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Free Home Chlamydia Tests Net High Return
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing.
Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site www.iwantthekit.org
About one-third of the kits were returned with vaginal swab samples collected at home, with positive chlamydia results in 10% and positive gonorrhea tests in 1%, Dr. Gaydos, professor of infectious diseases at the university, said in an interview.
Trichomonas testing was added in 2006 and has resulted in a detection rate of 12% in 1,032 returned samples.
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
Once someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage.
“I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens.
Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
Beyond identifying cases of sexually transmitted infections that might not otherwise have been detected, the researchers were able to obtain demographic and sexual information from women who responded.
A few 14-year-olds participated but none were positive for chlamydia.
On the other hand, more than one-quarter of all respondents were aged 15–19 years, and they had the highest prevalence for chlamydia of any age group, at 15%.
About one-third of the respondents were aged 20–24 years. In this group, the prevalence rate was 11%.
Somewhat surprising to researchers was the high rate of participation among women 25–29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%).
Researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race vs. white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%).
Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said. The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois.
“Theoretically, this program could go anywhere in the U.S.,” she said.
Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent, she said.
Dr. Gaydos disclosed that Gen-Probe, Inc. of San Diego provided free diagnostic kits for the study.
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing.
Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site www.iwantthekit.org
About one-third of the kits were returned with vaginal swab samples collected at home, with positive chlamydia results in 10% and positive gonorrhea tests in 1%, Dr. Gaydos, professor of infectious diseases at the university, said in an interview.
Trichomonas testing was added in 2006 and has resulted in a detection rate of 12% in 1,032 returned samples.
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
Once someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage.
“I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens.
Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
Beyond identifying cases of sexually transmitted infections that might not otherwise have been detected, the researchers were able to obtain demographic and sexual information from women who responded.
A few 14-year-olds participated but none were positive for chlamydia.
On the other hand, more than one-quarter of all respondents were aged 15–19 years, and they had the highest prevalence for chlamydia of any age group, at 15%.
About one-third of the respondents were aged 20–24 years. In this group, the prevalence rate was 11%.
Somewhat surprising to researchers was the high rate of participation among women 25–29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%).
Researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race vs. white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%).
Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said. The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois.
“Theoretically, this program could go anywhere in the U.S.,” she said.
Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent, she said.
Dr. Gaydos disclosed that Gen-Probe, Inc. of San Diego provided free diagnostic kits for the study.
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing.
Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site www.iwantthekit.org
About one-third of the kits were returned with vaginal swab samples collected at home, with positive chlamydia results in 10% and positive gonorrhea tests in 1%, Dr. Gaydos, professor of infectious diseases at the university, said in an interview.
Trichomonas testing was added in 2006 and has resulted in a detection rate of 12% in 1,032 returned samples.
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
Once someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage.
“I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens.
Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
Beyond identifying cases of sexually transmitted infections that might not otherwise have been detected, the researchers were able to obtain demographic and sexual information from women who responded.
A few 14-year-olds participated but none were positive for chlamydia.
On the other hand, more than one-quarter of all respondents were aged 15–19 years, and they had the highest prevalence for chlamydia of any age group, at 15%.
About one-third of the respondents were aged 20–24 years. In this group, the prevalence rate was 11%.
Somewhat surprising to researchers was the high rate of participation among women 25–29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%).
Researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race vs. white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%).
Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said. The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois.
“Theoretically, this program could go anywhere in the U.S.,” she said.
Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent, she said.
Dr. Gaydos disclosed that Gen-Probe, Inc. of San Diego provided free diagnostic kits for the study.
Free Home Chlamydia Tests Net High Return
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective that it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University (Baltimore) researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing. Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site, www.iwantthekit.org
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
After someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage. “I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens. Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
The researchers also were able to obtain demographic and sexual information from women who responded. A few 14-year-olds participated but none were positive for chlamydia. However, more than one-quarter of all respondents were aged 15-19 years, and they had the highest prevalence for chlamydia of any age group, at 15%. About one-third of the respondents were aged 20-24 years. In this group, the prevalence rate was 11%. Somewhat surprising to researchers was the high rate of participation among women 25-29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%)
The researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race versus white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%). Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said.
The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois. “Theoretically, this program could go anywhere in the U.S.,” she said. Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent.
Dr. Gaydos disclosed that Gen-Probe Inc. of San Diego provided free diagnostic kits for the study.
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective that it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University (Baltimore) researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing. Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site, www.iwantthekit.org
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
After someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage. “I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens. Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
The researchers also were able to obtain demographic and sexual information from women who responded. A few 14-year-olds participated but none were positive for chlamydia. However, more than one-quarter of all respondents were aged 15-19 years, and they had the highest prevalence for chlamydia of any age group, at 15%. About one-third of the respondents were aged 20-24 years. In this group, the prevalence rate was 11%. Somewhat surprising to researchers was the high rate of participation among women 25-29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%)
The researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race versus white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%). Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said.
The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois. “Theoretically, this program could go anywhere in the U.S.,” she said. Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent.
Dr. Gaydos disclosed that Gen-Probe Inc. of San Diego provided free diagnostic kits for the study.
LOS ANGELES — Free home swab test kits requested via the Internet have detected hundreds of cases of chlamydia, gonorrhea, and Trichomonas using a simple online recruitment strategy that was so effective that it is now being extended to several states.
The novel “I Want the Kit” program was devised by Johns Hopkins University (Baltimore) researchers in 2004, alerting young women to facts about chlamydia and other sexually transmitted diseases, and offering kits with prepaid postage to allow for confidential testing. Word went out via radio, magazine, and newspaper advertisements in Baltimore initially, but soon Internet traffic began to dominate responses.
“Our original objective was to reach out to teens who might have issues with fear and privacy going to a clinic,” Dr. Charlotte A. Gaydos said at the annual meeting of the Society for Adolescent Medicine, where she presented interim study results.
