) of 17 participating in the National HIV Behavioral Surveillance System further suggested that 25% of the 1,767 surveyed men who have sex with men have HIV, and 48% of those were unaware of their infection (MMWR 2005;54:597–601).

Men under 30 years who are nonwhite and not living in San Francisco accounted for the highest proportion of those who were unaware of their HIV status, according to the report, which was presented at the 2005 National HIV Prevention Conference in Atlanta.

Men who have sex with men should be encouraged to have HIV testing at least annually, and prevention programs should focus on reaching those who are unaware of their HIV status, the report concluded. Men who have sex with men were more likely to be tested for HIV during the previous year if a health professional they visited had recommended such testing.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such MRSA-related abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, she said.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, Dr. Hertweck said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

In addition, appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such MRSA-related abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, she said.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, Dr. Hertweck said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

In addition, appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

NEW ORLEANS — A recent series of “curious” cases of large vulvar or labial abscesses in previously healthy children were associated with methicillin-resistant Staphylococcus aureus and represent the first reported cases of such MRSA-related abscesses in the pediatric and adolescent population, S. Paige Hertweck, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Six patients, aged 2, 16, and 17 months and 3, 12, and 16 years, presented during 2004 with vulvar or labial abscesses requiring debridement and drainage. All had confirmed S. aureus infection, and five of the patients had MRSA.

The MRSA cases presented initially with a red papule that progressed rapidly, and by day 2 a fulminant abscess extended significantly beyond the labia. The abscesses had an area greater than 5 cm.

After debridement and 48–72 hours of continuous drainage, all patients were treated with antibiotics. The use of small incisions at each end of the abscess cavities allowed digital manipulation, and the use of a small Penrose drain threaded through each incision and tied to itself allowed continuous drainage that negated the need for extensive packing, which can be difficult in children.

None of the children had typical risk factors for MRSA, although three did have household contacts with lesions that might have been associated with MRSA. All infections were sensitive to clindamycin, Bactrim (trimethoprim-sulfamethoxazole), and vancomycin, she said.

MRSA should be considered in all patients presenting with rapidly progressing vulvar or labial erythema. Aggressive treatment with incision and drainage in such cases is warranted, Dr. Hertweck said, noting that a limited incision site and the use of a Penrose drain are recommended in children.

In addition, appropriate antibiotic therapy should also be initiated.

“While our sensitivities may not translate to your community, it might be appropriate to start with something like clindamycin,” she said.

NEW ORLEANS — Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations, and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), according to Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

The conventional approach does not take into account the fact that educational and career goals are not necessarily causally related to avoiding pregnancy, she wrote, concluding that more time within pregnancy prevention intervention programs should be spent not only encouraging such goals, but also teaching that pregnancy is likely to make the achievement of those goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS — Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations, and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), according to Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

The conventional approach does not take into account the fact that educational and career goals are not necessarily causally related to avoiding pregnancy, she wrote, concluding that more time within pregnancy prevention intervention programs should be spent not only encouraging such goals, but also teaching that pregnancy is likely to make the achievement of those goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

NEW ORLEANS — Higher educational and career goals among adolescent girls are widely considered to be protective against pregnancy, but a recent study suggests that this is true only among those who specifically view pregnancy as an impediment to achieving these goals.

Of 351 racially and ethnically diverse nulliparous teens who completed a questionnaire asking about such factors as educational and career goals, anticipated effects of childbearing on these goals, personal desire to avoid pregnancy, and sexual behavior and contraceptive use, 64% had college aspirations, and 58% planned to pursue a career as well as eventual motherhood, Sara Jumping Eagle, M.D., reported in a poster at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Most (74%) said their goals were achievable, but only 42% said that pregnancy would interfere with their achievement of those goals. Only those young women who considered pregnancy an obstacle to their goals were significantly more likely to want to remain nonpregnant (77% vs. 27%), had plans to abort if they became pregnant (27% vs. 4%), and had plans to use contraception consistently in the future (90% vs. 79%), according to Dr. Jumping Eagle of the University of Colorado, Denver.

The findings challenge the conventional approach to risk assessment, which assumes “that there are sets of risk and protective factors that differ in quantity between teenagers who do and do not become mothers but [that] exert similar effects on them.” Dr. Jumping Eagle noted.

The conventional approach does not take into account the fact that educational and career goals are not necessarily causally related to avoiding pregnancy, she wrote, concluding that more time within pregnancy prevention intervention programs should be spent not only encouraging such goals, but also teaching that pregnancy is likely to make the achievement of those goals so difficult that the girls would be “willing to overlook the inconveniences associated with using contraception.”

