[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

The American Academy of Pediatrics, citing a substantial increase in scientific evidence backing best practices for child passenger safety, is recommending changes in child car seat use that include keeping most infants and toddlers in rear-facing safety seats until they reach age 2 years, according to a new policy statement.

The new guidelines also recommend forward-facing car safety seats for most children until they outgrow the weight or height limits on those seats; belt-positioning booster seats for most children through age 8 years or well beyond; and lap-and-shoulder belts for all those children who have outgrown booster seats. In addition, the policy statement recommends that all children ride in the back seat of vehicles through age 12 years (Pediatrics 2011;127:788–93).

Although the AAP policy recommendations are not binding, states use them in crafting and revising child safety seat laws, said Dr. Benjamin Hoffman, an expert in child passenger safety and associate professor of pediatrics at the University of New Mexico, Albuquerque. Previous academy recommendations regarding the use of booster seats prompted many states to enact laws requiring booster seats for older children, which has improved safety dramatically, he said.

“The best way to get people to use child safety seats appropriately is to have state laws requiring their use,” Dr. Hoffman said in an interview. “Our job is to help consumer organizations and states understand what the best practice is.”

The new AAP guidelines represent big changes in the way car safety seat use has been viewed, said Dr. Hoffman, a new member of the AAP's committee on injury, violence, and poison prevention, which crafted the recommendations. Now, there's much more emphasis on the transitions between different types of seats – rear-facing seats to forward-facing seats, forward-facing seats to booster seats, and booster seats to seat belts.

“In these transitions, you lose protection every step of the way,” he noted. “Therefore, you need to delay these transitions for as long as possible.”

However, many parents and even older children themselves view the transitions as milestones, which encourages them to make the transition as quickly as they legally can, he said. “Parents are really viewing these transitions as graduations. There's a perception that this graduation is a positive thing. It's not.”

Instead of making the switch to a lower level of protection as soon as they're legally able, parents should keep their children in safety seats until they outgrow the weight and height limits, Dr. Hoffman said. For example, many rear-facing seats can handle children up to 35 pounds, and parents should use these seats in their rear-facing configuration until their children no longer can fit in them.

Likewise, parents should keep their children in forward-facing car seats until they have outgrown the weight or height limits on those seats, and should use a belt-positioning booster seat until the vehicle lap-and-shoulder belt fits properly, typically when children have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.

According to the technical report by committee member Dr. Dennis R. Durbin, professor of pediatrics and epidemiology at The Children's Hospital of Philadelphia, research in Sweden shows that rear-facing child safety seats reduce the risk of significant injuries by 90% relative to unrestrained children. Many infants and children in Sweden remain in rear-facing seats until age 4 years, when they transition directly to booster seats, according to the report (Pediatrics 2011;127:e1050–66). h

“There's a 500% increased risk of injury” for toddlers between the ages of 1 and 2 years when seated in a forward-facing seat, compared with a rear-facing seat, Dr. Hoffman said.

Analysis of the data also indicates substantial benefits for children aged 2 years and older seated in forward-facing car seats, compared with just booster seats or seat belts, and for children seated in booster seats who have outgrown car seats but who have not yet reached 4 feet, 9 inches, according to the report.

Some forward-facing seats can accommodate children up to 65 or 80 pounds, and should be used until that weight limit, according to the report.

Pediatricians should counsel their patients on these new recommendations at every well-child visit, the guidelines say.

“Pediatricians don't have to know how to install car seats, but they have to know what the best recommendations are,” said Dr. Hoffman. “They should know what the resources are in their communities [for car seat installation help], and it would be even better for them to make contact with those resources” in order to facilitate assistance for patients who might need it.

In addition, pediatricians should counsel parents to follow the AAP recommendations for the utmost car seat safety rather than simply follow state laws, which may allow “graduation” to the next level before the child is large enough, Dr. Hoffman said.

“The laws of physics will always trump the laws of the state,” he concluded.

All authors filed conflict of interest statements with the AAP, and any conflicts have been resolved through a process approved by the AAP Board of Directors, according to a statement in the journal.

A list of formal car seat inspection stations is available at www.seatcheck.orghttp://cert.safekids.org

The American Academy of Pediatrics, citing a substantial increase in scientific evidence backing best practices for child passenger safety, is recommending changes in child car seat use that include keeping most infants and toddlers in rear-facing safety seats until they reach age 2 years, according to a new policy statement.