Nearly 5,000 kits have been requested to date, 97% through the study's site, www.iwantthekit.org
Dr. Gaydos reported that more than 98% of women said the instructions for collection were easy, 97% said the collection itself was easy, and 92% said they would use an Internet-based program again for STD testing.
After someone requests a kit, it arrives at her home in a plain envelope, listing as the return address only the street address of the project in Baltimore. The packet contains detailed instructions, the test swab, and return packaging—including postage. “I'm reaching out to the 14-year-old who has no money for postage and is not going to tell her mother she's sexually active,” said Dr. Gaydos.
Completed samples can be dropped off in any mailbox and are tested by nucleic acid amplification tests for all three STDs. The test method has been found in previous research to be highly accurate—and even more so with self-collected vaginal swabs than with urine specimens. Positive test results are followed up by referrals to free treatment clinics close to the adolescents' or women's homes.
The researchers also were able to obtain demographic and sexual information from women who responded. A few 14-year-olds participated but none were positive for chlamydia. However, more than one-quarter of all respondents were aged 15-19 years, and they had the highest prevalence for chlamydia of any age group, at 15%. About one-third of the respondents were aged 20-24 years. In this group, the prevalence rate was 11%. Somewhat surprising to researchers was the high rate of participation among women 25-29 years (18% of respondents, with a prevalence rate of 7%) and those over 30 years (22% of the respondents, with a prevalence rate of 1%)
The researchers found a high rate of sexual risk among women participating in the study, with 55% reporting a history of an STD, 59% reporting more than one sex partner in the previous 90 days, 39% reporting a new partner in the previous 90 days, more than half reporting drinking before sex, 31% reporting anal sex, and 23% reporting a history of forced sex.
In a multivariate logistic regression analysis, only three factors were independently associated with a positive chlamydia test: black race versus white (odds ratio, 3.4); age less than 25 years (OR, 3.4); and having a new partner during the past 90 days (OR, 1.7).
Among all respondents (most of whom did not test positive for an STD), 62% reported at least one symptom, including vaginal discharge (48%), lower abdominal pain (17%), pain during intercourse (15%), abnormal vaginal bleeding (7%), and/or pain during urination (6%). Several audience members expressed concern about undiagnosed conditions in the population, but Dr. Gaydos assured them that the Web site makes it clear that respondents should seek medical attention in the face of symptoms and have a regular care provider.
A parallel study is ongoing for males, she said.
The “I Want the Kit” testing is currently available via the Internet to girls and young women in Maryland; West Virginia; Washington, D.C.; Denver; and some counties in Illinois. “Theoretically, this program could go anywhere in the U.S.,” she said. Every state receives Centers for Disease Control and Prevention funding for free STD testing through the CDC Infertility Prevention Program, and this strategy may reach a very high-risk group with intensive education and a means of confidentially, conveniently accessing a reliable test. Involving public health systems is critical, said Dr. Gaydos, because many commercial Internet sites offering STD tests use unreliable testing protocols. In fact, some are completely fraudulent.
Dr. Gaydos disclosed that Gen-Probe Inc. of San Diego provided free diagnostic kits for the study.
Sexual Health Info Online Can Lead Kids Astray
LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.
That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.
“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.
Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.
Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included.
The 35 Web sites examined were assessed for accuracy on 26 topics.
In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.
However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.
On other topics, the information on Web sites was inaccurate or incomplete.
More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials.
Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.
Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.
Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained.
Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.
Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, the researchers found.
Most Web sites offering information on Pap smears were updated in the past few years.
Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.
Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose with regard to their study.
Recommended Sites for Teens
▸ Go Ask Alice! at
▸ Center for Young Women's Health at
▸ TeenWire at
▸ TeensHealth at
Sources: Ms. Tolani and Dr. Yen
Common Sex Myths on the Internet
Myth: Emergency contraception is difficult to obtain.
Reality: Emergency contraception is over the counter for women 17 and older. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.
Myth: Emergency contraception induces an abortion.
Reality: Emergency contraception does not cause an abortion and is not RU-486.
Myth: IUDs are for multiparous women.
Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.
Myth: Oral contraceptives cause weight gain.
Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.
Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.
Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smear beginning at age 21 years or 3 years post coitarche.
Myth: Kissing is safe, even if your partner has herpes.
Reality: Herpes can be transmitted by kissing an infected individual.
Source: Dr. Yen
LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.
That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.
“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.
Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.
Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included.
The 35 Web sites examined were assessed for accuracy on 26 topics.
In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.
However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.
On other topics, the information on Web sites was inaccurate or incomplete.
More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials.
Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.
Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.
Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained.
Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.
Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, the researchers found.
Most Web sites offering information on Pap smears were updated in the past few years.
Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.
Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose with regard to their study.
Recommended Sites for Teens
▸ Go Ask Alice! at
▸ Center for Young Women's Health at
▸ TeenWire at
▸ TeensHealth at
Sources: Ms. Tolani and Dr. Yen
Common Sex Myths on the Internet
Myth: Emergency contraception is difficult to obtain.
Reality: Emergency contraception is over the counter for women 17 and older. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.
Myth: Emergency contraception induces an abortion.
Reality: Emergency contraception does not cause an abortion and is not RU-486.
Myth: IUDs are for multiparous women.
Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.
Myth: Oral contraceptives cause weight gain.
Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.
Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.
Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smear beginning at age 21 years or 3 years post coitarche.
Myth: Kissing is safe, even if your partner has herpes.
Reality: Herpes can be transmitted by kissing an infected individual.
Source: Dr. Yen
LOS ANGELES — Teenagers cruising mainstream Web sites can hardly be faulted for thinking that emergency contraception is difficult to obtain, birth control pills will make them fat, and IUDs are meant for older women, not adolescents.
That's because incomplete and inaccurate information abounds on the Internet, even within very well-known Web sites, according to an analysis performed in 2008 by Stanford (Calif.) University researchers.
“We found a lot of myths about IUDs, emergency contraception, birth control, and when women should be getting Pap smears, especially their first one,” said Alisha T. Tolani, a student in the human biology program at the university.
