Timothy F. Kirn

RANCHO MIRAGE, CALIF. — Current asthma guidelines, widely promoted to encourage more aggressive asthma management, actually result in missed diagnosis and undertreatment for children with asthma, Joseph D. Spahn, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Compared with adults who have asthma, children tend to have a much better forced expiratory volume in 1 second (FEV₁) for the severity of their asthma, and to have more irritable airways.

These differences have never been adequately addressed in the National Asthma Education and Prevention Program guidelines, which are promulgated by the National Heart, Lung, and Blood Institute, said Dr. Spahn, formerly the medical director of the childhood asthma management program at National Jewish Medical and Research Center, Denver, and now in private practice in Sacramento.

The guidelines' system of classifying asthma severity as mild, moderate, or severe, which then determines suggested treatment, was a convention adopted for practicality, not because there are evidence-based distinctions, Dr. Spahn said.

“It was basically a consensus decision among the experts, one that was largely based on the experience of adult-trained individuals. … That's the problem,” Dr. Spahn said. “We all know that asthma is a disease that has a natural history. Asthma in a 4-year-old is much different from asthma in a 14-year-old, and that disease is much different in an adult with a 34-year-old history.”

The guidelines, which were first introduced in 1991, define lung function in severe asthma as an FEV₁ less than 60% of predicted FEV₁, moderate asthma as 60%–80% of predicted, and mild asthma as 80%–100% of predicted.

But major studies have shown that few children with asthma have an FEV₁ less than 80% of predicted, and almost none have an FEV₁ less than 60%, despite the fact that many children do have severe, often brittle, asthma that can be difficult to control, Dr. Spahn said.

In one study, which recorded the FEV₁ of 3,452 children with asthma for 15 years, 94% of the children had an FEV₁ that was 80% or better, and less than 1% had an FEV₁ below 60% predicted.

In the influential Childhood Asthma Management Program study, which established the utility of inhaled corticosteroid management in moderate asthma, the mean prebronchodilator FEV₁ of the subjects was 94% predicted.

In a recent comparison done at National Jewish Medical and Research Center, 23% of more than 12,000 adult asthmatic patients seen at the center had an FEV₁ less than 60% predicted, but less than 5% of 2,700 children did. Moreover, 74% of the children had an FEV₁ that was greater than 80% predicted, and National Jewish Medical and Research Center is a referral center that tends to see the most severe or problematic patients, Dr. Spahn noted at the meeting, which was also sponsored by the American Academy of Pediatrics.

Other studies have shown that even children with an FEV₁ that is 100% of predicted or better can still have a 20%–30% chance of a serious asthma attack every year.

Clinically better measurements for childhood asthma severity are the FEV/FVC (forced vital capacity) ratio and forced expiratory flow_25-75 (during the middle half of the FVC), Dr. Spahn asserted. Both measures have greater sensitivity in children, as both have been shown to fall as severity increases.

Serial spirometry may also be more helpful than a single measurement, he added.

“The lung-function cut points have to be totally revamped, in my opinion,” Dr. Spahn said. “We have to stress the episodic nature of this illness, especially in children.”

RANCHO MIRAGE, CALIF. — Current asthma guidelines, widely promoted to encourage more aggressive asthma management, actually result in missed diagnosis and undertreatment for children with asthma, Joseph D. Spahn, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Compared with adults who have asthma, children tend to have a much better forced expiratory volume in 1 second (FEV₁) for the severity of their asthma, and to have more irritable airways.

These differences have never been adequately addressed in the National Asthma Education and Prevention Program guidelines, which are promulgated by the National Heart, Lung, and Blood Institute, said Dr. Spahn, formerly the medical director of the childhood asthma management program at National Jewish Medical and Research Center, Denver, and now in private practice in Sacramento.

The guidelines' system of classifying asthma severity as mild, moderate, or severe, which then determines suggested treatment, was a convention adopted for practicality, not because there are evidence-based distinctions, Dr. Spahn said.

“It was basically a consensus decision among the experts, one that was largely based on the experience of adult-trained individuals. … That's the problem,” Dr. Spahn said. “We all know that asthma is a disease that has a natural history. Asthma in a 4-year-old is much different from asthma in a 14-year-old, and that disease is much different in an adult with a 34-year-old history.”

The guidelines, which were first introduced in 1991, define lung function in severe asthma as an FEV₁ less than 60% of predicted FEV₁, moderate asthma as 60%–80% of predicted, and mild asthma as 80%–100% of predicted.

But major studies have shown that few children with asthma have an FEV₁ less than 80% of predicted, and almost none have an FEV₁ less than 60%, despite the fact that many children do have severe, often brittle, asthma that can be difficult to control, Dr. Spahn said.

In one study, which recorded the FEV₁ of 3,452 children with asthma for 15 years, 94% of the children had an FEV₁ that was 80% or better, and less than 1% had an FEV₁ below 60% predicted.

In the influential Childhood Asthma Management Program study, which established the utility of inhaled corticosteroid management in moderate asthma, the mean prebronchodilator FEV₁ of the subjects was 94% predicted.

In a recent comparison done at National Jewish Medical and Research Center, 23% of more than 12,000 adult asthmatic patients seen at the center had an FEV₁ less than 60% predicted, but less than 5% of 2,700 children did. Moreover, 74% of the children had an FEV₁ that was greater than 80% predicted, and National Jewish Medical and Research Center is a referral center that tends to see the most severe or problematic patients, Dr. Spahn noted at the meeting, which was also sponsored by the American Academy of Pediatrics.