The new guidelines also recommend forward-facing car safety seats for most children until they outgrow the weight or height limits on those seats; belt-positioning booster seats for most children through age 8 years or well beyond; and lap-and-shoulder belts for all those children who have outgrown booster seats. In addition, the policy statement recommends that all children ride in the back seat of vehicles through age 12 years (Pediatrics 2011;127:788–93).

Although the AAP policy recommendations are not binding, states use them in crafting and revising child safety seat laws, said Dr. Benjamin Hoffman, an expert in child passenger safety and associate professor of pediatrics at the University of New Mexico, Albuquerque. Previous academy recommendations regarding the use of booster seats prompted many states to enact laws requiring booster seats for older children, which has improved safety dramatically, he said.

“The best way to get people to use child safety seats appropriately is to have state laws requiring their use,” Dr. Hoffman said in an interview. “Our job is to help consumer organizations and states understand what the best practice is.”

The new AAP guidelines represent big changes in the way car safety seat use has been viewed, said Dr. Hoffman, a new member of the AAP's committee on injury, violence, and poison prevention, which crafted the recommendations. Now, there's much more emphasis on the transitions between different types of seats – rear-facing seats to forward-facing seats, forward-facing seats to booster seats, and booster seats to seat belts.

“In these transitions, you lose protection every step of the way,” he noted. “Therefore, you need to delay these transitions for as long as possible.”

However, many parents and even older children themselves view the transitions as milestones, which encourages them to make the transition as quickly as they legally can, he said. “Parents are really viewing these transitions as graduations. There's a perception that this graduation is a positive thing. It's not.”

Instead of making the switch to a lower level of protection as soon as they're legally able, parents should keep their children in safety seats until they outgrow the weight and height limits, Dr. Hoffman said. For example, many rear-facing seats can handle children up to 35 pounds, and parents should use these seats in their rear-facing configuration until their children no longer can fit in them.

Likewise, parents should keep their children in forward-facing car seats until they have outgrown the weight or height limits on those seats, and should use a belt-positioning booster seat until the vehicle lap-and-shoulder belt fits properly, typically when children have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.

According to the technical report by committee member Dr. Dennis R. Durbin, professor of pediatrics and epidemiology at The Children's Hospital of Philadelphia, research in Sweden shows that rear-facing child safety seats reduce the risk of significant injuries by 90% relative to unrestrained children. Many infants and children in Sweden remain in rear-facing seats until age 4 years, when they transition directly to booster seats, according to the report (Pediatrics 2011;127:e1050–66). h

“There's a 500% increased risk of injury” for toddlers between the ages of 1 and 2 years when seated in a forward-facing seat, compared with a rear-facing seat, Dr. Hoffman said.

Analysis of the data also indicates substantial benefits for children aged 2 years and older seated in forward-facing car seats, compared with just booster seats or seat belts, and for children seated in booster seats who have outgrown car seats but who have not yet reached 4 feet, 9 inches, according to the report.

Some forward-facing seats can accommodate children up to 65 or 80 pounds, and should be used until that weight limit, according to the report.

Pediatricians should counsel their patients on these new recommendations at every well-child visit, the guidelines say.

“Pediatricians don't have to know how to install car seats, but they have to know what the best recommendations are,” said Dr. Hoffman. “They should know what the resources are in their communities [for car seat installation help], and it would be even better for them to make contact with those resources” in order to facilitate assistance for patients who might need it.

In addition, pediatricians should counsel parents to follow the AAP recommendations for the utmost car seat safety rather than simply follow state laws, which may allow “graduation” to the next level before the child is large enough, Dr. Hoffman said.

“The laws of physics will always trump the laws of the state,” he concluded.

All authors filed conflict of interest statements with the AAP, and any conflicts have been resolved through a process approved by the AAP Board of Directors, according to a statement in the journal.

A list of formal car seat inspection stations is available at www.seatcheck.orghttp://cert.safekids.org

The American Academy of Pediatrics, citing a substantial increase in scientific evidence backing best practices for child passenger safety, is recommending changes in child car seat use that include keeping most infants and toddlers in rear-facing safety seats until they reach age 2 years, according to a new policy statement.

