Sharon Worcester

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a chart review including 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary artery disease (CAD), but many had risk factors: a history of smoking in 70%, high blood pressure in 63%, a family history of CAD in 52%, and obesity or overweight in 70%.

Sufficient data were available for 80 of the women with no history of CAD to allow risk stratification based on National Cholesterol Education Program guidelines. Of these women, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, said Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., in a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or for a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in younger women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a chart review including 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary artery disease (CAD), but many had risk factors: a history of smoking in 70%, high blood pressure in 63%, a family history of CAD in 52%, and obesity or overweight in 70%.

Sufficient data were available for 80 of the women with no history of CAD to allow risk stratification based on National Cholesterol Education Program guidelines. Of these women, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, said Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., in a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or for a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in younger women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Middle-aged women should routinely be assessed for metabolic syndrome, Ana M. Schaper, Ph.D., said at an international conference on women, heart disease, and stroke.

In a chart review including 147 women under 65 years who were treated for MI in a rural midwestern community, Dr. Schaper found that 113 (77%) had no history of coronary artery disease (CAD), but many had risk factors: a history of smoking in 70%, high blood pressure in 63%, a family history of CAD in 52%, and obesity or overweight in 70%.

Sufficient data were available for 80 of the women with no history of CAD to allow risk stratification based on National Cholesterol Education Program guidelines. Of these women, only 10% would have qualified for medical management under the guidelines, and only 18% would have qualified for therapeutic lifestyle changes, but 49% had metabolic syndrome, said Dr. Schaper of Gundersen Lutheran Medical Foundation, La Crosse, Wis., in a news conference at the meeting.

Of the 135 patients who survived their initial hospitalization, 54 were readmitted within a year for chest pain, myocardial infarction, or for a revascularization procedure. All women who were discharged on an ACE inhibitor or angiotensin receptor blocker, and lipid therapy, and 90% of those discharged on a β-blocker, remained on their medications at 1-year follow-up.

At that time, total- and LDL-cholesterol levels were lower, and HDL-cholesterol levels were higher. Triglyceride levels were unchanged, Dr. Schaper said.

The findings suggest that all components of metabolic syndrome in younger women should be identified and treated aggressively, she said.

ORLANDO, FLA. — Data have been conflicting on the role of calcium in gestational hypertension, but findings from a recent longitudinal study suggest it does not help prevent the condition, Yi Ning, M.D., of Harvard University, Boston, and colleagues reported in a poster at an international conference on women, heart disease, and stroke.

In the study, mean total calcium intake in 1,686 women was 1,310 mg/day in the first trimester, with most of that (85%) coming from foods. Gestational hypertension occurred in 118 of the women, and preeclampsia occurred in 61.

Adjustments were made for numerous variables, including maternal age, prepregnancy body mass index, race and ethnicity, income, parity, and smoking, as well as first measured systolic blood pressure and history of gestational hypertension or preeclampsia. No significant associations were found between the development of gestational hypertension or preeclampsia and the first-trimester intake of calcium.

The investigators also looked at intake of n-3 and n-6 polyunsaturated fatty acids and trans-fatty acids, and found no associations with gestational hypertension or preeclampsia. The same was true for second-trimester intake of the nutrients.

Participants completed food frequency questionnaires in both their first and second trimesters, and gestational hypertension and preeclampsia were identified using outpatient blood pressure and urine protein measurements, as well as delivery hospitalization diagnoses.

The findings support those of several other studies showing that calcium does not prevent gestational hypertension, according to Dr. Ning.

ORLANDO, FLA. — Data have been conflicting on the role of calcium in gestational hypertension, but findings from a recent longitudinal study suggest it does not help prevent the condition, Yi Ning, M.D., of Harvard University, Boston, and colleagues reported in a poster at an international conference on women, heart disease, and stroke.

In the study, mean total calcium intake in 1,686 women was 1,310 mg/day in the first trimester, with most of that (85%) coming from foods. Gestational hypertension occurred in 118 of the women, and preeclampsia occurred in 61.

Adjustments were made for numerous variables, including maternal age, prepregnancy body mass index, race and ethnicity, income, parity, and smoking, as well as first measured systolic blood pressure and history of gestational hypertension or preeclampsia. No significant associations were found between the development of gestational hypertension or preeclampsia and the first-trimester intake of calcium.

The investigators also looked at intake of n-3 and n-6 polyunsaturated fatty acids and trans-fatty acids, and found no associations with gestational hypertension or preeclampsia. The same was true for second-trimester intake of the nutrients.

Participants completed food frequency questionnaires in both their first and second trimesters, and gestational hypertension and preeclampsia were identified using outpatient blood pressure and urine protein measurements, as well as delivery hospitalization diagnoses.

The findings support those of several other studies showing that calcium does not prevent gestational hypertension, according to Dr. Ning.

ORLANDO, FLA. — Data have been conflicting on the role of calcium in gestational hypertension, but findings from a recent longitudinal study suggest it does not help prevent the condition, Yi Ning, M.D., of Harvard University, Boston, and colleagues reported in a poster at an international conference on women, heart disease, and stroke.

In the study, mean total calcium intake in 1,686 women was 1,310 mg/day in the first trimester, with most of that (85%) coming from foods. Gestational hypertension occurred in 118 of the women, and preeclampsia occurred in 61.

Adjustments were made for numerous variables, including maternal age, prepregnancy body mass index, race and ethnicity, income, parity, and smoking, as well as first measured systolic blood pressure and history of gestational hypertension or preeclampsia. No significant associations were found between the development of gestational hypertension or preeclampsia and the first-trimester intake of calcium.

The investigators also looked at intake of n-3 and n-6 polyunsaturated fatty acids and trans-fatty acids, and found no associations with gestational hypertension or preeclampsia. The same was true for second-trimester intake of the nutrients.

Participants completed food frequency questionnaires in both their first and second trimesters, and gestational hypertension and preeclampsia were identified using outpatient blood pressure and urine protein measurements, as well as delivery hospitalization diagnoses.

The findings support those of several other studies showing that calcium does not prevent gestational hypertension, according to Dr. Ning.

BAL HARBOUR, FLA. — Catheter-related bacteremia affecting catheter survival occurs frequently in children on hemodialysis, results of a recent study suggest.

A review of the charts of 60 children who had chronic hemodialysis catheters at the University of Miami between 1999 and 2003 showed that 188 catheter infections occurred in these patients; 49 (82%) of the children developed catheter-related bacteremia, Ali Mirza Onder, M.D., and colleagues at the University of Miami reported in a poster presentation at the annual Masters of Pediatrics conference sponsored by the university.

Of the 188 catheter infections, 67% were gram-positive infections, 14% were gram-negative infections, and 19% were polymicrobial. Of the gram-positive infections, 78% were oxacillin resistant.

Of the gram-negative infections, 22% were tobramycin resistant.

And of the polymicrobial infections, 88% were oxacillin resistant, and 72% were tobramycin resistant, the investigators found.

The occurrence of two or more catheter infections in a patient in 1 year was associated with increased risk of multiple episodes of catheter- related bacteremia, they noted.

Catheter replacement occurred 118 times; 63% of the replacements were due to infection, with catheter malfunction and cuff extension accounting for the remaining cases. Of the 118 replacements, 81 were wire-guided exchanges, as opposed to replacements following removal.

Catheter survival was not significantly different between those who had replacements and those who had exchanges (267 days vs. 249 days).

Systemic antibiotic therapy was effective for clearing infections in 60% of cases.

Catheter-related bacteremia affecting catheter survival is an important problem among children on maintenance hemodialysis.

Given the frequency of oxacillin- and tobramycin-resistant organisms seen in this study, regional prevalence of such resistance should be considered when selecting initial empiric therapy for catheter- related bacteremia, the investigators concluded.

When feasible, permanent vascular access should be considered, they added.

BAL HARBOUR, FLA. — Catheter-related bacteremia affecting catheter survival occurs frequently in children on hemodialysis, results of a recent study suggest.

A review of the charts of 60 children who had chronic hemodialysis catheters at the University of Miami between 1999 and 2003 showed that 188 catheter infections occurred in these patients; 49 (82%) of the children developed catheter-related bacteremia, Ali Mirza Onder, M.D., and colleagues at the University of Miami reported in a poster presentation at the annual Masters of Pediatrics conference sponsored by the university.

Of the 188 catheter infections, 67% were gram-positive infections, 14% were gram-negative infections, and 19% were polymicrobial. Of the gram-positive infections, 78% were oxacillin resistant.

Of the gram-negative infections, 22% were tobramycin resistant.

And of the polymicrobial infections, 88% were oxacillin resistant, and 72% were tobramycin resistant, the investigators found.

The occurrence of two or more catheter infections in a patient in 1 year was associated with increased risk of multiple episodes of catheter- related bacteremia, they noted.

Catheter replacement occurred 118 times; 63% of the replacements were due to infection, with catheter malfunction and cuff extension accounting for the remaining cases. Of the 118 replacements, 81 were wire-guided exchanges, as opposed to replacements following removal.

Catheter survival was not significantly different between those who had replacements and those who had exchanges (267 days vs. 249 days).

Systemic antibiotic therapy was effective for clearing infections in 60% of cases.

Catheter-related bacteremia affecting catheter survival is an important problem among children on maintenance hemodialysis.

Given the frequency of oxacillin- and tobramycin-resistant organisms seen in this study, regional prevalence of such resistance should be considered when selecting initial empiric therapy for catheter- related bacteremia, the investigators concluded.