Other studies have shown that even children with an FEV₁ that is 100% of predicted or better can still have a 20%–30% chance of a serious asthma attack every year.

Clinically better measurements for childhood asthma severity are the FEV/FVC (forced vital capacity) ratio and forced expiratory flow_25-75 (during the middle half of the FVC), Dr. Spahn asserted. Both measures have greater sensitivity in children, as both have been shown to fall as severity increases.

Serial spirometry may also be more helpful than a single measurement, he added.

“The lung-function cut points have to be totally revamped, in my opinion,” Dr. Spahn said. “We have to stress the episodic nature of this illness, especially in children.”

RANCHO MIRAGE, CALIF. — Current asthma guidelines, widely promoted to encourage more aggressive asthma management, actually result in missed diagnosis and undertreatment for children with asthma, Joseph D. Spahn, M.D., said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Compared with adults who have asthma, children tend to have a much better forced expiratory volume in 1 second (FEV₁) for the severity of their asthma, and to have more irritable airways.

These differences have never been adequately addressed in the National Asthma Education and Prevention Program guidelines, which are promulgated by the National Heart, Lung, and Blood Institute, said Dr. Spahn, formerly the medical director of the childhood asthma management program at National Jewish Medical and Research Center, Denver, and now in private practice in Sacramento.

The guidelines' system of classifying asthma severity as mild, moderate, or severe, which then determines suggested treatment, was a convention adopted for practicality, not because there are evidence-based distinctions, Dr. Spahn said.

“It was basically a consensus decision among the experts, one that was largely based on the experience of adult-trained individuals. … That's the problem,” Dr. Spahn said. “We all know that asthma is a disease that has a natural history. Asthma in a 4-year-old is much different from asthma in a 14-year-old, and that disease is much different in an adult with a 34-year-old history.”

The guidelines, which were first introduced in 1991, define lung function in severe asthma as an FEV₁ less than 60% of predicted FEV₁, moderate asthma as 60%–80% of predicted, and mild asthma as 80%–100% of predicted.

But major studies have shown that few children with asthma have an FEV₁ less than 80% of predicted, and almost none have an FEV₁ less than 60%, despite the fact that many children do have severe, often brittle, asthma that can be difficult to control, Dr. Spahn said.

In one study, which recorded the FEV₁ of 3,452 children with asthma for 15 years, 94% of the children had an FEV₁ that was 80% or better, and less than 1% had an FEV₁ below 60% predicted.

In the influential Childhood Asthma Management Program study, which established the utility of inhaled corticosteroid management in moderate asthma, the mean prebronchodilator FEV₁ of the subjects was 94% predicted.

In a recent comparison done at National Jewish Medical and Research Center, 23% of more than 12,000 adult asthmatic patients seen at the center had an FEV₁ less than 60% predicted, but less than 5% of 2,700 children did. Moreover, 74% of the children had an FEV₁ that was greater than 80% predicted, and National Jewish Medical and Research Center is a referral center that tends to see the most severe or problematic patients, Dr. Spahn noted at the meeting, which was also sponsored by the American Academy of Pediatrics.

Other studies have shown that even children with an FEV₁ that is 100% of predicted or better can still have a 20%–30% chance of a serious asthma attack every year.

Clinically better measurements for childhood asthma severity are the FEV/FVC (forced vital capacity) ratio and forced expiratory flow_25-75 (during the middle half of the FVC), Dr. Spahn asserted. Both measures have greater sensitivity in children, as both have been shown to fall as severity increases.

Serial spirometry may also be more helpful than a single measurement, he added.

“The lung-function cut points have to be totally revamped, in my opinion,” Dr. Spahn said. “We have to stress the episodic nature of this illness, especially in children.”

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with the disease should seriously consider inpatient treatment, Dr. Trent said.

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with the disease should seriously consider inpatient treatment, Dr. Trent said.

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with the disease should seriously consider inpatient treatment, Dr. Trent said.

LOS ANGELES — Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception.

The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. The participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary. Diary periods during which the participant either started or stopped oral contraception were excluded, but some participants were on oral contraception for an entire diary period at one time, but not at another.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

LOS ANGELES — Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception.

The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. The participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary. Diary periods during which the participant either started or stopped oral contraception were excluded, but some participants were on oral contraception for an entire diary period at one time, but not at another.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

LOS ANGELES — Oral contraceptive pills do not cause mood swings or depression in most adolescents. On the contrary, overall, it appears that oral contraceptives increase positive mood and decrease negative mood, Mary A. Ott, M.D., said at the annual meeting of the Society for Adolescent Medicine.

“Our pill users in our study felt better,” said Dr. Ott of Indiana University, Indianapolis. “This is different from the adult data.”

Data from studies of adults on whether oral contraception impacts mood negatively have been conflicting, and results of prospective studies have varied from those of retrospective studies. Overall, however, there has been a suggestion in adults that oral contraception can increase depression or exacerbate mood lability, and it is well known that mood changes are a common reason women stop using the pill, Dr. Ott said in a poster presentation.

In her study of 226 adolescent females, oral contraception decreased reports of negative mood by 27% over time and increased positive mood by 32% over time, relative to reports from subjects not on oral contraception.

The study involved having the 226 enrolled subjects keep daily mood diaries for two 12-week periods, twice each year, over 2 years. The participants were asked to rate the level of three negative moods they might have experienced during the day (irritable, angry, unhappy) and the level of three positive moods (cheerful, happy, friendly), each on a five-point scale reflecting a range from “not at all” to “all day.”