The new guidelines also recommend forward-facing car safety seats for most children until they outgrow the weight or height limits on those seats; belt-positioning booster seats for most children through age 8 years or well beyond; and lap-and-shoulder belts for all those children who have outgrown booster seats. In addition, the policy statement recommends that all children ride in the back seat of vehicles through age 12 years (Pediatrics 2011;127:788–93).

Although the AAP policy recommendations are not binding, states use them in crafting and revising child safety seat laws, said Dr. Benjamin Hoffman, an expert in child passenger safety and associate professor of pediatrics at the University of New Mexico, Albuquerque. Previous academy recommendations regarding the use of booster seats prompted many states to enact laws requiring booster seats for older children, which has improved safety dramatically, he said.

“The best way to get people to use child safety seats appropriately is to have state laws requiring their use,” Dr. Hoffman said in an interview. “Our job is to help consumer organizations and states understand what the best practice is.”

The new AAP guidelines represent big changes in the way car safety seat use has been viewed, said Dr. Hoffman, a new member of the AAP's committee on injury, violence, and poison prevention, which crafted the recommendations. Now, there's much more emphasis on the transitions between different types of seats – rear-facing seats to forward-facing seats, forward-facing seats to booster seats, and booster seats to seat belts.

“In these transitions, you lose protection every step of the way,” he noted. “Therefore, you need to delay these transitions for as long as possible.”

However, many parents and even older children themselves view the transitions as milestones, which encourages them to make the transition as quickly as they legally can, he said. “Parents are really viewing these transitions as graduations. There's a perception that this graduation is a positive thing. It's not.”

Instead of making the switch to a lower level of protection as soon as they're legally able, parents should keep their children in safety seats until they outgrow the weight and height limits, Dr. Hoffman said. For example, many rear-facing seats can handle children up to 35 pounds, and parents should use these seats in their rear-facing configuration until their children no longer can fit in them.

Likewise, parents should keep their children in forward-facing car seats until they have outgrown the weight or height limits on those seats, and should use a belt-positioning booster seat until the vehicle lap-and-shoulder belt fits properly, typically when children have reached 4 feet, 9 inches in height and are between 8 and 12 years of age.

According to the technical report by committee member Dr. Dennis R. Durbin, professor of pediatrics and epidemiology at The Children's Hospital of Philadelphia, research in Sweden shows that rear-facing child safety seats reduce the risk of significant injuries by 90% relative to unrestrained children. Many infants and children in Sweden remain in rear-facing seats until age 4 years, when they transition directly to booster seats, according to the report (Pediatrics 2011;127:e1050–66). h

“There's a 500% increased risk of injury” for toddlers between the ages of 1 and 2 years when seated in a forward-facing seat, compared with a rear-facing seat, Dr. Hoffman said.

Analysis of the data also indicates substantial benefits for children aged 2 years and older seated in forward-facing car seats, compared with just booster seats or seat belts, and for children seated in booster seats who have outgrown car seats but who have not yet reached 4 feet, 9 inches, according to the report.

Some forward-facing seats can accommodate children up to 65 or 80 pounds, and should be used until that weight limit, according to the report.

Pediatricians should counsel their patients on these new recommendations at every well-child visit, the guidelines say.

“Pediatricians don't have to know how to install car seats, but they have to know what the best recommendations are,” said Dr. Hoffman. “They should know what the resources are in their communities [for car seat installation help], and it would be even better for them to make contact with those resources” in order to facilitate assistance for patients who might need it.

In addition, pediatricians should counsel parents to follow the AAP recommendations for the utmost car seat safety rather than simply follow state laws, which may allow “graduation” to the next level before the child is large enough, Dr. Hoffman said.

“The laws of physics will always trump the laws of the state,” he concluded.

All authors filed conflict of interest statements with the AAP, and any conflicts have been resolved through a process approved by the AAP Board of Directors, according to a statement in the journal.