Ms. Tolani and her research mentor, Dr. Sophia Yen of the division of adolescent medicine at Stanford's Lucile Packard Children's Hospital, presented their findings in a poster at the annual meeting of the Society of Adolescent Medicine.
Web sites were selected for analysis based on practitioner recommendations and Google searches of key terms, such as “birth control,” “morning after pill,” and “sexually transmitted disease.” The top 10–15 results for each search term were included.
The 35 Web sites examined were assessed for accuracy on 26 topics.
In general, sites provided “fairly accurate” information on STDs, Ms. Tolani and Dr. Yen reported in their poster. For example, 100% of Web sites addressing STDs correctly noted that most sexually transmitted diseases are asymptomatic and that when symptoms are present, they may include burning with urination and discharge.
However, information about transmission was often vague or incomplete. Just 9 of 29 (31%) STD Web sites informed adolescents that herpes can be transmitted by kissing, and 14 of 29 (48%) mentioned skin-to-skin contact as a possible source of transmission.
On other topics, the information on Web sites was inaccurate or incomplete.
More than half of the Web sites that addressed contraception listed weight gain as a possible side effect of birth control pills, a myth contradicted by 47 randomized, controlled trials.
Five Web sites incorrectly stated that the calendar/rhythm method is effective at preventing pregnancy, and three misstated the effectiveness of emergency contraception.
Often, the Web sites omitted important information, considering that approximately a quarter of teens use the Internet to answer “some or a lot” of their questions about sexual health, Ms. Tolani said in an interview.
Although 16 of 34 (47%) Web sites noted that minors need a prescription for emergency contraception, they failed to mention that in many states, minors can obtain those prescriptions directly from authorized pharmacists. Very few sites explained exactly where emergency contraception can be obtained.
Nearly a third of Web sites failed to debunk common myths about emergency contraception by explaining that is not an abortifacient, and making a distinction between emergency contraception and RU-486, mifepristone.
Just 5 of 27 (19%) Web sites dealing with contraception reflected 2007 American College of Obstetricians and Gynecologists guidelines recommending IUDs as a safe means of contraception in adolescents. Many were neutral, failing to mention adolescents and IUDs. But three sites incorrectly stated that IUDs should be reserved for parous women, the researchers found.
Most Web sites offering information on Pap smears were updated in the past few years.
Nonetheless, their recommendations for when women should have Pap smears “were all over the place,” with 40% offering advice that contradicted ACOG's 2003 guidelines, which state that women should begin receiving Pap smears at age 21 years or 3 years post coitarche, said Ms. Tolani.
Neither Ms. Tolani nor Dr. Yen had any conflicts of interest to disclose with regard to their study.
Recommended Sites for Teens
▸ Go Ask Alice! at
▸ Center for Young Women's Health at
▸ TeenWire at
▸ TeensHealth at
Sources: Ms. Tolani and Dr. Yen
Common Sex Myths on the Internet
Myth: Emergency contraception is difficult to obtain.
Reality: Emergency contraception is over the counter for women 17 and older. Minors can currently receive prescriptions directly from authorized pharmacists in nine states: Alaska, California, Hawaii, Maine, Massachusetts, New Hampshire, New Mexico, Vermont, and Washington.
Myth: Emergency contraception induces an abortion.
Reality: Emergency contraception does not cause an abortion and is not RU-486.
Myth: IUDs are for multiparous women.
Reality: IUDs are safe for use in adolescents, including the nulliparous and serially monogamous.
Myth: Oral contraceptives cause weight gain.
Reality: A review of 47 randomized, controlled trials found no evidence that combined hormonal contraceptives caused weight gain.
Myth: Women should have Pap smears with each change of sexual partner, at age 18 years, or immediately following coitarche.
Reality: The American College of Obstetricians and Gynecologists recommends that women have a Pap smear beginning at age 21 years or 3 years post coitarche.
Myth: Kissing is safe, even if your partner has herpes.
Reality: Herpes can be transmitted by kissing an infected individual.
Source: Dr. Yen
JIA Patients Thrive, if They Can Find a Specialist
Hesitation on the part of nonpediatric rheumatologists to put children with juvenile idiopathic arthritis on biologics is harming these young patients who have the most to gain from such agents, according to physicians interviewed for this story.
Childrens Hospital Los Angeles stands as an object lesson in the benefits of biologics. For years, its rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement. In the summer months, even more children with JIA were admitted for what were known as “tune-ups,” consisting of rigorous treatments that had to be delayed until the school year ended in June.
Last year, Dr. Andreas Reiff, CHLA's pediatric rheumatology chief, resigned from his post as division head of the rehabilitation center. “Essentially, we had no more [JIA] patients there,” he said in a telephone interview. “Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe problems with their joints.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008.
Many other biologic therapies are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
Pediatric patients' access to biologic therapies for JIA may depend on how close they live to a primary care physician or specialist who is comfortable prescribing the new class of medications, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they say; practical access to biologics is spotty, which means that many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated early, before irreparable damage occurs.
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radio-graphic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance to traditional treatments.”
Although approximately 239 pediatric rheumatologists are licensed in the United States, only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo.
On average, families are required to travel 57 miles to see a pediatric rheumatologist. The physicians interviewed for this story said that many face much longer journeys, up to 5–6 hours each way.
“The majority of children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Reiff in an interview.
“They are often misdiagnosed, or treated with drugs used in adults such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
For Dr. Lawrence K. Jung, chief of the division of rheumatology at Children's National Medical Center in Washington, the disparity in care became personal with his recent move from Omaha, where he felt he had a handle on the close-knit JIA population, to Washington, a metropolitan area with more than 5 million people that happens to be seriously underserved by practicing pediatric rheumatologists. “I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
He saw one such child before Christmas whose arthritis had profoundly worsened while he was being managed solely with an over-the-counter nonsteroidal anti-inflammatory drug.