When feasible, permanent vascular access should be considered, they added.

BAL HARBOUR, FLA. — Catheter-related bacteremia affecting catheter survival occurs frequently in children on hemodialysis, results of a recent study suggest.

A review of the charts of 60 children who had chronic hemodialysis catheters at the University of Miami between 1999 and 2003 showed that 188 catheter infections occurred in these patients; 49 (82%) of the children developed catheter-related bacteremia, Ali Mirza Onder, M.D., and colleagues at the University of Miami reported in a poster presentation at the annual Masters of Pediatrics conference sponsored by the university.

Of the 188 catheter infections, 67% were gram-positive infections, 14% were gram-negative infections, and 19% were polymicrobial. Of the gram-positive infections, 78% were oxacillin resistant.

Of the gram-negative infections, 22% were tobramycin resistant.

And of the polymicrobial infections, 88% were oxacillin resistant, and 72% were tobramycin resistant, the investigators found.

The occurrence of two or more catheter infections in a patient in 1 year was associated with increased risk of multiple episodes of catheter- related bacteremia, they noted.

Catheter replacement occurred 118 times; 63% of the replacements were due to infection, with catheter malfunction and cuff extension accounting for the remaining cases. Of the 118 replacements, 81 were wire-guided exchanges, as opposed to replacements following removal.

Catheter survival was not significantly different between those who had replacements and those who had exchanges (267 days vs. 249 days).

Systemic antibiotic therapy was effective for clearing infections in 60% of cases.

Catheter-related bacteremia affecting catheter survival is an important problem among children on maintenance hemodialysis.

Given the frequency of oxacillin- and tobramycin-resistant organisms seen in this study, regional prevalence of such resistance should be considered when selecting initial empiric therapy for catheter- related bacteremia, the investigators concluded.

When feasible, permanent vascular access should be considered, they added.

BAL HARBOUR, FLA. — One of the most interesting pediatric infectious disease papers in the past year—according to Ralph D. Feigin, M.D.—suggests that cephalosporins are superior to penicillin for the treatment of group A beta-hemolytic streptococcal tonsillopharyngitis in children.

But take a closer look at the metaanalysis before changing your approach to the treatment of this common condition, Dr. Feigin advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

The authors included 35 trials involving 7,125 patients in their study, and found that the overall odds ratios for bacteriologic and clinical cure rates significantly favored cephalosporins. They concluded that the likelihood of treatment failure is less if an oral cephalosporin is used for treatment (Pediatrics. 2004;113:866-82).

However, the failure to exclude group A beta-hemolytic streptococcus (GABHS) carriers in some of the clinical trials included in the metaanalysis is of concern, said Dr. Feigin, chairman of the department of pediatrics at Baylor College of Medicine, Houston.

Cephalosporins have been shown to be superior to penicillin for eradicating the GABHS carrier states, so the inclusion of a high proportion of carriers would skew the results in favor of cephalosporins in those studies; the statistical analysis used in the metaanalysis fails to adequately address this issue, he said.

Furthermore, only 6 of the 35 studies included were double blinded, and only 9 were investigator blinded. Eleven studies did not include typing of organisms to determine if positive follow-up cultures represented new infection.

The numerous cephalosporins represented in the studies—11 were used in the 35 studies—and lack of compliance testing in 9 of the studies, were also items of concern, Dr. Feigin said.

Penicillin has a narrower spectrum and much lower cost than many of the cephalosporins included in the metaanalysis, and it is effective for shortening disease course and limiting suppurative sequelae and transmission. Studies have shown that penicillin is effective for preventing acute rheumatic fever—even when it is initiated 9 days after onset of acute illness. Therefore, it should not be discounted as a drug of choice for GABHS tonsillopharyngitis, he said.

Other topics among Dr. Feigin's picks for the most interesting papers of the year were:

▸ Linezolid vs. vancomycin for treatment-resistant gram-positive infections in children. Linezolid was shown in this study of more than 300 hospitalized children with serious gram-positive infections to be effective and well tolerated (Pediatr. Infect. Dis. J. 2003;22:677-85).

The children were randomized to receive either 10 mg/kg of intravenous linezolid every 8 hours followed by oral linezolid, or to receive 10-15 mg/kg every 6-24 hours followed by an oral agent as appropriate. The pathogen eradication rates for methicillin-susceptible S. aureus and for methicillin-resistant coagulase-negative staphylococci were high in both groups and did not differ significantly.

Significantly more days of IV therapy were required with vancomycin (10.9 vs. 8.0 days) and significantly more patients had adverse drug-related events with vancomycin (34% vs. 19% of patient).

But if this study has you thinking about using linezolid instead of vancomycin—think again, Dr. Feigin advised. To postpone development of resistance to this newer drug for as long as possible, reserve it for use only in patients with infections for which other agents cannot be used, he said.

▸ Human metapneumovirus and lower respiratory tract disease. A new RNA virus known as human metapneumovirus was identified in 2001, and this 2004 study showed that the virus might be the cause of a considerable number of respiratory illnesses in children. Of 248 specimens from children from whom no virus was previously isolated, 49 were found to be associated with metapneumovirus. About 25% of the infections were in children under age 6 months, and 49% were in those ages 6 months to 1 year (N. Engl. J. Med.2004;350:443-50).

The findings suggest that this is a relatively frequent cause of lower respiratory tract infection in children. It was also found in 15% of children with upper respiratory infections, Dr. Feigin noted.

▸ Monkeypox detection. A series of cases of monkeypox in children and adults in 2003 was traced to prairie dogs, which were shown in an epidemiological investigation to have been infected by exposure to giant Gambian rats. The human infections, as shown in this 2004 study, were associated with direct contact with sick prairies dogs kept or sold as pets (N. Engl. J. Med. 2004;350:342-50).

The study involved five males and six females ranging in age from 3 to 43 years, but a total of 35 cases were confirmed in a 2003 outbreak and another 36 were suspected, Dr. Feigin said.

Nearly half of the patients required hospitalization. Presentation included rash, fever, respiratory symptoms, and lymphadenitis, which all occurred in most of the patients. None of the U.S. cases were fatal, but there is a mortality rate of up to 10% associated with the infection in Africa.

Monkeypox can be differentiated from chickenpox by the fact that lesions in monkeypox are at the same stage at the same time, while chickenpox lesions can be seen in various stages at the same time as early as the second day of disease.

The smallpox vaccine can prevent monkeypox, and should be given to those with occupational exposures, and to close contacts of infected individuals.

The moral of the story: Get a real dog, not a prairie dog, Dr. Feigin quipped.

▸ Varicella vaccination. Two doses of varicella vaccine are better than one, according to the results of this study.

In 2,200 children randomized to receive either one or two doses of vaccine and followed for 10 years, the rate of varicella infection and persistence of varicella antibodies were compared. A total of 71 cases (including 15 confirmed cases) of varicella were reported in the one-dose group, compared with 25 cases (including 4 confirmed cases) in the two-dose group. The differences were statistically significant.

The vaccine efficacy rate was 94% for one dose, and 98% for two doses (Pediatr. Infect. Dis. J. 2004;23:132-7).

The authors concluded that both one and two doses result in long-term protection against varicella, but that the two-dose regimen is more effective. Dr. Feigin noted that in those over age 12 years, two doses are currently recommended, because after one dose the seroconversion rate is 78%-82%, and after two doses it is 99%.

BAL HARBOUR, FLA. — One of the most interesting pediatric infectious disease papers in the past year—according to Ralph D. Feigin, M.D.—suggests that cephalosporins are superior to penicillin for the treatment of group A beta-hemolytic streptococcal tonsillopharyngitis in children.

But take a closer look at the metaanalysis before changing your approach to the treatment of this common condition, Dr. Feigin advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

The authors included 35 trials involving 7,125 patients in their study, and found that the overall odds ratios for bacteriologic and clinical cure rates significantly favored cephalosporins. They concluded that the likelihood of treatment failure is less if an oral cephalosporin is used for treatment (Pediatrics. 2004;113:866-82).

However, the failure to exclude group A beta-hemolytic streptococcus (GABHS) carriers in some of the clinical trials included in the metaanalysis is of concern, said Dr. Feigin, chairman of the department of pediatrics at Baylor College of Medicine, Houston.

Cephalosporins have been shown to be superior to penicillin for eradicating the GABHS carrier states, so the inclusion of a high proportion of carriers would skew the results in favor of cephalosporins in those studies; the statistical analysis used in the metaanalysis fails to adequately address this issue, he said.

Furthermore, only 6 of the 35 studies included were double blinded, and only 9 were investigator blinded. Eleven studies did not include typing of organisms to determine if positive follow-up cultures represented new infection.

The numerous cephalosporins represented in the studies—11 were used in the 35 studies—and lack of compliance testing in 9 of the studies, were also items of concern, Dr. Feigin said.

Penicillin has a narrower spectrum and much lower cost than many of the cephalosporins included in the metaanalysis, and it is effective for shortening disease course and limiting suppurative sequelae and transmission. Studies have shown that penicillin is effective for preventing acute rheumatic fever—even when it is initiated 9 days after onset of acute illness. Therefore, it should not be discounted as a drug of choice for GABHS tonsillopharyngitis, he said.

Other topics among Dr. Feigin's picks for the most interesting papers of the year were:

▸ Linezolid vs. vancomycin for treatment-resistant gram-positive infections in children. Linezolid was shown in this study of more than 300 hospitalized children with serious gram-positive infections to be effective and well tolerated (Pediatr. Infect. Dis. J. 2003;22:677-85).