A list of formal car seat inspection stations is available at www.seatcheck.orghttp://cert.safekids.org

A supplement to Internal Medicine News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

Topics

• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With T2DM
• Early Identification and Screening
• CKD Strongly Effects CV Outcomes in Patients With DM
• Awareness of the Importance of CKD/RI Is Lacking
• CKD/RI Increases the Risk for Hypoglycemia in DM Treatment
• Multifactorial Therapy May Benefit Outcomes in Patients With T2DM and CKD

Faculty/Faculty Disclosure Mark Stolar, MD
Associate Professor of Clinical Medicine
Northwestern University Medical School
Chicago, IL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Mark Stolar, MD, has served on the Speakers Bureau of Takeda Pharmaceutical Company Limited and has developed educational programs for the TCL Institute and NACE. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

A supplement to Internal Medicine News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

Topics

• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With T2DM
• Early Identification and Screening
• CKD Strongly Effects CV Outcomes in Patients With DM
• Awareness of the Importance of CKD/RI Is Lacking
• CKD/RI Increases the Risk for Hypoglycemia in DM Treatment
• Multifactorial Therapy May Benefit Outcomes in Patients With T2DM and CKD

Faculty/Faculty Disclosure Mark Stolar, MD
Associate Professor of Clinical Medicine
Northwestern University Medical School
Chicago, IL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Mark Stolar, MD, has served on the Speakers Bureau of Takeda Pharmaceutical Company Limited and has developed educational programs for the TCL Institute and NACE. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

A supplement to Internal Medicine News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

Topics

• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With T2DM
• Early Identification and Screening
• CKD Strongly Effects CV Outcomes in Patients With DM
• Awareness of the Importance of CKD/RI Is Lacking
• CKD/RI Increases the Risk for Hypoglycemia in DM Treatment
• Multifactorial Therapy May Benefit Outcomes in Patients With T2DM and CKD

Faculty/Faculty Disclosure Mark Stolar, MD
Associate Professor of Clinical Medicine
Northwestern University Medical School
Chicago, IL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Mark Stolar, MD, has served on the Speakers Bureau of Takeda Pharmaceutical Company Limited and has developed educational programs for the TCL Institute and NACE. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

--Jame Abraham, MD, Editor

--Jame Abraham, MD, Editor

--Jame Abraham, MD, Editor

A supplement to Internal Medicine News®. This supplement was sponsored by Ferring Pharmaceuticals.

• Topics
• Faculty

Topics

• Introduction
• Definition & Diagnosis
• Tranexamic Acid for the Treatment of HMB
• Conclusion

Faculty/Faculty Disclosure

Lee Shulman, MD, FACOG, FACMG
The Anna Ross Lapham Professor in Obstetrics and Gynecology
Feinberg School of Medicine of Northwestern University
Chicago, Illinois

Dr Shulman is a consultant to Ferring Pharmaceuticals, Inc.  

Matt T. Rosenberg, MD
Family Physician
Mid-Michigan Health Centers
Jackson, Michigan

Dr Rosenberg

Copyright © 2011 Elsevier Inc.

A supplement to Internal Medicine News®. This supplement was sponsored by Ferring Pharmaceuticals.

• Topics
• Faculty

Topics

• Introduction
• Definition & Diagnosis
• Tranexamic Acid for the Treatment of HMB
• Conclusion

Faculty/Faculty Disclosure

Lee Shulman, MD, FACOG, FACMG
The Anna Ross Lapham Professor in Obstetrics and Gynecology
Feinberg School of Medicine of Northwestern University
Chicago, Illinois

Dr Shulman is a consultant to Ferring Pharmaceuticals, Inc.  

Matt T. Rosenberg, MD
Family Physician
Mid-Michigan Health Centers
Jackson, Michigan

Dr Rosenberg

Copyright © 2011 Elsevier Inc.

A supplement to Internal Medicine News®. This supplement was sponsored by Ferring Pharmaceuticals.

• Topics
• Faculty

Topics

• Introduction
• Definition & Diagnosis
• Tranexamic Acid for the Treatment of HMB
• Conclusion

Faculty/Faculty Disclosure

Lee Shulman, MD, FACOG, FACMG
The Anna Ross Lapham Professor in Obstetrics and Gynecology
Feinberg School of Medicine of Northwestern University
Chicago, Illinois

Dr Shulman is a consultant to Ferring Pharmaceuticals, Inc.  

Matt T. Rosenberg, MD
Family Physician
Mid-Michigan Health Centers
Jackson, Michigan

Dr Rosenberg

Copyright © 2011 Elsevier Inc.