“I put him on one of the biologics and within days, he was better,” said Dr. Jung.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring, they said.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” agreed Dr. Passo, professor in the division of pediatric rheumatology at the Medical University of South Carolina in Charleston.
“With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a wide variety of conditions, including Crohn's disease, as well as JIA. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.
“Having said that, there are a few case reports of malignancy and serious opportunistic infections. These have not been quite as severe, at least in my experience, in kids as they are in adults.
Hesitation on the part of nonpediatric rheumatologists to put children with juvenile idiopathic arthritis on biologics is harming these young patients who have the most to gain from such agents, according to physicians interviewed for this story.
Childrens Hospital Los Angeles stands as an object lesson in the benefits of biologics. For years, its rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement. In the summer months, even more children with JIA were admitted for what were known as “tune-ups,” consisting of rigorous treatments that had to be delayed until the school year ended in June.
Last year, Dr. Andreas Reiff, CHLA's pediatric rheumatology chief, resigned from his post as division head of the rehabilitation center. “Essentially, we had no more [JIA] patients there,” he said in a telephone interview. “Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe problems with their joints.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008.
Many other biologic therapies are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
Pediatric patients' access to biologic therapies for JIA may depend on how close they live to a primary care physician or specialist who is comfortable prescribing the new class of medications, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they say; practical access to biologics is spotty, which means that many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated early, before irreparable damage occurs.
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radio-graphic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance to traditional treatments.”
Although approximately 239 pediatric rheumatologists are licensed in the United States, only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo.
On average, families are required to travel 57 miles to see a pediatric rheumatologist. The physicians interviewed for this story said that many face much longer journeys, up to 5–6 hours each way.
“The majority of children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Reiff in an interview.
“They are often misdiagnosed, or treated with drugs used in adults such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
For Dr. Lawrence K. Jung, chief of the division of rheumatology at Children's National Medical Center in Washington, the disparity in care became personal with his recent move from Omaha, where he felt he had a handle on the close-knit JIA population, to Washington, a metropolitan area with more than 5 million people that happens to be seriously underserved by practicing pediatric rheumatologists. “I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
He saw one such child before Christmas whose arthritis had profoundly worsened while he was being managed solely with an over-the-counter nonsteroidal anti-inflammatory drug.
“I put him on one of the biologics and within days, he was better,” said Dr. Jung.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring, they said.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” agreed Dr. Passo, professor in the division of pediatric rheumatology at the Medical University of South Carolina in Charleston.
“With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a wide variety of conditions, including Crohn's disease, as well as JIA. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.
“Having said that, there are a few case reports of malignancy and serious opportunistic infections. These have not been quite as severe, at least in my experience, in kids as they are in adults.
Hesitation on the part of nonpediatric rheumatologists to put children with juvenile idiopathic arthritis on biologics is harming these young patients who have the most to gain from such agents, according to physicians interviewed for this story.
Childrens Hospital Los Angeles stands as an object lesson in the benefits of biologics. For years, its rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement. In the summer months, even more children with JIA were admitted for what were known as “tune-ups,” consisting of rigorous treatments that had to be delayed until the school year ended in June.
Last year, Dr. Andreas Reiff, CHLA's pediatric rheumatology chief, resigned from his post as division head of the rehabilitation center. “Essentially, we had no more [JIA] patients there,” he said in a telephone interview. “Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe problems with their joints.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008.
Many other biologic therapies are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
Pediatric patients' access to biologic therapies for JIA may depend on how close they live to a primary care physician or specialist who is comfortable prescribing the new class of medications, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they say; practical access to biologics is spotty, which means that many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated early, before irreparable damage occurs.
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radio-graphic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance to traditional treatments.”
Although approximately 239 pediatric rheumatologists are licensed in the United States, only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo.
On average, families are required to travel 57 miles to see a pediatric rheumatologist. The physicians interviewed for this story said that many face much longer journeys, up to 5–6 hours each way.
“The majority of children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Reiff in an interview.
“They are often misdiagnosed, or treated with drugs used in adults such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
For Dr. Lawrence K. Jung, chief of the division of rheumatology at Children's National Medical Center in Washington, the disparity in care became personal with his recent move from Omaha, where he felt he had a handle on the close-knit JIA population, to Washington, a metropolitan area with more than 5 million people that happens to be seriously underserved by practicing pediatric rheumatologists. “I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
He saw one such child before Christmas whose arthritis had profoundly worsened while he was being managed solely with an over-the-counter nonsteroidal anti-inflammatory drug.
“I put him on one of the biologics and within days, he was better,” said Dr. Jung.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring, they said.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” agreed Dr. Passo, professor in the division of pediatric rheumatology at the Medical University of South Carolina in Charleston.
“With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a wide variety of conditions, including Crohn's disease, as well as JIA. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.
“Having said that, there are a few case reports of malignancy and serious opportunistic infections. These have not been quite as severe, at least in my experience, in kids as they are in adults.
Heart Problems Can Occur Early in Anorexia
LOS ANGELES — Significant cardiac abnormalities were detected in nearly a third of adolescent girls hospitalized for the first time with anorexia nervosa in a San Francisco study, raising questions about whether detailed cardiac work-ups may be warranted early in the course of the disease.
Mortality estimates for anorexia range from 5% to 20%, with a third of adult deaths due to cardiovascular complications, Dr. Melissa Slivka said at the annual meeting of the Society for Adolescent Medicine.
In adolescents, much less is known about the toll the disease takes on the cardiovascular system and about when changes begin, said Dr. Slivka, a second-year fellow in adolescent medicine at the University of California, San Francisco.
She and her associates enrolled 31 adolescents with a mean age of 15 years whose reported food restricting behavior averaged 8.5 months.
“We chose subjects being hospitalized for the first time to specifically look at cardiovascular abnormalities in subjects with shorter-term restricting histories rather than those with a more chronic illness,” she said.