The children were randomized to receive either 10 mg/kg of intravenous linezolid every 8 hours followed by oral linezolid, or to receive 10-15 mg/kg every 6-24 hours followed by an oral agent as appropriate. The pathogen eradication rates for methicillin-susceptible S. aureus and for methicillin-resistant coagulase-negative staphylococci were high in both groups and did not differ significantly.

Significantly more days of IV therapy were required with vancomycin (10.9 vs. 8.0 days) and significantly more patients had adverse drug-related events with vancomycin (34% vs. 19% of patient).

But if this study has you thinking about using linezolid instead of vancomycin—think again, Dr. Feigin advised. To postpone development of resistance to this newer drug for as long as possible, reserve it for use only in patients with infections for which other agents cannot be used, he said.

▸ Human metapneumovirus and lower respiratory tract disease. A new RNA virus known as human metapneumovirus was identified in 2001, and this 2004 study showed that the virus might be the cause of a considerable number of respiratory illnesses in children. Of 248 specimens from children from whom no virus was previously isolated, 49 were found to be associated with metapneumovirus. About 25% of the infections were in children under age 6 months, and 49% were in those ages 6 months to 1 year (N. Engl. J. Med.2004;350:443-50).

The findings suggest that this is a relatively frequent cause of lower respiratory tract infection in children. It was also found in 15% of children with upper respiratory infections, Dr. Feigin noted.

▸ Monkeypox detection. A series of cases of monkeypox in children and adults in 2003 was traced to prairie dogs, which were shown in an epidemiological investigation to have been infected by exposure to giant Gambian rats. The human infections, as shown in this 2004 study, were associated with direct contact with sick prairies dogs kept or sold as pets (N. Engl. J. Med. 2004;350:342-50).

The study involved five males and six females ranging in age from 3 to 43 years, but a total of 35 cases were confirmed in a 2003 outbreak and another 36 were suspected, Dr. Feigin said.

Nearly half of the patients required hospitalization. Presentation included rash, fever, respiratory symptoms, and lymphadenitis, which all occurred in most of the patients. None of the U.S. cases were fatal, but there is a mortality rate of up to 10% associated with the infection in Africa.

Monkeypox can be differentiated from chickenpox by the fact that lesions in monkeypox are at the same stage at the same time, while chickenpox lesions can be seen in various stages at the same time as early as the second day of disease.

The smallpox vaccine can prevent monkeypox, and should be given to those with occupational exposures, and to close contacts of infected individuals.

The moral of the story: Get a real dog, not a prairie dog, Dr. Feigin quipped.

▸ Varicella vaccination. Two doses of varicella vaccine are better than one, according to the results of this study.

In 2,200 children randomized to receive either one or two doses of vaccine and followed for 10 years, the rate of varicella infection and persistence of varicella antibodies were compared. A total of 71 cases (including 15 confirmed cases) of varicella were reported in the one-dose group, compared with 25 cases (including 4 confirmed cases) in the two-dose group. The differences were statistically significant.

The vaccine efficacy rate was 94% for one dose, and 98% for two doses (Pediatr. Infect. Dis. J. 2004;23:132-7).

The authors concluded that both one and two doses result in long-term protection against varicella, but that the two-dose regimen is more effective. Dr. Feigin noted that in those over age 12 years, two doses are currently recommended, because after one dose the seroconversion rate is 78%-82%, and after two doses it is 99%.

BAL HARBOUR, FLA. — One of the most interesting pediatric infectious disease papers in the past year—according to Ralph D. Feigin, M.D.—suggests that cephalosporins are superior to penicillin for the treatment of group A beta-hemolytic streptococcal tonsillopharyngitis in children.

But take a closer look at the metaanalysis before changing your approach to the treatment of this common condition, Dr. Feigin advised at the annual Masters of Pediatrics conference sponsored by the University of Miami.

The authors included 35 trials involving 7,125 patients in their study, and found that the overall odds ratios for bacteriologic and clinical cure rates significantly favored cephalosporins. They concluded that the likelihood of treatment failure is less if an oral cephalosporin is used for treatment (Pediatrics. 2004;113:866-82).

However, the failure to exclude group A beta-hemolytic streptococcus (GABHS) carriers in some of the clinical trials included in the metaanalysis is of concern, said Dr. Feigin, chairman of the department of pediatrics at Baylor College of Medicine, Houston.

Cephalosporins have been shown to be superior to penicillin for eradicating the GABHS carrier states, so the inclusion of a high proportion of carriers would skew the results in favor of cephalosporins in those studies; the statistical analysis used in the metaanalysis fails to adequately address this issue, he said.

Furthermore, only 6 of the 35 studies included were double blinded, and only 9 were investigator blinded. Eleven studies did not include typing of organisms to determine if positive follow-up cultures represented new infection.

The numerous cephalosporins represented in the studies—11 were used in the 35 studies—and lack of compliance testing in 9 of the studies, were also items of concern, Dr. Feigin said.

Penicillin has a narrower spectrum and much lower cost than many of the cephalosporins included in the metaanalysis, and it is effective for shortening disease course and limiting suppurative sequelae and transmission. Studies have shown that penicillin is effective for preventing acute rheumatic fever—even when it is initiated 9 days after onset of acute illness. Therefore, it should not be discounted as a drug of choice for GABHS tonsillopharyngitis, he said.

Other topics among Dr. Feigin's picks for the most interesting papers of the year were:

▸ Linezolid vs. vancomycin for treatment-resistant gram-positive infections in children. Linezolid was shown in this study of more than 300 hospitalized children with serious gram-positive infections to be effective and well tolerated (Pediatr. Infect. Dis. J. 2003;22:677-85).

The children were randomized to receive either 10 mg/kg of intravenous linezolid every 8 hours followed by oral linezolid, or to receive 10-15 mg/kg every 6-24 hours followed by an oral agent as appropriate. The pathogen eradication rates for methicillin-susceptible S. aureus and for methicillin-resistant coagulase-negative staphylococci were high in both groups and did not differ significantly.

Significantly more days of IV therapy were required with vancomycin (10.9 vs. 8.0 days) and significantly more patients had adverse drug-related events with vancomycin (34% vs. 19% of patient).

But if this study has you thinking about using linezolid instead of vancomycin—think again, Dr. Feigin advised. To postpone development of resistance to this newer drug for as long as possible, reserve it for use only in patients with infections for which other agents cannot be used, he said.

▸ Human metapneumovirus and lower respiratory tract disease. A new RNA virus known as human metapneumovirus was identified in 2001, and this 2004 study showed that the virus might be the cause of a considerable number of respiratory illnesses in children. Of 248 specimens from children from whom no virus was previously isolated, 49 were found to be associated with metapneumovirus. About 25% of the infections were in children under age 6 months, and 49% were in those ages 6 months to 1 year (N. Engl. J. Med.2004;350:443-50).

The findings suggest that this is a relatively frequent cause of lower respiratory tract infection in children. It was also found in 15% of children with upper respiratory infections, Dr. Feigin noted.

▸ Monkeypox detection. A series of cases of monkeypox in children and adults in 2003 was traced to prairie dogs, which were shown in an epidemiological investigation to have been infected by exposure to giant Gambian rats. The human infections, as shown in this 2004 study, were associated with direct contact with sick prairies dogs kept or sold as pets (N. Engl. J. Med. 2004;350:342-50).

The study involved five males and six females ranging in age from 3 to 43 years, but a total of 35 cases were confirmed in a 2003 outbreak and another 36 were suspected, Dr. Feigin said.

Nearly half of the patients required hospitalization. Presentation included rash, fever, respiratory symptoms, and lymphadenitis, which all occurred in most of the patients. None of the U.S. cases were fatal, but there is a mortality rate of up to 10% associated with the infection in Africa.

Monkeypox can be differentiated from chickenpox by the fact that lesions in monkeypox are at the same stage at the same time, while chickenpox lesions can be seen in various stages at the same time as early as the second day of disease.

The smallpox vaccine can prevent monkeypox, and should be given to those with occupational exposures, and to close contacts of infected individuals.

The moral of the story: Get a real dog, not a prairie dog, Dr. Feigin quipped.

▸ Varicella vaccination. Two doses of varicella vaccine are better than one, according to the results of this study.

In 2,200 children randomized to receive either one or two doses of vaccine and followed for 10 years, the rate of varicella infection and persistence of varicella antibodies were compared. A total of 71 cases (including 15 confirmed cases) of varicella were reported in the one-dose group, compared with 25 cases (including 4 confirmed cases) in the two-dose group. The differences were statistically significant.

The vaccine efficacy rate was 94% for one dose, and 98% for two doses (Pediatr. Infect. Dis. J. 2004;23:132-7).

The authors concluded that both one and two doses result in long-term protection against varicella, but that the two-dose regimen is more effective. Dr. Feigin noted that in those over age 12 years, two doses are currently recommended, because after one dose the seroconversion rate is 78%-82%, and after two doses it is 99%.

BAL HARBOUR, FLA. — Tiptoe walking in young children is troubling to parents, but an extensive evaluation is necessary only in those over age 2 years, Stephen Stricker, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Before age 2 years, walking on the toes is considered a normal behavior. After that age, concerns arise about potentially serious physical or psychiatric problems, said Dr. Stricker, chief of pediatric orthopedics at the university.

In most patients, tiptoe walking is idiopathic and will resolve over time, but in some patients the behavior is a sign of neuromuscular problems, schizophrenia, or learning disorders.