A supplement to Family Practice News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

To view the supplement, click the image above.

Topics

• Complications Associated With T2DM
• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With DM
• Early Identification and Screening
• Healthcare Providers Are Unaware of the Negative Effects of CKD on Cardiovascular Outcomes in Patients With T2DM
• Awareness of CKD/RI: Clinicians
• Awareness of CKD/RI: Patients
• Awareness of CKD/RI: Glycemic Control
• Prevention and Management

Faculty/Faculty Disclosure
Fernando Ovalle, MD
Associate Professor, Medicine
Director, Fellowship Training Program,
Diabetes & Endocrine Research Unit and Comprehensive Diabetes Clinic
UAB School of Medicine
Birmingham, AL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Fernando Ovalle, MD, has disclosed no potential conflicts of interest. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

A supplement to Family Practice News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

To view the supplement, click the image above.

Topics

• Complications Associated With T2DM
• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With DM
• Early Identification and Screening
• Healthcare Providers Are Unaware of the Negative Effects of CKD on Cardiovascular Outcomes in Patients With T2DM
• Awareness of CKD/RI: Clinicians
• Awareness of CKD/RI: Patients
• Awareness of CKD/RI: Glycemic Control
• Prevention and Management

Faculty/Faculty Disclosure
Fernando Ovalle, MD
Associate Professor, Medicine
Director, Fellowship Training Program,
Diabetes & Endocrine Research Unit and Comprehensive Diabetes Clinic
UAB School of Medicine
Birmingham, AL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Fernando Ovalle, MD, has disclosed no potential conflicts of interest. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

A supplement to Family Practice News®. This supplement was sponsored by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company.

• Topics
• Faculty

To view the supplement, click the image above.

Topics

• Complications Associated With T2DM
• Epidemiology of CKD/RI With DM
• Risk Factors for CKD/RI in Patients With DM
• Early Identification and Screening
• Healthcare Providers Are Unaware of the Negative Effects of CKD on Cardiovascular Outcomes in Patients With T2DM
• Awareness of CKD/RI: Clinicians
• Awareness of CKD/RI: Patients
• Awareness of CKD/RI: Glycemic Control
• Prevention and Management

Faculty/Faculty Disclosure
Fernando Ovalle, MD
Associate Professor, Medicine
Director, Fellowship Training Program,
Diabetes & Endocrine Research Unit and Comprehensive Diabetes Clinic
UAB School of Medicine
Birmingham, AL

Michael Kodack, PharmD
Vice President, Medical
BlueSpark Healthcare Communications LLC
Basking Ridge, NJ

Fernando Ovalle, MD, has disclosed no potential conflicts of interest. Michael Kodack, PharmD, is an employee of BlueSpark Healthcare Communications LLC.

Copyright © 2011 Elsevier Inc.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.

LAS VEGAS – The results from the National Lung Screening Trial constitute a "game changer" for lung cancer screening, Dr. James R. Jett said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

The study results, reported in a press release by the National Cancer Institute last November, "changed the landscape" for screening by showing that lung imaging by low-dose helical CT done annually for 3 years in people with a smoking history of least 30 pack-years cut their mortality rate from lung cancer during follow-up by 20%, compared with people who underwent three annual chest x-rays. "This is the biggest advance in lung cancer in my career, an absolutely stunning result," said Dr. Jett, a pulmonologist and lung cancer specialist at National Jewish Health in Denver.

The researchers who ran the National Lung Screening Trial will likely publish their full results this spring, after which annual screening of people who match the profile of those in the study should become the standard of care, Dr. Jett predicted.

The screening trial enrolled 53,454 current or former cigarette smokers aged 55-74 years, who had each accumulated at least 30 pack-years of smoking history but had quit within the previous 15 years. The more than 75,000 total screening events by CT and more than 73,000 total screens by chest x-ray yielded 24% positive CT images and 7% positive x-ray images. During roughly 144,000 person-years of follow-up in each arm, the mortality due to lung cancer reached 246 deaths per 100,000 person-years in the CT group and 308 deaths per 100,000 person-years in the x-ray group, a 20% absolute mortality reduction with CT screening that was statistically significant, and which led the trial’s Data and Safety Monitoring Board to stop the study and release the results.