The population was mostly female (97%) and white or Asian/Pacific Islander (75%). On admission, the patients were at 80% of their ideal body mass index (BMI), based on 50th percentile ideal body weight for age. Their mean length of hospitalization was 16.5 days.
During the first 24 hours of hospitalization, their mean heart rate was 43.5 beats per minute (bpm), with 26 of 31 (84%) patients meeting criteria for sinus bradycardia (less than 50 bpm).
Their mean orthostatic heart rate change when they went from lying down to standing was 29.3 bpm, with 18 of 31 (58%) patients meeting criteria for orthostatic intolerance (an increase of more than 30 bpm).
Resting electrocardiography was performed, with special attention paid to prolonged QTc intervals. The patients' mean QTc was 412 milliseconds, with 5 of 31 (16%) adolescents meeting criteria for prolonged QTc (greater than 440 milliseconds). No other arrhythmias were found, Dr. Slivka reported.
Doppler echocardiography revealed pericardial effusion in 4 of 31 (13%) adolescents and mitral valve prolapse in 2 of 31 (7%). One patient had both findings on echocardiography.
In all, 10 of 31 patients (32%) had at least one significant cardiac finding (prolonged QTc, pericardial effusion, and/or mitral valve prolapse), despite the short duration of their illness.
The adolescents with cardiac findings were at 73% of their ideal BMI, compared with 83% in those without major cardiac issues, a significant difference. No other significant correlational factors were found.
“This study supports [the hypothesis] that cardiac abnormalities occur early in the anorexia nervosa disease course and may warrant consideration and possible work-up even early in the disease and at the time of first hospital admission,” she concluded.
Adolescents whose weight is a low percentage of their ideal BMI at diagnosis may warrant special concern, she added.
Dr. Gary Remafedi, professor of pediatrics at the University of Minnesota, Minneapolis, said the study led him to question whether he should incorporate an echocardiogram into his initial work-up of patients with anorexia nervosa.
“I wonder if there were other indicators of the mitral valve prolapse or pericardial effusions … such as distinctive heart sounds or murmurs suggestive of prolapse,” he said.
The issue of whether to order an echocardiogram soon after diagnosis “remains unanswered,” Dr. Slivka responded.
“In general, mitral valve prolapse, pericardial effusion, and other valve abnormalities may be audible on physical exam. Pericardial effusion may be noted on ECG. However, in our study patients, these changes were not noted on exam,” Dr. Slivka said in an interview.
Neither Dr. Slivka nor her coauthors reported any conflicts of interest with regard to their study.
LOS ANGELES — Significant cardiac abnormalities were detected in nearly a third of adolescent girls hospitalized for the first time with anorexia nervosa in a San Francisco study, raising questions about whether detailed cardiac work-ups may be warranted early in the course of the disease.
Mortality estimates for anorexia range from 5% to 20%, with a third of adult deaths due to cardiovascular complications, Dr. Melissa Slivka said at the annual meeting of the Society for Adolescent Medicine.
In adolescents, much less is known about the toll the disease takes on the cardiovascular system and about when changes begin, said Dr. Slivka, a second-year fellow in adolescent medicine at the University of California, San Francisco.
She and her associates enrolled 31 adolescents with a mean age of 15 years whose reported food restricting behavior averaged 8.5 months.
“We chose subjects being hospitalized for the first time to specifically look at cardiovascular abnormalities in subjects with shorter-term restricting histories rather than those with a more chronic illness,” she said.
The population was mostly female (97%) and white or Asian/Pacific Islander (75%). On admission, the patients were at 80% of their ideal body mass index (BMI), based on 50th percentile ideal body weight for age. Their mean length of hospitalization was 16.5 days.
During the first 24 hours of hospitalization, their mean heart rate was 43.5 beats per minute (bpm), with 26 of 31 (84%) patients meeting criteria for sinus bradycardia (less than 50 bpm).
Their mean orthostatic heart rate change when they went from lying down to standing was 29.3 bpm, with 18 of 31 (58%) patients meeting criteria for orthostatic intolerance (an increase of more than 30 bpm).
Resting electrocardiography was performed, with special attention paid to prolonged QTc intervals. The patients' mean QTc was 412 milliseconds, with 5 of 31 (16%) adolescents meeting criteria for prolonged QTc (greater than 440 milliseconds). No other arrhythmias were found, Dr. Slivka reported.
Doppler echocardiography revealed pericardial effusion in 4 of 31 (13%) adolescents and mitral valve prolapse in 2 of 31 (7%). One patient had both findings on echocardiography.
In all, 10 of 31 patients (32%) had at least one significant cardiac finding (prolonged QTc, pericardial effusion, and/or mitral valve prolapse), despite the short duration of their illness.
The adolescents with cardiac findings were at 73% of their ideal BMI, compared with 83% in those without major cardiac issues, a significant difference. No other significant correlational factors were found.
“This study supports [the hypothesis] that cardiac abnormalities occur early in the anorexia nervosa disease course and may warrant consideration and possible work-up even early in the disease and at the time of first hospital admission,” she concluded.
Adolescents whose weight is a low percentage of their ideal BMI at diagnosis may warrant special concern, she added.
Dr. Gary Remafedi, professor of pediatrics at the University of Minnesota, Minneapolis, said the study led him to question whether he should incorporate an echocardiogram into his initial work-up of patients with anorexia nervosa.
“I wonder if there were other indicators of the mitral valve prolapse or pericardial effusions … such as distinctive heart sounds or murmurs suggestive of prolapse,” he said.
The issue of whether to order an echocardiogram soon after diagnosis “remains unanswered,” Dr. Slivka responded.
“In general, mitral valve prolapse, pericardial effusion, and other valve abnormalities may be audible on physical exam. Pericardial effusion may be noted on ECG. However, in our study patients, these changes were not noted on exam,” Dr. Slivka said in an interview.
Neither Dr. Slivka nor her coauthors reported any conflicts of interest with regard to their study.