A diary in which the participant reported being on oral contraception both at the start and at the end of the period was considered an oral contraception diary. Diary periods during which the participant either started or stopped oral contraception were excluded, but some participants were on oral contraception for an entire diary period at one time, but not at another.

When mean scores were graphed, negative mood scores in the nonusers stayed relatively stable over time. Scores for the users were lower initially, but by the end of the study scores among users had improved 27% relative to the nonusers.

Positive mood increased for both groups over time, but increased 32% more for the oral contraception users.

INCLINE VILLAGE, NEV. — A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100-200 mg); the second, intoxication with mild hallucinations (200-400 mg); the third and most sought after, an “out of the body” experience (300-600 mg, or 14-16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable, and give instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested naloxone is effective in reversing dextromethorphan. But there also have been reports that naloxone does not work, Dr. Offerman said.

INCLINE VILLAGE, NEV. — A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100-200 mg); the second, intoxication with mild hallucinations (200-400 mg); the third and most sought after, an “out of the body” experience (300-600 mg, or 14-16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable, and give instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested naloxone is effective in reversing dextromethorphan. But there also have been reports that naloxone does not work, Dr. Offerman said.

INCLINE VILLAGE, NEV. — A 14-year-old intoxicated and confused girl is brought into the emergency department by her parents. She has nystagmus and is extremely ataxic. One of her friends reports that she may have taken some “skittles.”

What are “skittles”? How about “red hots”? “Triple C”?

All are street names for Coricidin, the dextromethorphan-containing cough and cold medication that has become one of the more frequent reasons for calls to poison control centers over the past few years, Steven R. Offerman, M.D., said at an annual emergency medicine meeting sponsored by the University of California, Davis.

“It is just rampant now,” said Dr. Offerman in the toxicology division of the department of emergency medicine at the University of California, Davis. “We're seeing this in poison control all the time.”

Between 2000 and 2003, the number of calls to poison control centers nationwide involving abuse or misuse of dextromethorphan by teenagers has roughly doubled, to 3,271 calls in 2003, according to the American Association of Poison Control Centers. Although there are several products that contain dextromethorphan, almost 90% of the calls involve Coricidin.

The reason that product is so popular has to do with the fact that it comes in gelatin tablets, Dr. Offerman said.

Dextromethorphan was first approved in 1958 and was introduced as a replacement for codeine in cough medications. The first product, Romilar, came in tablet form. Its abuse potential was quickly discovered, and in the 1970s Romilar tablets were taken out of the over-the-counter market. New products put dextromethorphan into cough syrups intentionally designed with a bad taste to discourage abuse.

In the 1990s, however, several products reintroduced it in tablet form.

The high that teens get from dextromethorphan is described as an LSD-like, hallucinogenic high. Dextromethorphan is a prodrug converted to the d-isomer of levorphanol, a semisynthetic morphine derivative, which noncompetitively antagonizes N-methyl-D-aspartate (NMDA) receptors, and possibly also affects serotonin receptors.

Teens who are in the know talk about using specific dosages to reach different “plateaus”: the first, a mild stimulant effect (100-200 mg); the second, intoxication with mild hallucinations (200-400 mg); the third and most sought after, an “out of the body” experience (300-600 mg, or 14-16 Coricidin HBP Cough/Cold tablets, each of which contains 30 mg dextromethorphan hydrobromide).

At doses above 600 mg, individuals become fully dissociated, the fourth plateau.

Web sites contain recipes for making dextromethorphan cough syrups more palatable, and give instructions on how to extract it from Sucrets lozenges, Dr. Offerman said.

Treatment of an overdose requires supportive care, but it is also a good idea to consider decontamination with activated charcoal, Dr. Offerman advised. Many of the products also contain an antihistamine, which delays gastric emptying.

Dr. Offerman said he recommends giving charcoal all the way up to 6 hours after ingestion.

Physicians also need to be aware that many of the dextromethorphan-containing products may also contain large amounts of other active ingredients, particularly acetaminophen.

Drug toxicology screens do not specifically test for dextromethorphan, but the drug can cross-react with the test for phencyclidine (PCP).

Some reports have suggested naloxone is effective in reversing dextromethorphan. But there also have been reports that naloxone does not work, Dr. Offerman said.

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine. Previous studies have suggested that even adults have a difficult time adhering to the outpatient regimen.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic in urban Baltimore.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with pelvic inflammatory disease should give serious consideration to inpatient treatment, she said.

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine. Previous studies have suggested that even adults have a difficult time adhering to the outpatient regimen.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic in urban Baltimore.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with pelvic inflammatory disease should give serious consideration to inpatient treatment, she said.

LOS ANGELES — Adolescents treated for pelvic inflammatory disease are not likely to complete a 14-day course of antibiotics nor return for 72-hour evaluation, according to a study designed to see if implementation of a rigorous institutional protocol could improve care.

The protocol helped, but only somewhat, Maria Trent, M.D., said at the annual meeting of the Society for Adolescent Medicine. Previous studies have suggested that even adults have a difficult time adhering to the outpatient regimen.

The study compared management of 56 adolescent females diagnosed with pelvic inflammatory disease before implementation of the protocol with the management of 72 females seen afterward.