The people screened by CT also had a 7% reduction in all-cause mortality, compared with those screened by x-ray, also a statistically significant difference.

As about 160,000 Americans die from lung cancer annually, a 20% cut in mortality from low-dose helical CT screening could potentially save about 32,000 lives a year in the United States alone. "That’s almost like eliminating all 40,000 breast cancer deaths each year," Dr. Jett said.

The results did not directly address the question of how long annual screening should continue. In the trial, screening stopped after three annual examinations because of limited financial resources, although despite that the study cost about $200 million, he said. But his review of the results identified no suggestion that in routine practice screening should stop after 3 years. "There was no drop in the number of cancers" during each sequential year of screening. "I don’t see anything that tells me you can stop [screening] after 3 years," he said.

"The biggest question is, can we afford" to do annual CT screening on the scale needed to include all people who fit the profile included in the trial.

A second issue is the safety of annual CT imaging, but Dr. Jett presented a brief analysis suggesting that it is safe. A low-dose CT scan involves a radiation exposure of about 0.65 mSv, less than 10% of the dose of a conventional chest CT, Dr. Jett said. With that level of exposure, annual low-dose CT imaging of currently smoking women aged 50 might cause an excess of 5 cancer deaths for every 10,000 people screened, compared with a background lung cancer mortality of 100 for every 10,000 people with no screening. Because screening could prevent 20% of these 100 deaths, it would avert more deaths that it might cause. For men, the risk: benefit ratio runs even higher because currently smoking men undergoing annual CT screening would have about 2 extra lung cancer deaths per 10,000 people due to the radiation exposure, compared with 110 per 10,000 without screening. Women face a higher risk from the radiation of screening than men because of the impact of chest radiation on breast cancer, Dr. Jett said.

Dr. Jett said that he has been an adviser to Genentech, Pfizer, and Bristol-Myers Squibb, and that he has a research grant pending from Oncimmune.

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

"For the specialty, it brings identity and awareness of all that we do," Erin Stucky, MD, MHM, a pediatric hospitalist at Rady Children's Hospital in San Diego, wrote in an email. "We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day."

The other MHMs, each of whom spoke to The Hospitalist via email, are:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM's Public Policy Committee. "I've had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field," Dr. Greeno says. "To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty."

Russell L. Holman, MD, MHM, Cogent's COO and past president of SHM. "Our specialty is constantly evolving; there is no paved road before us," Dr. Holman says. "We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me."

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care. "It is a terrific honor to be recognized by SHM in this way," Dr. Gorman says. "The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!"

SHM has now recognized seven MHMs. Last year's class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM. Each is recognized for what SHM says is the "utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession."

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

"For the specialty, it brings identity and awareness of all that we do," Erin Stucky, MD, MHM, a pediatric hospitalist at Rady Children's Hospital in San Diego, wrote in an email. "We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day."

The other MHMs, each of whom spoke to The Hospitalist via email, are:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM's Public Policy Committee. "I've had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field," Dr. Greeno says. "To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty."

Russell L. Holman, MD, MHM, Cogent's COO and past president of SHM. "Our specialty is constantly evolving; there is no paved road before us," Dr. Holman says. "We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me."

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care. "It is a terrific honor to be recognized by SHM in this way," Dr. Gorman says. "The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!"

SHM has now recognized seven MHMs. Last year's class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM. Each is recognized for what SHM says is the "utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession."

SHM will induct its second class of Masters in Hospital Medicine (MHM) at HM11 in May, and while each of the four honorees says the title is a personal honor, they all emphasize that it is a professional point of pride to see just how far HM has come in the past 15 years.

"For the specialty, it brings identity and awareness of all that we do," Erin Stucky, MD, MHM, a pediatric hospitalist at Rady Children's Hospital in San Diego, wrote in an email. "We are QI in mortal form, acting and pressing on to deliver excellence in healthcare within our systems. Each of us, members of the society, those with FHM, SFHM, and MHM—we each deliver on this promise every day."

The other MHMs, each of whom spoke to The Hospitalist via email, are:

Ron Greeno, MD, MHM, chief medical officer for Cogent Healthcare and a member of SHM's Public Policy Committee. "I've had the privilege of working in hospital medicine for 18 years and, along with my colleagues at Cogent, have helped shape the field," Dr. Greeno says. "To be one of a handful of hospitalists to be named a Master in Hospital Medicine is truly exciting, but equally exciting is to see the growing leadership capabilities of a number of our younger colleagues who will become the future leaders of our specialty."