LOS ANGELES — Significant cardiac abnormalities were detected in nearly a third of adolescent girls hospitalized for the first time with anorexia nervosa in a San Francisco study, raising questions about whether detailed cardiac work-ups may be warranted early in the course of the disease.
Mortality estimates for anorexia range from 5% to 20%, with a third of adult deaths due to cardiovascular complications, Dr. Melissa Slivka said at the annual meeting of the Society for Adolescent Medicine.
In adolescents, much less is known about the toll the disease takes on the cardiovascular system and about when changes begin, said Dr. Slivka, a second-year fellow in adolescent medicine at the University of California, San Francisco.
She and her associates enrolled 31 adolescents with a mean age of 15 years whose reported food restricting behavior averaged 8.5 months.
“We chose subjects being hospitalized for the first time to specifically look at cardiovascular abnormalities in subjects with shorter-term restricting histories rather than those with a more chronic illness,” she said.
The population was mostly female (97%) and white or Asian/Pacific Islander (75%). On admission, the patients were at 80% of their ideal body mass index (BMI), based on 50th percentile ideal body weight for age. Their mean length of hospitalization was 16.5 days.
During the first 24 hours of hospitalization, their mean heart rate was 43.5 beats per minute (bpm), with 26 of 31 (84%) patients meeting criteria for sinus bradycardia (less than 50 bpm).
Their mean orthostatic heart rate change when they went from lying down to standing was 29.3 bpm, with 18 of 31 (58%) patients meeting criteria for orthostatic intolerance (an increase of more than 30 bpm).
Resting electrocardiography was performed, with special attention paid to prolonged QTc intervals. The patients' mean QTc was 412 milliseconds, with 5 of 31 (16%) adolescents meeting criteria for prolonged QTc (greater than 440 milliseconds). No other arrhythmias were found, Dr. Slivka reported.
Doppler echocardiography revealed pericardial effusion in 4 of 31 (13%) adolescents and mitral valve prolapse in 2 of 31 (7%). One patient had both findings on echocardiography.
In all, 10 of 31 patients (32%) had at least one significant cardiac finding (prolonged QTc, pericardial effusion, and/or mitral valve prolapse), despite the short duration of their illness.
The adolescents with cardiac findings were at 73% of their ideal BMI, compared with 83% in those without major cardiac issues, a significant difference. No other significant correlational factors were found.
“This study supports [the hypothesis] that cardiac abnormalities occur early in the anorexia nervosa disease course and may warrant consideration and possible work-up even early in the disease and at the time of first hospital admission,” she concluded.
Adolescents whose weight is a low percentage of their ideal BMI at diagnosis may warrant special concern, she added.
Dr. Gary Remafedi, professor of pediatrics at the University of Minnesota, Minneapolis, said the study led him to question whether he should incorporate an echocardiogram into his initial work-up of patients with anorexia nervosa.
“I wonder if there were other indicators of the mitral valve prolapse or pericardial effusions … such as distinctive heart sounds or murmurs suggestive of prolapse,” he said.
The issue of whether to order an echocardiogram soon after diagnosis “remains unanswered,” Dr. Slivka responded.
“In general, mitral valve prolapse, pericardial effusion, and other valve abnormalities may be audible on physical exam. Pericardial effusion may be noted on ECG. However, in our study patients, these changes were not noted on exam,” Dr. Slivka said in an interview.
Neither Dr. Slivka nor her coauthors reported any conflicts of interest with regard to their study.
Overweight Women Risk Postterm Delivery
Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.
Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.
Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.
After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.
“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.
“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”
Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.
Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m2, 25–35 pounds for women with BMIs between 19.8 kg/m2 and 26 kg/m2, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m2 or greater.
Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.
More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m2 and 29.9 kg/m2 gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m2 gained more than 25 pounds during pregnancy.
About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.
Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.
“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.
Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).
In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.
A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).
The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.
Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY
Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.
Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.
Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.
After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.
“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.
“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”
Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.
Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m2, 25–35 pounds for women with BMIs between 19.8 kg/m2 and 26 kg/m2, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m2 or greater.
Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.
More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m2 and 29.9 kg/m2 gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m2 gained more than 25 pounds during pregnancy.
About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.
Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.
“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.
Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).
In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.
A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).
The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.
Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY
Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.
Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.
Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.
After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.
“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.
“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”
Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.
Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m2, 25–35 pounds for women with BMIs between 19.8 kg/m2 and 26 kg/m2, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m2 or greater.
Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.
More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m2 and 29.9 kg/m2 gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m2 gained more than 25 pounds during pregnancy.
About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.
Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.
“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.
Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).
In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.
A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).
The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.
Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY
Pediatric Rheums Advise Assertive JIA Approach
Juvenile idiopathic arthritis increasingly is being shown to respond well to treatment, yet therapeutic hesitation on the part of nonpediatric rheumatologists is working to the detriment of these young patients, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they said. Further, good results are impeded when physicians rely on therapies that work well in adults but not in children and when physicians hesitate to use newer therapies such as biologic agents.
For Dr. Lawrence K. Jung, the disparity in care became personal when he moved from Omaha, where he felt he had a handle on the close-knit JIA population, to Children's National Medical Center in Washington, D.C., where he became chief of the division of rheumatology in a metropolitan area of over 5 million people.
“I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
“Most children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Andreas Reiff, chief of pediatric rheumatology at Childrens Hospital Los Angeles, “They are often misdiagnosed, or treated with drugs used in adults, such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radiographic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance” to conventional treatments. Rarely would a nonrheumatologist act that fast.
Dr. Reiff said that his experiences at Childrens are an object lesson. For years, the hospital's rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement.
Last year, Dr. Reiff said, he resigned from his post as division head of the rehabilitation center. The reason:“Essentially, we had no more [JIA] patients there. Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe joint problems.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008. Other biologics are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” said Dr. Passo of the division of pediatric rheumatology at the Medical University of South Carolina in Charleston. “With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign, he said. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a variety of conditions. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.”