BAL HARBOUR, FLA. — In the 1970s, only about 20,000 girls in the United States were involved in high school sports. Now more than 3 million girls participate in sports at that level, and that means primary care physicians are seeing more sports-related injuries, Jordan Metzl, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In fact, studies suggest sports are the most common source of musculoskeletal problems seen in youngsters, said Dr. Metzl, medical director at the Sports Medicine Institute for Young Athletes, New York.

Girls are particularly prone to certain injuries and problems, including anterior cruciate ligament tears (fourfold increased risk compared with boys), stress fractures, and problems associated with the female athlete triad, which includes amenorrhea, anorexia athletica, and osteoporosis, he said.

Primary care physicians can help prevent or provide early recognition of these sports-related injuries and health problems because they see girls at a young age, often before they become highly competitive, he added.

The following tips are helpful in identifying sports-related problems in teen girls:

▸ Provide education about injury prevention, and screen for things such as delayed menarche and bone health at every opportunity, Dr. Metzl advised.

It helps to keep in mind stages of development. For example, a girl's axis of rotation, which is important in many sports such as ice-skating and gymnastics, can change dramatically during Tanner stage IV-V, and this is the time when disordered eating is most likely to emerge.

▸ Weight loss of more than 5% of body weight in the absence of medical illness, along with excessive fear of obesity and severe calorie restrictions, could be an indicator of anorexia athletica. Primary amenorrhea, gastrointestinal complaints, and compulsive exercise also can suggest this.

▸ Remember the importance of early bone health. Bone mass peaks at age 31 years; osteopenic teens become osteopenic adults, Dr. Metzl said.

To promote good bone health, advise young patients—particularly those who are active in sports—to maintain an intake of 1,500 mg/day of calcium.

A landmark study in the early 1990s showed that young girls randomized to receive a 500-mg supplement of calcium citrate (for an average total of 1,350 mg/day) had a significant (1.3%) increase of 24 g in total body and spine bone mineral density after 18 months, compared with those who did not receive a calcium supplement (and who had an average daily calcium intake of 940 mg), he said (JAMA 1993;270:841–4).

The investigators concluded that this increase could protect against future osteoporotic fractures.

Dr. Metzl also recommends 400 units of vitamin D daily to promote bone health.

When evaluating a patient with an injury or sports-related complaint, consider not only the patient's level of activity, but also biomechanics and bone density, he advised.

It's not enough to say, “Just stay off of it until you feel better,” Dr. Metzl noted.

BAL HARBOUR, FLA. — In the 1970s, only about 20,000 girls in the United States were involved in high school sports. Now more than 3 million girls participate in sports at that level, and that means primary care physicians are seeing more sports-related injuries, Jordan Metzl, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In fact, studies suggest sports are the most common source of musculoskeletal problems seen in youngsters, said Dr. Metzl, medical director at the Sports Medicine Institute for Young Athletes, New York.

Girls are particularly prone to certain injuries and problems, including anterior cruciate ligament tears (fourfold increased risk compared with boys), stress fractures, and problems associated with the female athlete triad, which includes amenorrhea, anorexia athletica, and osteoporosis, he said.

Primary care physicians can help prevent or provide early recognition of these sports-related injuries and health problems because they see girls at a young age, often before they become highly competitive, he added.

The following tips are helpful in identifying sports-related problems in teen girls:

▸ Provide education about injury prevention, and screen for things such as delayed menarche and bone health at every opportunity, Dr. Metzl advised.

It helps to keep in mind stages of development. For example, a girl's axis of rotation, which is important in many sports such as ice-skating and gymnastics, can change dramatically during Tanner stage IV-V, and this is the time when disordered eating is most likely to emerge.

▸ Weight loss of more than 5% of body weight in the absence of medical illness, along with excessive fear of obesity and severe calorie restrictions, could be an indicator of anorexia athletica. Primary amenorrhea, gastrointestinal complaints, and compulsive exercise also can suggest this.

▸ Remember the importance of early bone health. Bone mass peaks at age 31 years; osteopenic teens become osteopenic adults, Dr. Metzl said.

To promote good bone health, advise young patients—particularly those who are active in sports—to maintain an intake of 1,500 mg/day of calcium.

A landmark study in the early 1990s showed that young girls randomized to receive a 500-mg supplement of calcium citrate (for an average total of 1,350 mg/day) had a significant (1.3%) increase of 24 g in total body and spine bone mineral density after 18 months, compared with those who did not receive a calcium supplement (and who had an average daily calcium intake of 940 mg), he said (JAMA 1993;270:841–4).