Unilateral tiptoe walking is usually a result of leg length discrepancy, spastic hemiparesis, or Achilles tendinitis. Less often, it is associated with calf hemangioma, linear scleroderma, or conversion reaction.

Bilateral tiptoe walking also is typically idiopathic, but can be associated with spastic diplegia. Less common causes are peripheral neuropathy, muscular dystrophy, psychosis, learning disorders, and spinal cord anomaly, Dr. Stricker said.

Four basic questions can help in sorting out the differential diagnosis. These include:

▸ When was the onset of tiptoe gait? Early onset tiptoe walking—defined as tiptoeing from initial ambulation or within 3 months of initial ambulation—usually is idiopathic or associated with spastic diplegic cerebral palsy.

Late onset tiptoe walking—defined as tiptoeing which begins 4 or more months after a heel-toe gait has been established—usually indicates a neuromuscular problem such as Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a spinal cord anomaly, and requires evaluation by a pediatric neurologist, Dr. Stricker said.

▸ Is there a family history of toe walking? Tiptoe walking is idiopathic in about 40% of children with a family history of tiptoe walkers, but it is important to obtain a family history because this can help in diagnosing Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a psychiatric disorder. For example, if a parent has schizophrenia, a psychiatric evaluation of the child is warranted.

▸ Is the neurologic examination abnormal? An abnormal neurologic examination can help sort out the finer details of the cause of tiptoe walking in a child with a neuromuscular basis for the behavior.

▸ Is there Achilles contracture? A normal child should have 10 degrees of dorsal flexion. Proper measurement of dorsal flexion requires that the knee be extended, and the midfoot stabilized using the thumb (allowing midfoot pronation will falsely add 5-10 degrees of dorsal flexion). If you are unable to flex the ankle to neutral in this position, the Achilles tendon is tight.

Consider referring children older than age 2 years with tiptoe walking for evaluation by a neurologist, psychiatrist (particularly if there is a family history of psychiatric disorder), and orthopedist, Dr. Stricker advised.

Treatment depends on the cause and type of tiptoe walking.

▸ Dynamic Achilles contracture. This—also known as overactive gastrocsoleus—might be managed with observation (idiopathic cases have been shown to resolve over time and to be clinically undetectable at 15-year follow-up); serial casting; botulinum toxin injections; gastroc recession (although his own studies have shown a 30% recurrence rate with this procedure, Dr. Stricker noted); or bracing. This is true for both idiopathic cases and spastic diplegic cases with this type of contracture.

▸ Static Achilles contracture. This—also known as tight gastrocsoleus—might be treated with gastroc recession or Achilles tendon lengthening in those with idiopathic and spastic diplegic tiptoe walking.

There are few data on treatment of psychiatric tiptoe walking, but generally this is treated the same as idiopathic tiptoe walking. Outcomes, however, are less predictable in these patients, Dr. Stricker noted.

In those with Charcot-Marie-Tooth disease, treatments include ankle-foot orthosis splinting, plantar fasciotomy, tendon transfers, and foot osteotomies. In Duchenne's muscular dystrophy, treatment may include ankle-foot orthosis splinting, or early surgery to lengthen the Achilles tendon or perform tendon transfer.

BAL HARBOUR, FLA. — Tiptoe walking in young children is troubling to parents, but an extensive evaluation is necessary only in those over age 2 years, Stephen Stricker, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Before age 2 years, walking on the toes is considered a normal behavior. After that age, concerns arise about potentially serious physical or psychiatric problems, said Dr. Stricker, chief of pediatric orthopedics at the university.

In most patients, tiptoe walking is idiopathic and will resolve over time, but in some patients the behavior is a sign of neuromuscular problems, schizophrenia, or learning disorders.

Unilateral tiptoe walking is usually a result of leg length discrepancy, spastic hemiparesis, or Achilles tendinitis. Less often, it is associated with calf hemangioma, linear scleroderma, or conversion reaction.

Bilateral tiptoe walking also is typically idiopathic, but can be associated with spastic diplegia. Less common causes are peripheral neuropathy, muscular dystrophy, psychosis, learning disorders, and spinal cord anomaly, Dr. Stricker said.

Four basic questions can help in sorting out the differential diagnosis. These include:

▸ When was the onset of tiptoe gait? Early onset tiptoe walking—defined as tiptoeing from initial ambulation or within 3 months of initial ambulation—usually is idiopathic or associated with spastic diplegic cerebral palsy.

Late onset tiptoe walking—defined as tiptoeing which begins 4 or more months after a heel-toe gait has been established—usually indicates a neuromuscular problem such as Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a spinal cord anomaly, and requires evaluation by a pediatric neurologist, Dr. Stricker said.

▸ Is there a family history of toe walking? Tiptoe walking is idiopathic in about 40% of children with a family history of tiptoe walkers, but it is important to obtain a family history because this can help in diagnosing Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a psychiatric disorder. For example, if a parent has schizophrenia, a psychiatric evaluation of the child is warranted.

▸ Is the neurologic examination abnormal? An abnormal neurologic examination can help sort out the finer details of the cause of tiptoe walking in a child with a neuromuscular basis for the behavior.

▸ Is there Achilles contracture? A normal child should have 10 degrees of dorsal flexion. Proper measurement of dorsal flexion requires that the knee be extended, and the midfoot stabilized using the thumb (allowing midfoot pronation will falsely add 5-10 degrees of dorsal flexion). If you are unable to flex the ankle to neutral in this position, the Achilles tendon is tight.

Consider referring children older than age 2 years with tiptoe walking for evaluation by a neurologist, psychiatrist (particularly if there is a family history of psychiatric disorder), and orthopedist, Dr. Stricker advised.

Treatment depends on the cause and type of tiptoe walking.

▸ Dynamic Achilles contracture. This—also known as overactive gastrocsoleus—might be managed with observation (idiopathic cases have been shown to resolve over time and to be clinically undetectable at 15-year follow-up); serial casting; botulinum toxin injections; gastroc recession (although his own studies have shown a 30% recurrence rate with this procedure, Dr. Stricker noted); or bracing. This is true for both idiopathic cases and spastic diplegic cases with this type of contracture.

▸ Static Achilles contracture. This—also known as tight gastrocsoleus—might be treated with gastroc recession or Achilles tendon lengthening in those with idiopathic and spastic diplegic tiptoe walking.

There are few data on treatment of psychiatric tiptoe walking, but generally this is treated the same as idiopathic tiptoe walking. Outcomes, however, are less predictable in these patients, Dr. Stricker noted.

In those with Charcot-Marie-Tooth disease, treatments include ankle-foot orthosis splinting, plantar fasciotomy, tendon transfers, and foot osteotomies. In Duchenne's muscular dystrophy, treatment may include ankle-foot orthosis splinting, or early surgery to lengthen the Achilles tendon or perform tendon transfer.

BAL HARBOUR, FLA. — Tiptoe walking in young children is troubling to parents, but an extensive evaluation is necessary only in those over age 2 years, Stephen Stricker, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Before age 2 years, walking on the toes is considered a normal behavior. After that age, concerns arise about potentially serious physical or psychiatric problems, said Dr. Stricker, chief of pediatric orthopedics at the university.

In most patients, tiptoe walking is idiopathic and will resolve over time, but in some patients the behavior is a sign of neuromuscular problems, schizophrenia, or learning disorders.

Unilateral tiptoe walking is usually a result of leg length discrepancy, spastic hemiparesis, or Achilles tendinitis. Less often, it is associated with calf hemangioma, linear scleroderma, or conversion reaction.

Bilateral tiptoe walking also is typically idiopathic, but can be associated with spastic diplegia. Less common causes are peripheral neuropathy, muscular dystrophy, psychosis, learning disorders, and spinal cord anomaly, Dr. Stricker said.

Four basic questions can help in sorting out the differential diagnosis. These include:

▸ When was the onset of tiptoe gait? Early onset tiptoe walking—defined as tiptoeing from initial ambulation or within 3 months of initial ambulation—usually is idiopathic or associated with spastic diplegic cerebral palsy.

Late onset tiptoe walking—defined as tiptoeing which begins 4 or more months after a heel-toe gait has been established—usually indicates a neuromuscular problem such as Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a spinal cord anomaly, and requires evaluation by a pediatric neurologist, Dr. Stricker said.

▸ Is there a family history of toe walking? Tiptoe walking is idiopathic in about 40% of children with a family history of tiptoe walkers, but it is important to obtain a family history because this can help in diagnosing Charcot-Marie-Tooth disease, Duchenne's muscular dystrophy, or a psychiatric disorder. For example, if a parent has schizophrenia, a psychiatric evaluation of the child is warranted.

▸ Is the neurologic examination abnormal? An abnormal neurologic examination can help sort out the finer details of the cause of tiptoe walking in a child with a neuromuscular basis for the behavior.

▸ Is there Achilles contracture? A normal child should have 10 degrees of dorsal flexion. Proper measurement of dorsal flexion requires that the knee be extended, and the midfoot stabilized using the thumb (allowing midfoot pronation will falsely add 5-10 degrees of dorsal flexion). If you are unable to flex the ankle to neutral in this position, the Achilles tendon is tight.

Consider referring children older than age 2 years with tiptoe walking for evaluation by a neurologist, psychiatrist (particularly if there is a family history of psychiatric disorder), and orthopedist, Dr. Stricker advised.

Treatment depends on the cause and type of tiptoe walking.