The protocol included disseminating a treatment algorithm and a clinical practice guideline based on Centers for Disease Control and Prevention recommendations, making available a full 14-day course of medications at discharge, providing written discharge instructions, and following up by telephone 24 hours to 2 weeks after the patients were initially seen. The patients were seen in a pediatric emergency department or a primary care clinic in urban Baltimore.

Before the intervention, 38% of patients did not receive an appropriate regimen, and only 10% returned at 72 hours to check on resolution of symptoms, as the CDC guidelines recommend, said Dr. Trent, an adolescent medicine specialist at Johns Hopkins University, Baltimore.

During the intervention, 91% of patients received an appropriate regimen. But only 43% returned for reevaluation, and an interview with 28 patients contacted after treatment found that only 61% had taken all of their doses.

Physicians treating adolescents with pelvic inflammatory disease should give serious consideration to inpatient treatment, she said.

RENO, NEV. — Sickle cell trait is associated with previously unreported signs of fetal hypoxia, placental infarcts, and possibly excess risk of fetal demise, according to a study presented in poster form at the annual meeting of the Society for Maternal-Fetal Medicine.

“In the past, we have just told these patients, 'Come in every trimester, and we will check your urine [because of increased risk for a urinary tract infection].' Maybe that's not safe,” the study's lead author, Michelle Y. Taylor, M.D., of the department of obstetrics and gynecology at the University of Mississippi Medical Center, Jackson, said in an interview.

In a case review of 131 pregnancies with confirmed sickle cell trait, in which a detailed pathological examination of the placenta was performed, the researchers found that all of the placentas had aggregates of sickled red blood cells in the intervillous space and decidual vessels.

In addition, 92% of the cases had evidence of meconium passage, suggesting hypoxia, and 50% had evidence of an ascending amniotic fluid infection.

There were frank placental infarcts in 16 cases and retroplacental hemorrhage in 11 cases.

There were 10 cases of intrauterine fetal demise (of which 4 were in the cases with infarction), and 1 neonatal death.

Intrauterine growth restriction occurred in 14 cases.

The investigation found a higher-than-expected rate of fetal loss, and no risk factors were noted other than the probability that sickling in the decidual vessels resulted in decreased placental perfusion, Dr. Taylor said in the interview.

All patients in the study were African American, and the group's average age was 24 years.

The average gestational age at delivery was 30 weeks, and all the pregnancies had to be at least 16 weeks to be in the study. A total of 123 pregnancies were singleton gestations, and 8 were twin gestations.

Hypertension was present in 16% of cases.

RENO, NEV. — Sickle cell trait is associated with previously unreported signs of fetal hypoxia, placental infarcts, and possibly excess risk of fetal demise, according to a study presented in poster form at the annual meeting of the Society for Maternal-Fetal Medicine.

“In the past, we have just told these patients, 'Come in every trimester, and we will check your urine [because of increased risk for a urinary tract infection].' Maybe that's not safe,” the study's lead author, Michelle Y. Taylor, M.D., of the department of obstetrics and gynecology at the University of Mississippi Medical Center, Jackson, said in an interview.

In a case review of 131 pregnancies with confirmed sickle cell trait, in which a detailed pathological examination of the placenta was performed, the researchers found that all of the placentas had aggregates of sickled red blood cells in the intervillous space and decidual vessels.

In addition, 92% of the cases had evidence of meconium passage, suggesting hypoxia, and 50% had evidence of an ascending amniotic fluid infection.

There were frank placental infarcts in 16 cases and retroplacental hemorrhage in 11 cases.

There were 10 cases of intrauterine fetal demise (of which 4 were in the cases with infarction), and 1 neonatal death.

Intrauterine growth restriction occurred in 14 cases.

The investigation found a higher-than-expected rate of fetal loss, and no risk factors were noted other than the probability that sickling in the decidual vessels resulted in decreased placental perfusion, Dr. Taylor said in the interview.

All patients in the study were African American, and the group's average age was 24 years.

The average gestational age at delivery was 30 weeks, and all the pregnancies had to be at least 16 weeks to be in the study. A total of 123 pregnancies were singleton gestations, and 8 were twin gestations.

Hypertension was present in 16% of cases.

RENO, NEV. — Sickle cell trait is associated with previously unreported signs of fetal hypoxia, placental infarcts, and possibly excess risk of fetal demise, according to a study presented in poster form at the annual meeting of the Society for Maternal-Fetal Medicine.

“In the past, we have just told these patients, 'Come in every trimester, and we will check your urine [because of increased risk for a urinary tract infection].' Maybe that's not safe,” the study's lead author, Michelle Y. Taylor, M.D., of the department of obstetrics and gynecology at the University of Mississippi Medical Center, Jackson, said in an interview.

In a case review of 131 pregnancies with confirmed sickle cell trait, in which a detailed pathological examination of the placenta was performed, the researchers found that all of the placentas had aggregates of sickled red blood cells in the intervillous space and decidual vessels.

In addition, 92% of the cases had evidence of meconium passage, suggesting hypoxia, and 50% had evidence of an ascending amniotic fluid infection.

There were frank placental infarcts in 16 cases and retroplacental hemorrhage in 11 cases.

There were 10 cases of intrauterine fetal demise (of which 4 were in the cases with infarction), and 1 neonatal death.

Intrauterine growth restriction occurred in 14 cases.

The investigation found a higher-than-expected rate of fetal loss, and no risk factors were noted other than the probability that sickling in the decidual vessels resulted in decreased placental perfusion, Dr. Taylor said in the interview.

All patients in the study were African American, and the group's average age was 24 years.