Approximately 239 pediatric rheumatologists are licensed in the United States, but only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo. On average, families are required to travel 57 miles to see a pediatric rheumatologist.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring. As a result, practical access to biologics is spotty and many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated before irreparable damage occurs, they said.
Juvenile idiopathic arthritis increasingly is being shown to respond well to treatment, yet therapeutic hesitation on the part of nonpediatric rheumatologists is working to the detriment of these young patients, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they said. Further, good results are impeded when physicians rely on therapies that work well in adults but not in children and when physicians hesitate to use newer therapies such as biologic agents.
For Dr. Lawrence K. Jung, the disparity in care became personal when he moved from Omaha, where he felt he had a handle on the close-knit JIA population, to Children's National Medical Center in Washington, D.C., where he became chief of the division of rheumatology in a metropolitan area of over 5 million people.
“I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
“Most children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Andreas Reiff, chief of pediatric rheumatology at Childrens Hospital Los Angeles, “They are often misdiagnosed, or treated with drugs used in adults, such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radiographic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance” to conventional treatments. Rarely would a nonrheumatologist act that fast.
Dr. Reiff said that his experiences at Childrens are an object lesson. For years, the hospital's rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement.
Last year, Dr. Reiff said, he resigned from his post as division head of the rehabilitation center. The reason:“Essentially, we had no more [JIA] patients there. Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe joint problems.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008. Other biologics are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” said Dr. Passo of the division of pediatric rheumatology at the Medical University of South Carolina in Charleston. “With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign, he said. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a variety of conditions. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.”
Approximately 239 pediatric rheumatologists are licensed in the United States, but only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo. On average, families are required to travel 57 miles to see a pediatric rheumatologist.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring. As a result, practical access to biologics is spotty and many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated before irreparable damage occurs, they said.
Juvenile idiopathic arthritis increasingly is being shown to respond well to treatment, yet therapeutic hesitation on the part of nonpediatric rheumatologists is working to the detriment of these young patients, according to pediatric rheumatologists interviewed for this story.
The well-documented critical shortage of pediatric rheumatologists has real consequences in this disease, they said. Further, good results are impeded when physicians rely on therapies that work well in adults but not in children and when physicians hesitate to use newer therapies such as biologic agents.
For Dr. Lawrence K. Jung, the disparity in care became personal when he moved from Omaha, where he felt he had a handle on the close-knit JIA population, to Children's National Medical Center in Washington, D.C., where he became chief of the division of rheumatology in a metropolitan area of over 5 million people.
“I'm seeing so many patients who have not seen a rheumatologist in 2 years and have gone for long periods of time without good care,” he said.
“Most children with rheumatic conditions are still treated by pediatricians, internists, or adult rheumatologists,” said Dr. Andreas Reiff, chief of pediatric rheumatology at Childrens Hospital Los Angeles, “They are often misdiagnosed, or treated with drugs used in adults, such as Plaquenil, hydroxychloroquine, sulfasalazine, penicillamine, and steroids, which have been shown in a meta-analysis to be no better than placebo in children.”
“There is really a critical timeline here,” said Dr. Reiff. “It depends on the presentation and how quickly radiographic evidence develops, but we would usually start a child on biologics within 3 months of nonresponse or insufficient response or intolerance” to conventional treatments. Rarely would a nonrheumatologist act that fast.
Dr. Reiff said that his experiences at Childrens are an object lesson. For years, the hospital's rehabilitation center was filled with children with JIA who were there to receive splints and casts, undergo physical therapy, and recover from hip and knee replacement.
Last year, Dr. Reiff said, he resigned from his post as division head of the rehabilitation center. The reason:“Essentially, we had no more [JIA] patients there. Nowadays, we don't wait to treat kids until they're wheelchair bound and suffering severe joint problems.”
Dozens of studies presented at American College of Rheumatology meetings and summarized in a review article by Dr. Murray Passo (Curr. Probl. Pediatr. Adolesc. Health Care 2006;36:97–103) have documented the short- and long-term safety and efficacy of various biologic agents, including etanercept (Enbrel), approved for children with JIA in 1998, and adalimumab (Humira), which received pediatric approval from the Food and Drug Administration in 2008. Other biologics are also under study—and are sometimes used off label—for JIA, including infliximab (Remicade), an anti-tumor necrosis factor-alpha chimeric monoclonal antibody; anakinra (Kineret), a recombinant form of human interleukin-1 receptor antagonist; atlizumab, an anti-IL-6 receptor monoclonal antibody; and abatacept (Orencia), which selectively inhibits T-cell activation with the fusion protein CTLA41g.
“Many adult rheumatologists I work with may be very aggressive in treating arthritis in adults, but are unsure just how aggressive to be in children,” said Dr. Passo of the division of pediatric rheumatology at the Medical University of South Carolina in Charleston. “With children, there are long-term side effects to worry about.”
So far, the side-effect profile for children with JIA who take biologics has largely been benign, he said. Nevertheless, the drugs are new and their effect on children's health is not fully known.
The FDA is conducting an ongoing safety review of TNF blockers in children and young adults who are being treated for a variety of conditions. The FDA reported in a June 4, 2008, communication that 30 cancers—half of them lymphomas—had been reported in young people who were prescribed biologic therapies.
“Quite honestly, malignancy has not been a big issue” in the JIA population, said Dr. Passo. “The pediatric population does not have the same propensity for lymphoma as [do] adults with rheumatoid arthritis and lupus, at least not that we have been able to prove.”
Approximately 239 pediatric rheumatologists are licensed in the United States, but only about 125 of them treat patients, according to Dr. Reiff. At the same time, the American College of Rheumatology estimates that 300,000 children in this country have JIA. Simple arithmetic points to a level of need that is perhaps even greater than the 75% increase in the number of pediatric rheumatologists that was called for in a Department of Health and Human Services report to Congress in 2007.
At the time of that report, 13 states had no pediatric rheumatologist; 9 still don't, according to Dr. Passo. On average, families are required to travel 57 miles to see a pediatric rheumatologist.