▸ Dynamic Achilles contracture. This—also known as overactive gastrocsoleus—might be managed with observation (idiopathic cases have been shown to resolve over time and to be clinically undetectable at 15-year follow-up); serial casting; botulinum toxin injections; gastroc recession (although his own studies have shown a 30% recurrence rate with this procedure, Dr. Stricker noted); or bracing. This is true for both idiopathic cases and spastic diplegic cases with this type of contracture.

▸ Static Achilles contracture. This—also known as tight gastrocsoleus—might be treated with gastroc recession or Achilles tendon lengthening in those with idiopathic and spastic diplegic tiptoe walking.

There are few data on treatment of psychiatric tiptoe walking, but generally this is treated the same as idiopathic tiptoe walking. Outcomes, however, are less predictable in these patients, Dr. Stricker noted.

In those with Charcot-Marie-Tooth disease, treatments include ankle-foot orthosis splinting, plantar fasciotomy, tendon transfers, and foot osteotomies. In Duchenne's muscular dystrophy, treatment may include ankle-foot orthosis splinting, or early surgery to lengthen the Achilles tendon or perform tendon transfer.

NEW ORLEANS – The chemically induced dissociation that can occur with opioid use may affect the development of substance use disorder among victims of childhood abuse and interfere with recovery from the disorder, Eli Somer, Ph.D., said at the annual conference of the International Society for the Study of Dissociation.

Evidence from the literature and a qualitative study of 100 patients recovering from a drug use disorder provides preliminary support for this theory, said Dr. Somer of the Israel Institute for Treatment and Study of Stress, Haifa.

A chemical dissociation serving a purpose similar to nonchemical dissociation, and inducing the same powerful tranquilizing and numbing effects, appears to occur in many individuals with opiate disorder. It may be a tool for coping with intolerable experiences when psychological coping–such as dissociation–fails, he explained, adding that, in some cases, dissociative symptoms themselves are distressing enough to lead to “self-medication” with heroin.

The literature shows that a childhood trauma history is present in a substantial proportion of opioid users. In fact, several studies show that the odds of a comorbid substance abuse disorder are three times greater in those with posttraumatic stress disorder versus those without PTSD, he said.

In one study, PTSD occurred first in up to 65% of men and 84% of women with comorbid PTSD and substance use disorders, which suggests that substance use among survivors of childhood abuse develops out of attempts to self-medicate.

“Indeed, the most prominent consequence of childhood abuse turns out to be adult substance use disorder,” Dr. Somer noted.

This has been demonstrated in at least three major studies, and data consistently show higher traumatization history scores–typically reflecting childhood abuse or neglect–among patients recovering from opiate use disorder, compared with the scores of nonusing patients presenting to outpatient stress clinics, he said.

An apparent neurobiologic basis for the heroin-induced dissociation theory also exists. Areas of the brain most responsible for emotions and stress–such as the hippocampus and amygdala–share a high density of both norepinephrine and opioid receptors, and when a person is in danger these areas produce high levels of natural opioids, which can temporarily mask pain.

“Scientists have found that people with PTSD continue to produce these higher levels even when the danger has passed, so this may be associated with the blunted emotions” that occur in the condition, he said.

Other studies show that serious physical threat can induce analgesia, and anesthesia and analgesia in these studies were the symptoms that best predicted cases of posttraumatic dissociative disorders. Traumatized individuals appear capable of producing elevated levels of natural opioids that can temporarily mask emotional and physical pain, Dr. Somer explained.

“Therefore, it is conceivable that traumatized individuals would find the effects of exogenous opioids to be a gratifying shield between posttraumatic torment and conscious awareness,” he added, explaining that abuse survivors might self-medicate with opioids to mimic the chemically endogenous release to attenuate traumatic stress.

In a study of 100 recovering heroin addicts, Dr. Somer found that patients who were more traumatized were more likely to experience dissociative experiences when they had been under the influence of the drug. “We found preliminary evidence that recovering heroin users experiencing dissociation phenomena live through heroin intoxication differently than heroin users who are low 'dissociators,'” he said, noting also that abstinence periods were shorter for those experiencing dissociation.

Qualitative interviews with the patients about their experiences with heroin revealed four common uses for the drug. The first was induction of chemical amnesia. As one patient described, the drug temporarily erased the horrors of his childhood.

The second use–suppression of posttraumatic arousal symptoms–was defined by one patient as elimination of her many fears. The third use was chemical numbing or depersonalization and derealization. For one patient, this meant pain relief; for another it meant diminished self-hatred.

And the fourth use, induction of soothing and gratifying pleasure, meant warmth for a patient who said she always felt cold from the inside out except for when she was using heroin.

“These results render credible, preliminary support for the idea that some survivors of abuse or neglect use heroin as a dissociative agent,” said Dr. Somer, adding that some recovering addicts assigned benevolent, nurturing, human qualities to the drug.

“This was, to our minds, a sad testimonial to the emotional emaciation of these individuals,” he said.

NEW ORLEANS – The chemically induced dissociation that can occur with opioid use may affect the development of substance use disorder among victims of childhood abuse and interfere with recovery from the disorder, Eli Somer, Ph.D., said at the annual conference of the International Society for the Study of Dissociation.

Evidence from the literature and a qualitative study of 100 patients recovering from a drug use disorder provides preliminary support for this theory, said Dr. Somer of the Israel Institute for Treatment and Study of Stress, Haifa.

A chemical dissociation serving a purpose similar to nonchemical dissociation, and inducing the same powerful tranquilizing and numbing effects, appears to occur in many individuals with opiate disorder. It may be a tool for coping with intolerable experiences when psychological coping–such as dissociation–fails, he explained, adding that, in some cases, dissociative symptoms themselves are distressing enough to lead to “self-medication” with heroin.

The literature shows that a childhood trauma history is present in a substantial proportion of opioid users. In fact, several studies show that the odds of a comorbid substance abuse disorder are three times greater in those with posttraumatic stress disorder versus those without PTSD, he said.

In one study, PTSD occurred first in up to 65% of men and 84% of women with comorbid PTSD and substance use disorders, which suggests that substance use among survivors of childhood abuse develops out of attempts to self-medicate.

“Indeed, the most prominent consequence of childhood abuse turns out to be adult substance use disorder,” Dr. Somer noted.

This has been demonstrated in at least three major studies, and data consistently show higher traumatization history scores–typically reflecting childhood abuse or neglect–among patients recovering from opiate use disorder, compared with the scores of nonusing patients presenting to outpatient stress clinics, he said.

An apparent neurobiologic basis for the heroin-induced dissociation theory also exists. Areas of the brain most responsible for emotions and stress–such as the hippocampus and amygdala–share a high density of both norepinephrine and opioid receptors, and when a person is in danger these areas produce high levels of natural opioids, which can temporarily mask pain.

“Scientists have found that people with PTSD continue to produce these higher levels even when the danger has passed, so this may be associated with the blunted emotions” that occur in the condition, he said.

Other studies show that serious physical threat can induce analgesia, and anesthesia and analgesia in these studies were the symptoms that best predicted cases of posttraumatic dissociative disorders. Traumatized individuals appear capable of producing elevated levels of natural opioids that can temporarily mask emotional and physical pain, Dr. Somer explained.

“Therefore, it is conceivable that traumatized individuals would find the effects of exogenous opioids to be a gratifying shield between posttraumatic torment and conscious awareness,” he added, explaining that abuse survivors might self-medicate with opioids to mimic the chemically endogenous release to attenuate traumatic stress.

In a study of 100 recovering heroin addicts, Dr. Somer found that patients who were more traumatized were more likely to experience dissociative experiences when they had been under the influence of the drug. “We found preliminary evidence that recovering heroin users experiencing dissociation phenomena live through heroin intoxication differently than heroin users who are low 'dissociators,'” he said, noting also that abstinence periods were shorter for those experiencing dissociation.

Qualitative interviews with the patients about their experiences with heroin revealed four common uses for the drug. The first was induction of chemical amnesia. As one patient described, the drug temporarily erased the horrors of his childhood.

The second use–suppression of posttraumatic arousal symptoms–was defined by one patient as elimination of her many fears. The third use was chemical numbing or depersonalization and derealization. For one patient, this meant pain relief; for another it meant diminished self-hatred.

And the fourth use, induction of soothing and gratifying pleasure, meant warmth for a patient who said she always felt cold from the inside out except for when she was using heroin.

“These results render credible, preliminary support for the idea that some survivors of abuse or neglect use heroin as a dissociative agent,” said Dr. Somer, adding that some recovering addicts assigned benevolent, nurturing, human qualities to the drug.

“This was, to our minds, a sad testimonial to the emotional emaciation of these individuals,” he said.

NEW ORLEANS – The chemically induced dissociation that can occur with opioid use may affect the development of substance use disorder among victims of childhood abuse and interfere with recovery from the disorder, Eli Somer, Ph.D., said at the annual conference of the International Society for the Study of Dissociation.

Evidence from the literature and a qualitative study of 100 patients recovering from a drug use disorder provides preliminary support for this theory, said Dr. Somer of the Israel Institute for Treatment and Study of Stress, Haifa.

A chemical dissociation serving a purpose similar to nonchemical dissociation, and inducing the same powerful tranquilizing and numbing effects, appears to occur in many individuals with opiate disorder. It may be a tool for coping with intolerable experiences when psychological coping–such as dissociation–fails, he explained, adding that, in some cases, dissociative symptoms themselves are distressing enough to lead to “self-medication” with heroin.

The literature shows that a childhood trauma history is present in a substantial proportion of opioid users. In fact, several studies show that the odds of a comorbid substance abuse disorder are three times greater in those with posttraumatic stress disorder versus those without PTSD, he said.