Russell L. Holman, MD, MHM, Cogent's COO and past president of SHM. "Our specialty is constantly evolving; there is no paved road before us," Dr. Holman says. "We are cutting the path, and are part of an historical transformation of the way care is provided in this country. Twenty years from now we will reflect on an enduring legacy of dramatically improving the quality, safety, and sustainability of care for hospitalized patients. The privilege of being part of this movement is rewarding and inspirational for me."

Mary Jo Gorman, MD, MBA, MHM, former SHM president and CEO of St. Louis-based Advanced ICU Care. "It is a terrific honor to be recognized by SHM in this way," Dr. Gorman says. "The group that is included has accomplished many things and it's gratifying to be recognized with them. It’s hard to believe that SHM has come so far that we have fellows and masters in the society! Those early days seem a long way away!"

SHM has now recognized seven MHMs. Last year's class consisted of Winthrop F. Whitcomb, MD, MHM, Robert Wachter, MD, MHM, and John Nelson, MD, MHM. Each is recognized for what SHM says is the "utmost demonstration of dedication to the field of hospital medicine through significant contributions to the development and maturation of the profession."

Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

Clinical question: Are such alternatives as tiotropium bromide, a long-acting anticholinergic agent, effective in improving symptoms and lung function in those patients who are inadequately controlled on a low-dose inhaled glucocorticoid?

Background: Many asthmatics remain uncontrolled on low doses of inhaled glucocorticoid therapy. Treatment options include increasing the dose or adding a long-acting beta-agonist (LABA). Safety concerns, however, have emerged recently regarding LABA use. It is unclear whether the use of alternatives, such as anticholinergics, is beneficial in managing symptoms.

Study design: Double-blind, three-way crossover trial.

Setting: Multicenter study.

Synopsis: Researchers studied a total of 210 patients with uncontrolled asthma. Three treatments were used with low-dose inhaled glucocorticoids (beclomethasone) as a baseline: adding tiotropium, doubling the dose of inhaled glucocorticoids, or adding an LABA (salmeterol). Patients were treated in all three groups, each lasting 14 weeks with a two-week washout period between treatments (when only the baseline medication was used). The primary outcome measure was the morning peak expiratory flow (PEF).

When compared to doubling the inhaled glucocorticoid dose, patients receiving tiotropium had a higher morning PEF (25.8 liters, 95% CI 14.4-37.1, P<0.001). Tiotropium use also showed statistically significant improvement in the evening PEF, pre-bronchodilator FEV1, proportion of asthma control days, and scores for daily symptoms.

Tiotropium was found to be noninferior to salmeterol, including no difference in morning PEF. Other measurements were similar, except that pre-bronchodilator FEV1 favored tiotropium (0.11 liter increase, 95% CI 0.04-0.18, P=0.003). Because treatments did not last for more than 14 weeks, long-term safety issues and exacerbation rates could not be determined.

Bottom line: When added to a low-dose inhaled glucocorticoid, tiotropium improves asthma symptoms and lung function compared with doubling the corticosteroid dose and is noninferior when compared to a LABA.

Citation: Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363(18):1715-1726.

Reviewed for TH eWire by Elizabeth Schulwolf, MD, MA, Sean Greenhalgh, MD, Aziz Ansari, DO, FHM, Nathan Derhammer, MD, FAAP, Paula Marfia, MD, Elizabeth Wantuch, MD, MS, Division of Hospital Medicine, Loyola University, Chicago.

For more physician reviews of HM-related research, visit our website.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.

HOLLYWOOD, FLA. – New data have led to upgrades of two rituximab regimens and radioimmunotherapy for follicular lymphoma in the National Comprehensive Cancer Network’s clinical practice guidelines for non-Hodgkin’s lymphoma.

Other changes include a section that addresses the utility of positron emission tomography in the assessment of follicular lymphoma and the addition of recommendations for the evaluation and management of posttransplant lymphoproliferative disorder (PTLD), according to Dr. Andrew D. Zelenetz of Memorial Sloan-Kettering Cancer Center in New York.