The investigators concluded that this increase could protect against future osteoporotic fractures.

Dr. Metzl also recommends 400 units of vitamin D daily to promote bone health.

When evaluating a patient with an injury or sports-related complaint, consider not only the patient's level of activity, but also biomechanics and bone density, he advised.

It's not enough to say, “Just stay off of it until you feel better,” Dr. Metzl noted.

BAL HARBOUR, FLA. — In the 1970s, only about 20,000 girls in the United States were involved in high school sports. Now more than 3 million girls participate in sports at that level, and that means primary care physicians are seeing more sports-related injuries, Jordan Metzl, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In fact, studies suggest sports are the most common source of musculoskeletal problems seen in youngsters, said Dr. Metzl, medical director at the Sports Medicine Institute for Young Athletes, New York.

Girls are particularly prone to certain injuries and problems, including anterior cruciate ligament tears (fourfold increased risk compared with boys), stress fractures, and problems associated with the female athlete triad, which includes amenorrhea, anorexia athletica, and osteoporosis, he said.

Primary care physicians can help prevent or provide early recognition of these sports-related injuries and health problems because they see girls at a young age, often before they become highly competitive, he added.

The following tips are helpful in identifying sports-related problems in teen girls:

▸ Provide education about injury prevention, and screen for things such as delayed menarche and bone health at every opportunity, Dr. Metzl advised.

It helps to keep in mind stages of development. For example, a girl's axis of rotation, which is important in many sports such as ice-skating and gymnastics, can change dramatically during Tanner stage IV-V, and this is the time when disordered eating is most likely to emerge.

▸ Weight loss of more than 5% of body weight in the absence of medical illness, along with excessive fear of obesity and severe calorie restrictions, could be an indicator of anorexia athletica. Primary amenorrhea, gastrointestinal complaints, and compulsive exercise also can suggest this.

▸ Remember the importance of early bone health. Bone mass peaks at age 31 years; osteopenic teens become osteopenic adults, Dr. Metzl said.

To promote good bone health, advise young patients—particularly those who are active in sports—to maintain an intake of 1,500 mg/day of calcium.

A landmark study in the early 1990s showed that young girls randomized to receive a 500-mg supplement of calcium citrate (for an average total of 1,350 mg/day) had a significant (1.3%) increase of 24 g in total body and spine bone mineral density after 18 months, compared with those who did not receive a calcium supplement (and who had an average daily calcium intake of 940 mg), he said (JAMA 1993;270:841–4).

The investigators concluded that this increase could protect against future osteoporotic fractures.

Dr. Metzl also recommends 400 units of vitamin D daily to promote bone health.

When evaluating a patient with an injury or sports-related complaint, consider not only the patient's level of activity, but also biomechanics and bone density, he advised.

It's not enough to say, “Just stay off of it until you feel better,” Dr. Metzl noted.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children. More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long said.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long commented.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether they are associated with long-term arthropathy, she noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long said.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children. More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long said.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long commented.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether they are associated with long-term arthropathy, she noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long said.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

BAL HARBOUR, FLA. — Fluoroquinolones must be used judiciously in children, Sarah S. Long, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

These drugs are increasingly available, and they are being widely prescribed to children. More than 520,000 prescriptions for fluoroquinolones were written for this population in 2002—with more than 16,000 written for those under age 6 years and nearly 3,000 written for those under age 2 years, said Dr. Long, professor of pediatrics at Drexel University, Philadelphia.

And that was before ciprofloxacin received Food and Drug Administration approval for use in those under age 18 years with complicated urinary tract infections, pyelonephritis, and inhalation anthrax exposure, Dr. Long said.

The FDA granted this approval last year, but there is little guidance beyond that for the use of fluoroquinolones in the pediatric population.

The advantages of fluoroquinolones include oral administration, excellent oral bioavailability, and a gram-negative spectrum, but these drugs are associated with adverse musculoskeletal events. The potential for spontaneous Achilles tendon rupture is of particular concern, Dr. Long commented.

Tendon rupture is a rare event, but it is definitely “above the radar,” she said.

“These drugs do have some effect on cartilage—there is no question,” she added.

In addition, there is some concern about whether they are associated with long-term arthropathy, she noted.

Central nervous system, hepatic, and metabolic effects are also possible, and some patients experience photosensitivity and rashes after taking fluoroquinolones.