In one study, PTSD occurred first in up to 65% of men and 84% of women with comorbid PTSD and substance use disorders, which suggests that substance use among survivors of childhood abuse develops out of attempts to self-medicate.

“Indeed, the most prominent consequence of childhood abuse turns out to be adult substance use disorder,” Dr. Somer noted.

This has been demonstrated in at least three major studies, and data consistently show higher traumatization history scores–typically reflecting childhood abuse or neglect–among patients recovering from opiate use disorder, compared with the scores of nonusing patients presenting to outpatient stress clinics, he said.

An apparent neurobiologic basis for the heroin-induced dissociation theory also exists. Areas of the brain most responsible for emotions and stress–such as the hippocampus and amygdala–share a high density of both norepinephrine and opioid receptors, and when a person is in danger these areas produce high levels of natural opioids, which can temporarily mask pain.

“Scientists have found that people with PTSD continue to produce these higher levels even when the danger has passed, so this may be associated with the blunted emotions” that occur in the condition, he said.

Other studies show that serious physical threat can induce analgesia, and anesthesia and analgesia in these studies were the symptoms that best predicted cases of posttraumatic dissociative disorders. Traumatized individuals appear capable of producing elevated levels of natural opioids that can temporarily mask emotional and physical pain, Dr. Somer explained.

“Therefore, it is conceivable that traumatized individuals would find the effects of exogenous opioids to be a gratifying shield between posttraumatic torment and conscious awareness,” he added, explaining that abuse survivors might self-medicate with opioids to mimic the chemically endogenous release to attenuate traumatic stress.

In a study of 100 recovering heroin addicts, Dr. Somer found that patients who were more traumatized were more likely to experience dissociative experiences when they had been under the influence of the drug. “We found preliminary evidence that recovering heroin users experiencing dissociation phenomena live through heroin intoxication differently than heroin users who are low 'dissociators,'” he said, noting also that abstinence periods were shorter for those experiencing dissociation.

Qualitative interviews with the patients about their experiences with heroin revealed four common uses for the drug. The first was induction of chemical amnesia. As one patient described, the drug temporarily erased the horrors of his childhood.

The second use–suppression of posttraumatic arousal symptoms–was defined by one patient as elimination of her many fears. The third use was chemical numbing or depersonalization and derealization. For one patient, this meant pain relief; for another it meant diminished self-hatred.

And the fourth use, induction of soothing and gratifying pleasure, meant warmth for a patient who said she always felt cold from the inside out except for when she was using heroin.

“These results render credible, preliminary support for the idea that some survivors of abuse or neglect use heroin as a dissociative agent,” said Dr. Somer, adding that some recovering addicts assigned benevolent, nurturing, human qualities to the drug.

“This was, to our minds, a sad testimonial to the emotional emaciation of these individuals,” he said.

ORLANDO, FLA. — Antiviral therapy for recurrent hepatitis C infection in patients who have had orthotopic liver transplantation promotes a sustained virologic response, but also appears to contribute to a substantial number of allograft failures, Don C. Rockey, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 49 patients who had liver transplantation for chronic hepatitis C virus (HCV) infection between 1991 and 2004 and who received antiviral therapy with interferon and ribavirin for recurrent HCV, 12 had a sustained virologic response, 18 had a measurable improvement in liver test results, and 7 developed acute and/or ductopenic allograft rejection during therapy.

In each case, the development of abnormalities was associated with elimination of HCV RNA from the serum, said Dr. Rockey of Duke University, Durham, N.C. Three patients died from complications associated with profound cholestasis.

Other reports of allograft rejection during antiviral therapy in transplant patients have raised questions about the appropriateness of such treatment. Although aggressive anti-HCV therapy led to a sustained virologic response in nearly a third of the transplant patients with recurrent HCV who did not experience allograft rejection, there is an apparent tradeoff in terms of an increased risk of rejection in some patients, Dr. Rockey noted.

Large randomized, controlled studies are needed to better assess the effects of antiviral therapy on liver transplant patients, he concluded.

ORLANDO, FLA. — Antiviral therapy for recurrent hepatitis C infection in patients who have had orthotopic liver transplantation promotes a sustained virologic response, but also appears to contribute to a substantial number of allograft failures, Don C. Rockey, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 49 patients who had liver transplantation for chronic hepatitis C virus (HCV) infection between 1991 and 2004 and who received antiviral therapy with interferon and ribavirin for recurrent HCV, 12 had a sustained virologic response, 18 had a measurable improvement in liver test results, and 7 developed acute and/or ductopenic allograft rejection during therapy.

In each case, the development of abnormalities was associated with elimination of HCV RNA from the serum, said Dr. Rockey of Duke University, Durham, N.C. Three patients died from complications associated with profound cholestasis.

Other reports of allograft rejection during antiviral therapy in transplant patients have raised questions about the appropriateness of such treatment. Although aggressive anti-HCV therapy led to a sustained virologic response in nearly a third of the transplant patients with recurrent HCV who did not experience allograft rejection, there is an apparent tradeoff in terms of an increased risk of rejection in some patients, Dr. Rockey noted.

Large randomized, controlled studies are needed to better assess the effects of antiviral therapy on liver transplant patients, he concluded.

ORLANDO, FLA. — Antiviral therapy for recurrent hepatitis C infection in patients who have had orthotopic liver transplantation promotes a sustained virologic response, but also appears to contribute to a substantial number of allograft failures, Don C. Rockey, M.D., reported at the annual meeting of the American College of Gastroenterology.

Of 49 patients who had liver transplantation for chronic hepatitis C virus (HCV) infection between 1991 and 2004 and who received antiviral therapy with interferon and ribavirin for recurrent HCV, 12 had a sustained virologic response, 18 had a measurable improvement in liver test results, and 7 developed acute and/or ductopenic allograft rejection during therapy.

In each case, the development of abnormalities was associated with elimination of HCV RNA from the serum, said Dr. Rockey of Duke University, Durham, N.C. Three patients died from complications associated with profound cholestasis.

Other reports of allograft rejection during antiviral therapy in transplant patients have raised questions about the appropriateness of such treatment. Although aggressive anti-HCV therapy led to a sustained virologic response in nearly a third of the transplant patients with recurrent HCV who did not experience allograft rejection, there is an apparent tradeoff in terms of an increased risk of rejection in some patients, Dr. Rockey noted.

Large randomized, controlled studies are needed to better assess the effects of antiviral therapy on liver transplant patients, he concluded.

Flu Vaccine Production

Chiron's license to manufacture influenza vaccine, which was suspended in October as a result of contamination at the company's Liverpool, England, facility, has been reinstated, and vaccine manufacturing for the coming season will proceed.

The British Medicines and Healthcare Products Regulatory Agency (MHRA), working closely with the U.S. Food and Drug Administration, has been monitoring Chiron's progress in correcting the manufacturing problems that reduced the doses of vaccine slated for the U.S. market for the 2004-2005 flu season by nearly 50 million. The MHRA made the decision to lift the suspension, but the FDA will conduct a comprehensive inspection of the facility once manufacturing resumes and the corrective action can be evaluated to ensure production of a safe and effective vaccine, according to a statement by Jesse Goodman, M.D., director of the FDA's Center for Biologics Evaluation and Research.

The vaccine shortages that resulted from Chiron's license suspension brought the FDA under fire from government officials, who said the crisis was in part a result of the agency's lax oversight of the facility after previous findings of bacterial contamination and poor sanitary procedures.

TB Transmission Detection

The incidence of tuberculosis continues to decline, but an outbreak in a homeless shelter has underscored the importance of rapid DNA genotyping for detection of possible transmissions, particularly in such settings, according to the Centers for Disease Control and Prevention.

The outbreak in a shelter in New York initially involved a cluster of eight cases. A search of the Mycobacterium tuberculosis-genotyping databases for strains matching these cases revealed many other associated cases. Screening of shelter residents identified 29 cases among residents between 2000 and 2003, and 11 of 26 cases with genotype data available matched those in the outbreak (MMWR 2005;54:149-52).

Genotyping suggested that multiple chains of transmission were occurring simultaneously. To improve access to the genotyping technology, the CDC began offering universal M. tuberculosis rapid genotyping to health department TB control programs last year.

Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis has been associated with aerosolized Mycobacterium avium complex in indoor hot tubs, but a recent case suggests that showering water might also pose a risk, Theodore K. Marras, M.D., of the University of Toronto and his colleagues reported.

The case involved a 50-year-old man with histologically proven hypersensitivity pneumonitis; MAC-positive sputum culture findings; and progressive dyspnea, episodic fever, and myalgias. The symptoms were similar to those of reported hot tub-associated cases (often called “hot tub lung”), but multiple samples from the respiratory tract and from the patient's shower and bathtub grew MAC with matching pulsed-field gel electrophoresis patterns, while specimens from his hot tub were negative (Chest 2005;127:664-71).

He switched from showering to tub bathing, and after about 1 year of treatment with prednisone and antimycobacterial drugs, his condition resolved. This is the first reported case of MAC-associated hypersensitivity pneumonitis believed to be associated with routine use of household water; the potential for sources other than hot tubs should be considered in patients presenting with MAC-hypersensitivity pneumonitis, the researchers said.

HIV-1 Viremia

The intermittent episodes of detectable viremia common in HIV-1 patients on highly active antiretroviral therapy generally do not represent new drug-resistant mutations of the virus, a study suggests.