The average gestational age at delivery was 30 weeks, and all the pregnancies had to be at least 16 weeks to be in the study. A total of 123 pregnancies were singleton gestations, and 8 were twin gestations.

Hypertension was present in 16% of cases.

RENO, NEV. — Allowing a labor induction in a nulliparous patient to proceed for up to 18 hours is a reasonable practice that does not increase the rate of serious neonatal or maternal morbidity and results in vaginal delivery for most patients.

That finding emerged from a study presented in a poster by Charla E. Simon, M.D., and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

The investigators reported on the outcomes of 397 prospectively enrolled nulliparous patients undergoing labor induction, some of whom had a latent phase that went on for 24 hours.

During the first 18 hours, there was no great increase in the percentage of patients who went to cesarean delivery, and—although chorioamnionitis and postpartum hemorrhage became more frequent the longer an induction went on—this did not result in a greater rate of transfusion, hysterectomy, or prolonged hospitalization.

“I think the investigation shows we can be a little patient, and everything is still going to be okay,” Dr. Simon, of the department of obstetrics and gynecology at Northwestern University, Chicago, said in an interview.

After 18 hours, however, the rate of cesarean delivery increased significantly, as did the rate of infant admission to the neonatal intensive care unit.

All of the patients in Dr. Simon's investigation were at 36 weeks' gestation or later, and the outcomes were stratified by the length of the patient's latent phase of labor, which started with the initiation of oxytocin and the performance of an amniotomy and ended either with a cervical dilation of 4 cm with 80% effacement or with a 5-cm dilation with less effacement.

The cesarean rate was less than 20% for those with a latent phase of 0-6 hours. That rate increased to about 30% for those with a longer latent phase and stayed there, even for those in latent labor up to 18 hours. But after 18 hours, the rate rose to almost 70%.

The rate of postpartum hemorrhage was about 12% for those with a latent phase of 12-18 hours. It jumped to 26% for those with a latent phase longer than 18 hours.

The rate of chorioamnionitis was 10% for those with a latent phase of 6-12 hours, jumped to 28% for 12-18 hours, and fell to 16% for those latent over 18 hours.

Regarding neonatal morbidity, the percentage of infants with an Apgar score less than 7 was about 2% when the mothers had latent labor lasting 6-12 hours; it rose to 8% when mothers were latent for 12-18 hours, and to 10% when mothers were latent longer than 18 hours.

The rate of infants admitted to the neonatal intensive care unit was 6% when the mothers had a latent phase of 12-18 hours, and slightly more than 10% when latent labor was longer than 18 hours.

Overall, the study found that by 18 hours, 95% of the induced nulliparous women had entered active labor.

Source: Dr. Rochon

RENO, NEV. — Allowing a labor induction in a nulliparous patient to proceed for up to 18 hours is a reasonable practice that does not increase the rate of serious neonatal or maternal morbidity and results in vaginal delivery for most patients.

That finding emerged from a study presented in a poster by Charla E. Simon, M.D., and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

The investigators reported on the outcomes of 397 prospectively enrolled nulliparous patients undergoing labor induction, some of whom had a latent phase that went on for 24 hours.

During the first 18 hours, there was no great increase in the percentage of patients who went to cesarean delivery, and—although chorioamnionitis and postpartum hemorrhage became more frequent the longer an induction went on—this did not result in a greater rate of transfusion, hysterectomy, or prolonged hospitalization.

“I think the investigation shows we can be a little patient, and everything is still going to be okay,” Dr. Simon, of the department of obstetrics and gynecology at Northwestern University, Chicago, said in an interview.

After 18 hours, however, the rate of cesarean delivery increased significantly, as did the rate of infant admission to the neonatal intensive care unit.

All of the patients in Dr. Simon's investigation were at 36 weeks' gestation or later, and the outcomes were stratified by the length of the patient's latent phase of labor, which started with the initiation of oxytocin and the performance of an amniotomy and ended either with a cervical dilation of 4 cm with 80% effacement or with a 5-cm dilation with less effacement.

The cesarean rate was less than 20% for those with a latent phase of 0-6 hours. That rate increased to about 30% for those with a longer latent phase and stayed there, even for those in latent labor up to 18 hours. But after 18 hours, the rate rose to almost 70%.

The rate of postpartum hemorrhage was about 12% for those with a latent phase of 12-18 hours. It jumped to 26% for those with a latent phase longer than 18 hours.

The rate of chorioamnionitis was 10% for those with a latent phase of 6-12 hours, jumped to 28% for 12-18 hours, and fell to 16% for those latent over 18 hours.

Regarding neonatal morbidity, the percentage of infants with an Apgar score less than 7 was about 2% when the mothers had latent labor lasting 6-12 hours; it rose to 8% when mothers were latent for 12-18 hours, and to 10% when mothers were latent longer than 18 hours.

The rate of infants admitted to the neonatal intensive care unit was 6% when the mothers had a latent phase of 12-18 hours, and slightly more than 10% when latent labor was longer than 18 hours.

Overall, the study found that by 18 hours, 95% of the induced nulliparous women had entered active labor.

Source: Dr. Rochon

RENO, NEV. — Allowing a labor induction in a nulliparous patient to proceed for up to 18 hours is a reasonable practice that does not increase the rate of serious neonatal or maternal morbidity and results in vaginal delivery for most patients.

That finding emerged from a study presented in a poster by Charla E. Simon, M.D., and associates at the annual meeting of the Society for Maternal-Fetal Medicine.