At the National Comprehensive Cancer Network’s annual conference on clinical practice guidelines, he reported updates in the following areas on behalf of the NCCN’s 30-member panel on non-Hodgkin’s lymphoma:

Rituximab plus bendamustine. The combination of rituximab (Rituxan) plus bendamustine (Treanda) has been upgraded from a category 2A to a category 1 recommendation for first-line treatment of follicular lymphoma, a common form of NHL, Dr. Zelenetz announced.

The most widely used first-line regimen for follicular lymphoma has been R-CHOP (a combination of rituximab, cyclophosphamide, doxorubicin HCl, vincristine sulfate, and prednisone). In a study presented in 2009 at the American Society of Hematology (ASH) annual meeting comparing the efficacy of the R-CHOP protocol with that of the rituximab-bendamustine (RB) combination, the complete remission rate among patients randomized to RB treatment was 73% vs. 39.6% in the R-CHOP arm, Dr. Zelenetz said (Blood [ASH Annual Meeting Abstracts] 2009 Nov.;114:405).

"The median progression-free survival was also higher [in the RB group], at 54.9 months compared with 34.8 months [in the R-CHOP arm]," a finding that he described as unexpected. "This study was designed as an equivalency study, and it certainly surprised many of us that rituximab-bendamustine was significantly better in terms of progression-free survival," he said.

Although there was no difference in overall survival between the two groups, he noted, the RB protocol was better tolerated with less hematologic toxicity and no alopecia.

Rituximab maintenance and radioimmunotherapy. The panel also upgraded rituximab maintenance and chemotherapy followed by radioimmunotherapy from a category 2B to a category 1 recommendation for the treatment of follicular lymphoma after the first remission. The guideline change regarding postremission management was sparked by the results of two recent studies, Dr. Zelenetz said.

The first demonstrated a significant reduction in the risk of recurrence among patients who received rituximab maintenance after responding to induction with rituximab plus chemotherapy (Lancet 2011;377:42-51). The other, presented at the 2010 ASH meeting, showed that postremission radioimmunotherapy following chemotherapy significantly improved the complete response and progression-free survival rates relative to the experience in patients who received no additional treatment following remission (Blood [ASH Annual Meeting Abstracts] 2010 Nov.;116:594).

"Unfortunately, neither study was associated with improvement in overall survival," he said.

PET imaging. In the assessment of follicular lymphoma, "studies have shown that PET imaging can be used to distinguish between indolent and aggressive lymphoma and can help guide the site for optimal biopsy, "especially in patients in whom there is a concern about transformation from indolent to aggressive disease," Dr. Zelenetz said. While it cannot replace biopsy, "[PET imaging] can help identify the best vs. the most convenient lymph node to biopsy," he said(J. Clin. Oncol. 2005;23:4643-51; Ann. Oncol. 2009; 20:508-12).

In addition, PET–computed tomography (PET-CT) has a role in the assessment of treatment response because "the predictive power of posttreatment PET-CT is stronger than other prognostic factors," Dr. Zelenetz explained.

Posttransplant lymphoproliferative disorder. PTLD "has emerged as a significant complication of solid organ and allogeneic bone marrow transplantation," according to Dr. Zelenetz.

The revised guidelines recommend outlining the procedure for establishing a diagnosis based on histology and immunophenotype, and categorizes relevant tests as essential or useful under certain circumstances. Among information deemed "essential," he said, is the determination of patients’ Epstein Barr virus (EBV) status, as well as their histopathology (polymorphic or monomorphic cells) and immunophenotype.

NCCN recommendations include reducing immunosuppression for patients with early lesions, which are usually associated with Epstein-Barr virus, and for those with polymorphic systemic and monomorphic disease. Treatment may include antiviral prophylaxis with gancyclovir (Cytovene), rituximab, or chemoimmunotherapy, depending on PTLD subtype, said Dr. Zelenetz, noting that "stem cell transplantation is usually reserved for relapse or refractory situations, as we would manage other aggressive lymphomas."

Dr. Zelenetz disclosed receiving grant and research support from companies including Amgen Inc., Celgene Corp., Cell Therapeutics Inc., Cephalon Inc., Genentech Inc., GlaxoSmithKline, and Sanofi-Aventis US.