These so-called blips probably represent random biologic and statistical variation around mean steady-state HIV-1 RNA levels slightly below 50 copies/mL. Blips tend to raise concerns about drug resistance, and can lead to costly medical tests and changes in drug therapy, Richard E. Nettles, M.D., of Johns Hopkins University, Baltimore, and his colleagues reported (JAMA 2005;293:817-29).

Intensive sampling over a 3- to 4-month period in 10 HIV-positive patients with long-term infection control revealed that blips usually have short duration (median of less than 3 days) and low magnitude (median of 79 copies/mL). Frequency was not associated with demographic, clinical, or treatment variables. Despite extensive analysis, no new genotypic resistance was detected in association with the blips.

Unlike blips, consistently detectable viremia and high-magnitude spikes (over 200 copies/mL) in viral load remain a cause for concern, the investigators concluded, noting that more study is needed to define when such viremia should trigger a change in therapy.

Flu Vaccine Production

Chiron's license to manufacture influenza vaccine, which was suspended in October as a result of contamination at the company's Liverpool, England, facility, has been reinstated, and vaccine manufacturing for the coming season will proceed.

The British Medicines and Healthcare Products Regulatory Agency (MHRA), working closely with the U.S. Food and Drug Administration, has been monitoring Chiron's progress in correcting the manufacturing problems that reduced the doses of vaccine slated for the U.S. market for the 2004-2005 flu season by nearly 50 million. The MHRA made the decision to lift the suspension, but the FDA will conduct a comprehensive inspection of the facility once manufacturing resumes and the corrective action can be evaluated to ensure production of a safe and effective vaccine, according to a statement by Jesse Goodman, M.D., director of the FDA's Center for Biologics Evaluation and Research.

The vaccine shortages that resulted from Chiron's license suspension brought the FDA under fire from government officials, who said the crisis was in part a result of the agency's lax oversight of the facility after previous findings of bacterial contamination and poor sanitary procedures.

TB Transmission Detection

The incidence of tuberculosis continues to decline, but an outbreak in a homeless shelter has underscored the importance of rapid DNA genotyping for detection of possible transmissions, particularly in such settings, according to the Centers for Disease Control and Prevention.

The outbreak in a shelter in New York initially involved a cluster of eight cases. A search of the Mycobacterium tuberculosis-genotyping databases for strains matching these cases revealed many other associated cases. Screening of shelter residents identified 29 cases among residents between 2000 and 2003, and 11 of 26 cases with genotype data available matched those in the outbreak (MMWR 2005;54:149-52).

Genotyping suggested that multiple chains of transmission were occurring simultaneously. To improve access to the genotyping technology, the CDC began offering universal M. tuberculosis rapid genotyping to health department TB control programs last year.

Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis has been associated with aerosolized Mycobacterium avium complex in indoor hot tubs, but a recent case suggests that showering water might also pose a risk, Theodore K. Marras, M.D., of the University of Toronto and his colleagues reported.

The case involved a 50-year-old man with histologically proven hypersensitivity pneumonitis; MAC-positive sputum culture findings; and progressive dyspnea, episodic fever, and myalgias. The symptoms were similar to those of reported hot tub-associated cases (often called “hot tub lung”), but multiple samples from the respiratory tract and from the patient's shower and bathtub grew MAC with matching pulsed-field gel electrophoresis patterns, while specimens from his hot tub were negative (Chest 2005;127:664-71).

He switched from showering to tub bathing, and after about 1 year of treatment with prednisone and antimycobacterial drugs, his condition resolved. This is the first reported case of MAC-associated hypersensitivity pneumonitis believed to be associated with routine use of household water; the potential for sources other than hot tubs should be considered in patients presenting with MAC-hypersensitivity pneumonitis, the researchers said.

HIV-1 Viremia

The intermittent episodes of detectable viremia common in HIV-1 patients on highly active antiretroviral therapy generally do not represent new drug-resistant mutations of the virus, a study suggests.

These so-called blips probably represent random biologic and statistical variation around mean steady-state HIV-1 RNA levels slightly below 50 copies/mL. Blips tend to raise concerns about drug resistance, and can lead to costly medical tests and changes in drug therapy, Richard E. Nettles, M.D., of Johns Hopkins University, Baltimore, and his colleagues reported (JAMA 2005;293:817-29).

Intensive sampling over a 3- to 4-month period in 10 HIV-positive patients with long-term infection control revealed that blips usually have short duration (median of less than 3 days) and low magnitude (median of 79 copies/mL). Frequency was not associated with demographic, clinical, or treatment variables. Despite extensive analysis, no new genotypic resistance was detected in association with the blips.

Unlike blips, consistently detectable viremia and high-magnitude spikes (over 200 copies/mL) in viral load remain a cause for concern, the investigators concluded, noting that more study is needed to define when such viremia should trigger a change in therapy.

Flu Vaccine Production

Chiron's license to manufacture influenza vaccine, which was suspended in October as a result of contamination at the company's Liverpool, England, facility, has been reinstated, and vaccine manufacturing for the coming season will proceed.

The British Medicines and Healthcare Products Regulatory Agency (MHRA), working closely with the U.S. Food and Drug Administration, has been monitoring Chiron's progress in correcting the manufacturing problems that reduced the doses of vaccine slated for the U.S. market for the 2004-2005 flu season by nearly 50 million. The MHRA made the decision to lift the suspension, but the FDA will conduct a comprehensive inspection of the facility once manufacturing resumes and the corrective action can be evaluated to ensure production of a safe and effective vaccine, according to a statement by Jesse Goodman, M.D., director of the FDA's Center for Biologics Evaluation and Research.

The vaccine shortages that resulted from Chiron's license suspension brought the FDA under fire from government officials, who said the crisis was in part a result of the agency's lax oversight of the facility after previous findings of bacterial contamination and poor sanitary procedures.

TB Transmission Detection

The incidence of tuberculosis continues to decline, but an outbreak in a homeless shelter has underscored the importance of rapid DNA genotyping for detection of possible transmissions, particularly in such settings, according to the Centers for Disease Control and Prevention.

The outbreak in a shelter in New York initially involved a cluster of eight cases. A search of the Mycobacterium tuberculosis-genotyping databases for strains matching these cases revealed many other associated cases. Screening of shelter residents identified 29 cases among residents between 2000 and 2003, and 11 of 26 cases with genotype data available matched those in the outbreak (MMWR 2005;54:149-52).

Genotyping suggested that multiple chains of transmission were occurring simultaneously. To improve access to the genotyping technology, the CDC began offering universal M. tuberculosis rapid genotyping to health department TB control programs last year.

Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis has been associated with aerosolized Mycobacterium avium complex in indoor hot tubs, but a recent case suggests that showering water might also pose a risk, Theodore K. Marras, M.D., of the University of Toronto and his colleagues reported.

The case involved a 50-year-old man with histologically proven hypersensitivity pneumonitis; MAC-positive sputum culture findings; and progressive dyspnea, episodic fever, and myalgias. The symptoms were similar to those of reported hot tub-associated cases (often called “hot tub lung”), but multiple samples from the respiratory tract and from the patient's shower and bathtub grew MAC with matching pulsed-field gel electrophoresis patterns, while specimens from his hot tub were negative (Chest 2005;127:664-71).

He switched from showering to tub bathing, and after about 1 year of treatment with prednisone and antimycobacterial drugs, his condition resolved. This is the first reported case of MAC-associated hypersensitivity pneumonitis believed to be associated with routine use of household water; the potential for sources other than hot tubs should be considered in patients presenting with MAC-hypersensitivity pneumonitis, the researchers said.

HIV-1 Viremia

The intermittent episodes of detectable viremia common in HIV-1 patients on highly active antiretroviral therapy generally do not represent new drug-resistant mutations of the virus, a study suggests.

These so-called blips probably represent random biologic and statistical variation around mean steady-state HIV-1 RNA levels slightly below 50 copies/mL. Blips tend to raise concerns about drug resistance, and can lead to costly medical tests and changes in drug therapy, Richard E. Nettles, M.D., of Johns Hopkins University, Baltimore, and his colleagues reported (JAMA 2005;293:817-29).

Intensive sampling over a 3- to 4-month period in 10 HIV-positive patients with long-term infection control revealed that blips usually have short duration (median of less than 3 days) and low magnitude (median of 79 copies/mL). Frequency was not associated with demographic, clinical, or treatment variables. Despite extensive analysis, no new genotypic resistance was detected in association with the blips.

Unlike blips, consistently detectable viremia and high-magnitude spikes (over 200 copies/mL) in viral load remain a cause for concern, the investigators concluded, noting that more study is needed to define when such viremia should trigger a change in therapy.

ORLANDO, FLA. — Pregnancy-induced hypertension and polycystic ovarian syndrome may be risk markers for later development of metabolic syndrome, Stephen Franks, M.D., said at an international conference on women, heart disease, and stroke.

The findings are important because they suggest that identification of those at risk for metabolic syndrome, and interventions to reduce that risk, can begin as early as adolescence, when polycystic ovarian syndrome (PCOS) typically emerges, said Dr. Franks of the Imperial College London.

The prevalence of metabolic syndrome in women is “staggeringly high,” and the hazard ratio for cardiovascular mortality in women with metabolic syndrome is nearly 2.8. For diabetes, the hazard ratio is 6.3.

“So there is an enormously increased risk of heart disease and diabetes; it would be very useful if we could try to predict [metabolic syndrome] and identify those factors that alert us to the possibility of a high risk for metabolic syndrome,” Dr. Franks said.