The investigators reported on the outcomes of 397 prospectively enrolled nulliparous patients undergoing labor induction, some of whom had a latent phase that went on for 24 hours.

During the first 18 hours, there was no great increase in the percentage of patients who went to cesarean delivery, and—although chorioamnionitis and postpartum hemorrhage became more frequent the longer an induction went on—this did not result in a greater rate of transfusion, hysterectomy, or prolonged hospitalization.

“I think the investigation shows we can be a little patient, and everything is still going to be okay,” Dr. Simon, of the department of obstetrics and gynecology at Northwestern University, Chicago, said in an interview.

After 18 hours, however, the rate of cesarean delivery increased significantly, as did the rate of infant admission to the neonatal intensive care unit.

All of the patients in Dr. Simon's investigation were at 36 weeks' gestation or later, and the outcomes were stratified by the length of the patient's latent phase of labor, which started with the initiation of oxytocin and the performance of an amniotomy and ended either with a cervical dilation of 4 cm with 80% effacement or with a 5-cm dilation with less effacement.

The cesarean rate was less than 20% for those with a latent phase of 0-6 hours. That rate increased to about 30% for those with a longer latent phase and stayed there, even for those in latent labor up to 18 hours. But after 18 hours, the rate rose to almost 70%.

The rate of postpartum hemorrhage was about 12% for those with a latent phase of 12-18 hours. It jumped to 26% for those with a latent phase longer than 18 hours.

The rate of chorioamnionitis was 10% for those with a latent phase of 6-12 hours, jumped to 28% for 12-18 hours, and fell to 16% for those latent over 18 hours.

Regarding neonatal morbidity, the percentage of infants with an Apgar score less than 7 was about 2% when the mothers had latent labor lasting 6-12 hours; it rose to 8% when mothers were latent for 12-18 hours, and to 10% when mothers were latent longer than 18 hours.

The rate of infants admitted to the neonatal intensive care unit was 6% when the mothers had a latent phase of 12-18 hours, and slightly more than 10% when latent labor was longer than 18 hours.

Overall, the study found that by 18 hours, 95% of the induced nulliparous women had entered active labor.

Source: Dr. Rochon

RENO, NEV. — New technologies that can screen through the entire metabolite or protein compliment of a fluid will soon produce both a test that can correctly identify the patient experiencing early contractions who will deliver prematurely, and a maternal blood test perhaps 100% accurate for Down syndrome, predicted two speakers at the annual meeting of the Society for Maternal-Fetal Medicine.

These tests could be ready for the clinic in a few years, the speakers said.

In much the same way that researchers can study genomics to identify all the genes in a particular cell, and RNA transcriptomics to identify specific genes being expressed in a cell, it is now possible to study proteomics and even metabolomics, to profile all the biochemical components of a given cell, organ system, or fluid in hopes of identifying specific biomarkers for a given condition.

Using that technology, investigators have now identified a profile of amniotic fluid that predicts which patients who go into premature labor with intact membranes will deliver early and therefore warrant tocolysis, said Roberto Romero, M.D., chief of the perinatology research branch of the National Institute of Child Health and Human Development.

Dr. Romero said he and his coworkers profiled 186 metabolites from the amniotic fluid taken from 115 women who were having premature contractions, and were able to find a group of carbohydrates that correctly identified those who actually delivered preterm with 88% accuracy. The women who delivered early had low concentrations of this group of carbohydrates, while those who did not deliver had high concentrations.

The profile correctly identified 39 of 40 patients who delivered at term, 29 of 33 patients who delivered early but had no evidence of intraamniotic inflammation, and all 42 of the patients who delivered early and had evidence of inflammation.

The individual carbohydrates in the group are not unique in any way, Dr. Romero said, and he speculated that they are fetal products.

Dr. Romero declared no personal financial conflict of interest with regard to the study, but the National Institutes of Health has applied for a patent based on the team's findings.

In another presentation, Mary D'Alton, M.D., said she and her colleagues took maternal serum from 50 Down syndrome-affected pregnancies and compared it with serum from 50 unaffected pregnancies, and have been able to identify a group of six proteins that when combined as biomarkers can pick up Down syndrome with 100% accuracy.

Two of these protein biomarkers are overexpressed in Down syndrome cases and four are underexpressed, and this pattern is present in both the first and second trimesters, said Dr. D'Alton, director of the division of maternal-fetal medicine at New York-Presbyterian Hospital, New York.

Most of these proteins have not previously been known to be associated with Down syndrome, and none of them are products of the expression of genes on chromosome 21, she added.

Dr. D'Alton's study was supported by the NIH and ProteoGenix Inc. of Portland, Ore.

RENO, NEV. — New technologies that can screen through the entire metabolite or protein compliment of a fluid will soon produce both a test that can correctly identify the patient experiencing early contractions who will deliver prematurely, and a maternal blood test perhaps 100% accurate for Down syndrome, predicted two speakers at the annual meeting of the Society for Maternal-Fetal Medicine.

These tests could be ready for the clinic in a few years, the speakers said.

In much the same way that researchers can study genomics to identify all the genes in a particular cell, and RNA transcriptomics to identify specific genes being expressed in a cell, it is now possible to study proteomics and even metabolomics, to profile all the biochemical components of a given cell, organ system, or fluid in hopes of identifying specific biomarkers for a given condition.

Using that technology, investigators have now identified a profile of amniotic fluid that predicts which patients who go into premature labor with intact membranes will deliver early and therefore warrant tocolysis, said Roberto Romero, M.D., chief of the perinatology research branch of the National Institute of Child Health and Human Development.