Therefore, the use of these drugs in children should be limited mainly to serious gram-negative rod infections for which there are no other treatment alternatives, Dr. Long said.

Conditions for which fluoroquinolones may be appropriate in children—other than the approved uses—include chronic otitis, chronic or acute Pseudomonas aeruginosa osteomyelitis, cystic fibrosis exacerbations, certain mycobacterium infections, and multidrug-resistant shigella, salmonella, or vibrio infections.

Topical treatment is acceptable for conjunctivitis and otitis externa that are refractory or resistant to other treatments, but fluoroquinolones should not be used for plain conjunctivitis or otitis media or for community-acquired bronchitis and pneumonia, Dr. Long said.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response.

On the 8th day, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies and was removed from isolation. She was discharged to home on hospital day 76.

At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient does not change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response.

On the 8th day, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies and was removed from isolation. She was discharged to home on hospital day 76.

At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient does not change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response.

On the 8th day, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies and was removed from isolation. She was discharged to home on hospital day 76.

At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient does not change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity.

It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that because the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity.

It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that because the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity.

It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that because the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis, and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis, and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

The doctors who treated the first known patient to survive rabies without prior vaccination have published their aggressive and previously untested treatment protocol, but they caution that it requires further study.

“Clearly, our experience with this patient requires replication in other patients and proof-of-concept experiments in animal models,” said Rodney E. Willoughby Jr., M.D., of the Medical College of Wisconsin, Milwaukee, and his colleagues.

The 15-year-old patient developed confirmed clinical rabies 1 month after being bitten on the left index finger by a bat. She was treated with a strategy that involved induction of therapeutic coma, and antiexcitatory and antiviral drug therapy under supportive intensive care. The concept was to protect the brain from injury while allowing the launch of a natural immune response against the virus (N. Engl. J. Med. 2005;352:2508–14).

The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Doses were adjusted as needed due to responses and probable drug-related toxicities, which included hemolysis, pancreatitis, acidosis, and hepatotoxicity. She did not receive rabies vaccine or rabies immunoglobulin because she demonstrated immune response and because of concern regarding harm from a potentiated immune response, the investigators noted.

On the eighth day of hospitalization, a lumbar puncture indicated an increased level of rabies antibody, and sedation was tapered. On hospital day 31, the patient was determined to be cleared of transmissible rabies, and was removed from isolation.

She was discharged to home on hospital day 76. At a follow-up visit 131 days after her initial hospitalization, the patient was progressing, and had returned to school part time. She continues to experience dysarthrotic speech, buccolingual choreoathetosis with generalized choreoathetosis, and intermittent dystonia and ballismus, which affect her gait and fine-motor skills, Dr. Willoughby and his associates said.

Prior to this case, five cases of survival following rabies had been well documented, but all received occupationally related preexposure rabies vaccination or postexposure prophylaxis; this is the first known patient to survive with only naturally acquired immunity. It should be noted that the patient was young and athletic, and may have received a limited quantity of inoculum, the investigators stressed, adding that since the bat was not recovered, it is unclear if the patient's survival was due to an “unusual, more temperate or attenuated variant of the virus, or a rare host polymorphism.”

“Therapy may have been more effective than in past cases because of the inferred limited exposure to rabies virus, early recognition of the disease, and aggressive management,” the investigators said, noting that the survival of this patient doesn't change the fact that rabies has the highest case fatality ratio of any infectious disease.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%–75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston. In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised. Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients).

Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%–75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0–20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers. “We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%–75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston. In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised. Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients).

Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%–75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0–20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers. “We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%–75% of patients achieve good control of solid and liquid bowel movements. But the limited data available on long-term outcomes are less promising, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

Few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, said Dr. Weiss of Cleveland Clinic Florida, Weston. In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up.

One factor that has emerged as a predictor of poor surgical outcome is the presence of neuropathy, he noted.

In patients who don't do well following surgery, consider whether the repair was successful from an anatomic standpoint, he advised. Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are:

▸ The artificial anal sphincter. A recent report on the North American experience with the artificial sphincter showed that nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients).

Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%.

“When it works, it works well, but it takes a lot to get it to work well,” Dr. Weiss said.

▸ Sacral nerve stimulation. This procedure, involving implantation of a device that stimulates nerves originating from the sacral nerve foramen, was originally used to treat urinary incontinence but also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%–75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores.

Durasphere EXP Injectable Bulking Agent is approved for the treatment of stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0–20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers. “We try to avoid it, but … there are patients who really do benefit from having a stoma,” Dr. Weiss said.