Several studies show that pregnancy-induced hypertension—including gestational hypertension and preeclampsia—is associated with increased prevalence of markers of metabolic syndrome as well as a higher lifetime risk of heart disease. In one study of nearly 2,700 women with prior gestational hypertension or preeclampsia and an average age of 31 years, the conditions were shown to be associated with increased systolic and diastolic blood pressure, as well as higher body mass index, waist-hip ratio, and other metabolic syndrome markers, compared with a reference population.

PCOS, which affects more than 5% of women of reproductive age, also appears to be associated with risk for metabolic syndrome. Since it presents so early, it may be the first identifiable sign predicting metabolic syndrome, Dr. Franks said.

The definitions of metabolic syndrome vary from study to study, so it is difficult to say just how common metabolic syndrome is in those with PCOS, but one review article suggests the prevalence is about 50% among obese women with PCOS, he said.

Obesity, which already is established as a marker for metabolic syndrome, appears to act as an amplifier of other etiologic factors, including pregnancy-induced hypertension and PCOS.

Furthermore, at least one study showed that PCOS patients who are obese in their teen years and who remain obese in adulthood have an even greater risk of developing metabolic syndrome.

A fundamental abnormality seen in obese PCOS patients is increased insulin resistance and higher insulin levels, compared with age- and weight-matched controls. In the normal population, as body mass index increases insulin levels also increase, but in PCOS this curve is steeper. In one study of more than 300 women with an average age of 57 years and a history of PCOS, the risk of diabetes was increased nearly threefold compared with controls.

Estimates of PCOS prevalence in young women range from 10% to 40% and the relationship between PCOS and obesity suggests the prevalence is set to increase.

“Adults are getting fatter, children are getting fatter, and obese children become obese adults,” Dr. Franks said.

But there is hope, because even modest reductions in weight with caloric restriction and exercise is proven to modify a woman's risk profile, he said.

Young women with PCOS or pregnancy-induced hypertension—particularly those who are obese—should be identified as being at risk for metabolic syndrome, and interventions should be initiated.

ORLANDO, FLA. — Pregnancy-induced hypertension and polycystic ovarian syndrome may be risk markers for later development of metabolic syndrome, Stephen Franks, M.D., said at an international conference on women, heart disease, and stroke.

The findings are important because they suggest that identification of those at risk for metabolic syndrome, and interventions to reduce that risk, can begin as early as adolescence, when polycystic ovarian syndrome (PCOS) typically emerges, said Dr. Franks of the Imperial College London.

The prevalence of metabolic syndrome in women is “staggeringly high,” and the hazard ratio for cardiovascular mortality in women with metabolic syndrome is nearly 2.8. For diabetes, the hazard ratio is 6.3.

“So there is an enormously increased risk of heart disease and diabetes; it would be very useful if we could try to predict [metabolic syndrome] and identify those factors that alert us to the possibility of a high risk for metabolic syndrome,” Dr. Franks said.

Several studies show that pregnancy-induced hypertension—including gestational hypertension and preeclampsia—is associated with increased prevalence of markers of metabolic syndrome as well as a higher lifetime risk of heart disease. In one study of nearly 2,700 women with prior gestational hypertension or preeclampsia and an average age of 31 years, the conditions were shown to be associated with increased systolic and diastolic blood pressure, as well as higher body mass index, waist-hip ratio, and other metabolic syndrome markers, compared with a reference population.

PCOS, which affects more than 5% of women of reproductive age, also appears to be associated with risk for metabolic syndrome. Since it presents so early, it may be the first identifiable sign predicting metabolic syndrome, Dr. Franks said.

The definitions of metabolic syndrome vary from study to study, so it is difficult to say just how common metabolic syndrome is in those with PCOS, but one review article suggests the prevalence is about 50% among obese women with PCOS, he said.

Obesity, which already is established as a marker for metabolic syndrome, appears to act as an amplifier of other etiologic factors, including pregnancy-induced hypertension and PCOS.

Furthermore, at least one study showed that PCOS patients who are obese in their teen years and who remain obese in adulthood have an even greater risk of developing metabolic syndrome.

A fundamental abnormality seen in obese PCOS patients is increased insulin resistance and higher insulin levels, compared with age- and weight-matched controls. In the normal population, as body mass index increases insulin levels also increase, but in PCOS this curve is steeper. In one study of more than 300 women with an average age of 57 years and a history of PCOS, the risk of diabetes was increased nearly threefold compared with controls.

Estimates of PCOS prevalence in young women range from 10% to 40% and the relationship between PCOS and obesity suggests the prevalence is set to increase.

“Adults are getting fatter, children are getting fatter, and obese children become obese adults,” Dr. Franks said.

But there is hope, because even modest reductions in weight with caloric restriction and exercise is proven to modify a woman's risk profile, he said.

Young women with PCOS or pregnancy-induced hypertension—particularly those who are obese—should be identified as being at risk for metabolic syndrome, and interventions should be initiated.

ORLANDO, FLA. — Pregnancy-induced hypertension and polycystic ovarian syndrome may be risk markers for later development of metabolic syndrome, Stephen Franks, M.D., said at an international conference on women, heart disease, and stroke.

The findings are important because they suggest that identification of those at risk for metabolic syndrome, and interventions to reduce that risk, can begin as early as adolescence, when polycystic ovarian syndrome (PCOS) typically emerges, said Dr. Franks of the Imperial College London.

The prevalence of metabolic syndrome in women is “staggeringly high,” and the hazard ratio for cardiovascular mortality in women with metabolic syndrome is nearly 2.8. For diabetes, the hazard ratio is 6.3.

“So there is an enormously increased risk of heart disease and diabetes; it would be very useful if we could try to predict [metabolic syndrome] and identify those factors that alert us to the possibility of a high risk for metabolic syndrome,” Dr. Franks said.

Several studies show that pregnancy-induced hypertension—including gestational hypertension and preeclampsia—is associated with increased prevalence of markers of metabolic syndrome as well as a higher lifetime risk of heart disease. In one study of nearly 2,700 women with prior gestational hypertension or preeclampsia and an average age of 31 years, the conditions were shown to be associated with increased systolic and diastolic blood pressure, as well as higher body mass index, waist-hip ratio, and other metabolic syndrome markers, compared with a reference population.

PCOS, which affects more than 5% of women of reproductive age, also appears to be associated with risk for metabolic syndrome. Since it presents so early, it may be the first identifiable sign predicting metabolic syndrome, Dr. Franks said.

The definitions of metabolic syndrome vary from study to study, so it is difficult to say just how common metabolic syndrome is in those with PCOS, but one review article suggests the prevalence is about 50% among obese women with PCOS, he said.

Obesity, which already is established as a marker for metabolic syndrome, appears to act as an amplifier of other etiologic factors, including pregnancy-induced hypertension and PCOS.

Furthermore, at least one study showed that PCOS patients who are obese in their teen years and who remain obese in adulthood have an even greater risk of developing metabolic syndrome.

A fundamental abnormality seen in obese PCOS patients is increased insulin resistance and higher insulin levels, compared with age- and weight-matched controls. In the normal population, as body mass index increases insulin levels also increase, but in PCOS this curve is steeper. In one study of more than 300 women with an average age of 57 years and a history of PCOS, the risk of diabetes was increased nearly threefold compared with controls.

Estimates of PCOS prevalence in young women range from 10% to 40% and the relationship between PCOS and obesity suggests the prevalence is set to increase.

“Adults are getting fatter, children are getting fatter, and obese children become obese adults,” Dr. Franks said.

But there is hope, because even modest reductions in weight with caloric restriction and exercise is proven to modify a woman's risk profile, he said.

Young women with PCOS or pregnancy-induced hypertension—particularly those who are obese—should be identified as being at risk for metabolic syndrome, and interventions should be initiated.

Black women account for the majority of new cases of HIV and AIDS among women in the United States, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher for black women, compared with white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication.

Improved availability of HIV and STD testing and treatment and attention to the economic constraints that appear to contribute to increased HIV risk in black women are also needed, according to the CDC.

Black women account for the majority of new cases of HIV and AIDS among women in the United States, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher for black women, compared with white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication.

Improved availability of HIV and STD testing and treatment and attention to the economic constraints that appear to contribute to increased HIV risk in black women are also needed, according to the CDC.

Black women account for the majority of new cases of HIV and AIDS among women in the United States, and this is particularly true in North Carolina, according to the Centers for Disease Control and Prevention.

In 2003, the HIV infection rate in that state was 14 times higher for black women, compared with white women (MMWR 2005;54:89-94).

An epidemiologic investigation of 31 of the 208 black women aged 18-40 years in North Carolina who were diagnosed with HIV between January 2003 and August 2004 and 101 controls recruited from HIV testing sites showed that most women in both groups engaged in HIV sexual risk behaviors. Those receiving public assistance were more likely to be HIV positive (adjusted odds ratio 7.3), as were those with a history of genital herpes (adjusted OR 10.6). Women who discussed sexual behaviors and history with their male partners were less likely to be HIV positive (adjusted OR 0.6).

The most common reasons given for engaging in risky sexual behaviors were financial dependence on male partners, feeling invincible, low self-esteem coupled with a need to feel loved by a male, and alcohol/drug use.

The findings underscore the need for a multifaceted approach to reducing HIV infection among black women, including programs that encourage delayed sexual activity, condom use, monogamy, and communication.

Improved availability of HIV and STD testing and treatment and attention to the economic constraints that appear to contribute to increased HIV risk in black women are also needed, according to the CDC.