Dr. Romero said he and his coworkers profiled 186 metabolites from the amniotic fluid taken from 115 women who were having premature contractions, and were able to find a group of carbohydrates that correctly identified those who actually delivered preterm with 88% accuracy. The women who delivered early had low concentrations of this group of carbohydrates, while those who did not deliver had high concentrations.

The profile correctly identified 39 of 40 patients who delivered at term, 29 of 33 patients who delivered early but had no evidence of intraamniotic inflammation, and all 42 of the patients who delivered early and had evidence of inflammation.

The individual carbohydrates in the group are not unique in any way, Dr. Romero said, and he speculated that they are fetal products.

Dr. Romero declared no personal financial conflict of interest with regard to the study, but the National Institutes of Health has applied for a patent based on the team's findings.

In another presentation, Mary D'Alton, M.D., said she and her colleagues took maternal serum from 50 Down syndrome-affected pregnancies and compared it with serum from 50 unaffected pregnancies, and have been able to identify a group of six proteins that when combined as biomarkers can pick up Down syndrome with 100% accuracy.

Two of these protein biomarkers are overexpressed in Down syndrome cases and four are underexpressed, and this pattern is present in both the first and second trimesters, said Dr. D'Alton, director of the division of maternal-fetal medicine at New York-Presbyterian Hospital, New York.

Most of these proteins have not previously been known to be associated with Down syndrome, and none of them are products of the expression of genes on chromosome 21, she added.

Dr. D'Alton's study was supported by the NIH and ProteoGenix Inc. of Portland, Ore.

RENO, NEV. — New technologies that can screen through the entire metabolite or protein compliment of a fluid will soon produce both a test that can correctly identify the patient experiencing early contractions who will deliver prematurely, and a maternal blood test perhaps 100% accurate for Down syndrome, predicted two speakers at the annual meeting of the Society for Maternal-Fetal Medicine.

These tests could be ready for the clinic in a few years, the speakers said.

In much the same way that researchers can study genomics to identify all the genes in a particular cell, and RNA transcriptomics to identify specific genes being expressed in a cell, it is now possible to study proteomics and even metabolomics, to profile all the biochemical components of a given cell, organ system, or fluid in hopes of identifying specific biomarkers for a given condition.

Using that technology, investigators have now identified a profile of amniotic fluid that predicts which patients who go into premature labor with intact membranes will deliver early and therefore warrant tocolysis, said Roberto Romero, M.D., chief of the perinatology research branch of the National Institute of Child Health and Human Development.

Dr. Romero said he and his coworkers profiled 186 metabolites from the amniotic fluid taken from 115 women who were having premature contractions, and were able to find a group of carbohydrates that correctly identified those who actually delivered preterm with 88% accuracy. The women who delivered early had low concentrations of this group of carbohydrates, while those who did not deliver had high concentrations.

The profile correctly identified 39 of 40 patients who delivered at term, 29 of 33 patients who delivered early but had no evidence of intraamniotic inflammation, and all 42 of the patients who delivered early and had evidence of inflammation.

The individual carbohydrates in the group are not unique in any way, Dr. Romero said, and he speculated that they are fetal products.

Dr. Romero declared no personal financial conflict of interest with regard to the study, but the National Institutes of Health has applied for a patent based on the team's findings.

In another presentation, Mary D'Alton, M.D., said she and her colleagues took maternal serum from 50 Down syndrome-affected pregnancies and compared it with serum from 50 unaffected pregnancies, and have been able to identify a group of six proteins that when combined as biomarkers can pick up Down syndrome with 100% accuracy.

Two of these protein biomarkers are overexpressed in Down syndrome cases and four are underexpressed, and this pattern is present in both the first and second trimesters, said Dr. D'Alton, director of the division of maternal-fetal medicine at New York-Presbyterian Hospital, New York.

Most of these proteins have not previously been known to be associated with Down syndrome, and none of them are products of the expression of genes on chromosome 21, she added.

Dr. D'Alton's study was supported by the NIH and ProteoGenix Inc. of Portland, Ore.

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients who were successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%).

The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases. However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

The mean length of stay was 8 days for all the babies that were admitted to the NICU and 4 days for those admitted with hypoglycemia.

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients who were successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%).

The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases. However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

The mean length of stay was 8 days for all the babies that were admitted to the NICU and 4 days for those admitted with hypoglycemia.

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients who were successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%).

The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases. However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

The mean length of stay was 8 days for all the babies that were admitted to the NICU and 4 days for those admitted with hypoglycemia.

RENO, NEV. — Oral glucose challenge test results appear to have different values for patients of different ethnicity, reported Tania Esakoff, M.D.

Specifically, Asians may need to meet a higher threshold cutoff than whites before undergoing a 3-hour fasting glucose tolerance test to determine whether they have gestational diabetes, and African Americans need a lower cutoff, Dr. Esakoff and her colleagues wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers reviewed the records of 14,565 pregnancies screened for gestational diabetes with the 50-g glucose loading test in ethnically diverse San Francisco. They then computed the sensitivities and false-positive rates based on study results and known results for fasting glucose tolerance testing.

The results show Asians tend to be more sensitive to an oral glucose challenge and therefore need a higher cutoff, said Dr. Esakoff of the University of California, San Francisco.

With the currently recommended cutoff of a serum-glucose level of 140 mg/dL, which is now used for everyone regardless of ethnicity, the test would have a sensitivity of 89% and a false-positive rate of 14% for Asian women.

To reduce the false-positive rate closer to 10%, Asians need to have a cutoff threshold of 145 mg/dL, but then the sensitivity is only 80%.

In African Americans, on the other hand, the test at a cutoff of 140 mg/dL has a sensitivity of 94%, but a false-positive rate of only 6%.

The study suggests if the goal is to have the maximum sensitivity with a near 10% false-positive rate, the threshold cutoff glucose level for African Americans should be 135 mg/dL; for Hispanics and whites, 140 mg/dL; for Asians, 145 mg/dL.

If the goal is to have at least a 95% sensitivity, then the cutoff needs to be 135 mg/dL for African Americans (sensitivity 97%, false-positive rate 9%), and 130 mg/dL for the other ethnic groups.

At the 130 mg/dL cutoff, the false-positive rates are high for those groups (whites 18%, Hispanics 19%, and Asians 24%), but a higher cutoff of 135 mg/dL does not achieve a 95% sensitivity.

The researchers also found an overall prevalence of gestational diabetes in its population of 6%, with a prevalence among whites of 4%, and African Americans of 4%, and Hispanics of 7%, and a prevalence among Asians of 10%.

RENO, NEV. — Oral glucose challenge test results appear to have different values for patients of different ethnicity, reported Tania Esakoff, M.D.

Specifically, Asians may need to meet a higher threshold cutoff than whites before undergoing a 3-hour fasting glucose tolerance test to determine whether they have gestational diabetes, and African Americans need a lower cutoff, Dr. Esakoff and her colleagues wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers reviewed the records of 14,565 pregnancies screened for gestational diabetes with the 50-g glucose loading test in ethnically diverse San Francisco. They then computed the sensitivities and false-positive rates based on study results and known results for fasting glucose tolerance testing.

The results show Asians tend to be more sensitive to an oral glucose challenge and therefore need a higher cutoff, said Dr. Esakoff of the University of California, San Francisco.

With the currently recommended cutoff of a serum-glucose level of 140 mg/dL, which is now used for everyone regardless of ethnicity, the test would have a sensitivity of 89% and a false-positive rate of 14% for Asian women.

To reduce the false-positive rate closer to 10%, Asians need to have a cutoff threshold of 145 mg/dL, but then the sensitivity is only 80%.

In African Americans, on the other hand, the test at a cutoff of 140 mg/dL has a sensitivity of 94%, but a false-positive rate of only 6%.

The study suggests if the goal is to have the maximum sensitivity with a near 10% false-positive rate, the threshold cutoff glucose level for African Americans should be 135 mg/dL; for Hispanics and whites, 140 mg/dL; for Asians, 145 mg/dL.

If the goal is to have at least a 95% sensitivity, then the cutoff needs to be 135 mg/dL for African Americans (sensitivity 97%, false-positive rate 9%), and 130 mg/dL for the other ethnic groups.

At the 130 mg/dL cutoff, the false-positive rates are high for those groups (whites 18%, Hispanics 19%, and Asians 24%), but a higher cutoff of 135 mg/dL does not achieve a 95% sensitivity.

The researchers also found an overall prevalence of gestational diabetes in its population of 6%, with a prevalence among whites of 4%, and African Americans of 4%, and Hispanics of 7%, and a prevalence among Asians of 10%.

RENO, NEV. — Oral glucose challenge test results appear to have different values for patients of different ethnicity, reported Tania Esakoff, M.D.

Specifically, Asians may need to meet a higher threshold cutoff than whites before undergoing a 3-hour fasting glucose tolerance test to determine whether they have gestational diabetes, and African Americans need a lower cutoff, Dr. Esakoff and her colleagues wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers reviewed the records of 14,565 pregnancies screened for gestational diabetes with the 50-g glucose loading test in ethnically diverse San Francisco. They then computed the sensitivities and false-positive rates based on study results and known results for fasting glucose tolerance testing.

The results show Asians tend to be more sensitive to an oral glucose challenge and therefore need a higher cutoff, said Dr. Esakoff of the University of California, San Francisco.

With the currently recommended cutoff of a serum-glucose level of 140 mg/dL, which is now used for everyone regardless of ethnicity, the test would have a sensitivity of 89% and a false-positive rate of 14% for Asian women.

To reduce the false-positive rate closer to 10%, Asians need to have a cutoff threshold of 145 mg/dL, but then the sensitivity is only 80%.

In African Americans, on the other hand, the test at a cutoff of 140 mg/dL has a sensitivity of 94%, but a false-positive rate of only 6%.

The study suggests if the goal is to have the maximum sensitivity with a near 10% false-positive rate, the threshold cutoff glucose level for African Americans should be 135 mg/dL; for Hispanics and whites, 140 mg/dL; for Asians, 145 mg/dL.

If the goal is to have at least a 95% sensitivity, then the cutoff needs to be 135 mg/dL for African Americans (sensitivity 97%, false-positive rate 9%), and 130 mg/dL for the other ethnic groups.

At the 130 mg/dL cutoff, the false-positive rates are high for those groups (whites 18%, Hispanics 19%, and Asians 24%), but a higher cutoff of 135 mg/dL does not achieve a 95% sensitivity.

The researchers also found an overall prevalence of gestational diabetes in its population of 6%, with a prevalence among whites of 4%, and African Americans of 4%, and Hispanics of 7%, and a prevalence among Asians of 10%.