Some adult rheumatologists, internists, pediatricians, and even orthopedic surgeons treat JIA with great skill and compassion, all of the experts interviewed for this story agreed. But nonpediatric rheumatologists balk when it comes to prescribing biologic therapies, which require finesse in family communication, administration, and monitoring. As a result, practical access to biologics is spotty and many children still live with preventable pain and progressive disability. As is the case with rheumatoid arthritis in adults, early diagnosis is imperative and disease-modifying drugs must be initiated before irreparable damage occurs, they said.
Oral Cavity SCC in Young Adults Is on the 'Surge'
SANTA BARBARA, CALIF. Squamous cell carcinoma of the oral cavity, particularly of the tongue, is not a diagnosis seen only in smokers aged 65 and older, reports in the literature suggest.
"We're seeing a surge of cases among younger people," Dr. Janellen Smith said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.
Current literature from around the world documents the story: a puzzling rise of oral squamous cell carcinoma (SCC) cases in people as young as their 20s, often in the absence of traditional risk factors such as years of smoking, tobacco chewing, or alcohol use.
Among the young as well as older patients, the tongue is the most common intraoral site for SCC, at 40% of newly diagnosed cases.
Theories abound as to what may be driving this increase of cancer cases, said Dr. Smith, professor of dermatology at the University of California, Irvine.
Marijuana use, chewing tobacco, and human papillomavirus are all considered potential contributors.
Factors predicting prognosis include stage of the cancer, tumor location, and whether the cancer has spread.
It is important is to diagnose SCC in its early stages, while it is treatable. The 5-year survival in cases diagnosed late "has not changed in years and years," and hovers around 50%. "As dermatologists, we are in a position to diagnose this early," she said.
"We know this is not lichen planus," she added, describing the rosy red macules and plaques of erythroplakia, a sign of SCC.
White patches and plaques of leukoplakia are other telltale signs.
Common early presentations are along the posterolateral border and the ventral surface of the tongueregions of thin, nonkeratinized mucosa and saliva pooling, she said.
Studies show that such SCCs frequently drain to cervical nodes, 66% of which are positive at the time of diagnosis.
Although the precise cause of an uptick in cases is unknown, the theoretical involvement of HPV makes vaccination of young women all the more sensible, Dr. Smith said at a second lecture during a seminar held in Las Vegas and sponsored by Skin Disease Education Foundation.
"We are actually quite anxious to see that people get vaccinated," she said.
Dr. Smith reported no potential conflicts of interest regarding her lectures.
SDEF and this newspaper are owned by Elsevier.
SANTA BARBARA, CALIF. Squamous cell carcinoma of the oral cavity, particularly of the tongue, is not a diagnosis seen only in smokers aged 65 and older, reports in the literature suggest.
"We're seeing a surge of cases among younger people," Dr. Janellen Smith said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.
Current literature from around the world documents the story: a puzzling rise of oral squamous cell carcinoma (SCC) cases in people as young as their 20s, often in the absence of traditional risk factors such as years of smoking, tobacco chewing, or alcohol use.
Among the young as well as older patients, the tongue is the most common intraoral site for SCC, at 40% of newly diagnosed cases.
Theories abound as to what may be driving this increase of cancer cases, said Dr. Smith, professor of dermatology at the University of California, Irvine.
Marijuana use, chewing tobacco, and human papillomavirus are all considered potential contributors.
Factors predicting prognosis include stage of the cancer, tumor location, and whether the cancer has spread.
It is important is to diagnose SCC in its early stages, while it is treatable. The 5-year survival in cases diagnosed late "has not changed in years and years," and hovers around 50%. "As dermatologists, we are in a position to diagnose this early," she said.
"We know this is not lichen planus," she added, describing the rosy red macules and plaques of erythroplakia, a sign of SCC.
White patches and plaques of leukoplakia are other telltale signs.
Common early presentations are along the posterolateral border and the ventral surface of the tongueregions of thin, nonkeratinized mucosa and saliva pooling, she said.
Studies show that such SCCs frequently drain to cervical nodes, 66% of which are positive at the time of diagnosis.
Although the precise cause of an uptick in cases is unknown, the theoretical involvement of HPV makes vaccination of young women all the more sensible, Dr. Smith said at a second lecture during a seminar held in Las Vegas and sponsored by Skin Disease Education Foundation.
"We are actually quite anxious to see that people get vaccinated," she said.
Dr. Smith reported no potential conflicts of interest regarding her lectures.
SDEF and this newspaper are owned by Elsevier.
SANTA BARBARA, CALIF. Squamous cell carcinoma of the oral cavity, particularly of the tongue, is not a diagnosis seen only in smokers aged 65 and older, reports in the literature suggest.
"We're seeing a surge of cases among younger people," Dr. Janellen Smith said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.
Current literature from around the world documents the story: a puzzling rise of oral squamous cell carcinoma (SCC) cases in people as young as their 20s, often in the absence of traditional risk factors such as years of smoking, tobacco chewing, or alcohol use.
Among the young as well as older patients, the tongue is the most common intraoral site for SCC, at 40% of newly diagnosed cases.
Theories abound as to what may be driving this increase of cancer cases, said Dr. Smith, professor of dermatology at the University of California, Irvine.
Marijuana use, chewing tobacco, and human papillomavirus are all considered potential contributors.
Factors predicting prognosis include stage of the cancer, tumor location, and whether the cancer has spread.
It is important is to diagnose SCC in its early stages, while it is treatable. The 5-year survival in cases diagnosed late "has not changed in years and years," and hovers around 50%. "As dermatologists, we are in a position to diagnose this early," she said.
"We know this is not lichen planus," she added, describing the rosy red macules and plaques of erythroplakia, a sign of SCC.
White patches and plaques of leukoplakia are other telltale signs.
Common early presentations are along the posterolateral border and the ventral surface of the tongueregions of thin, nonkeratinized mucosa and saliva pooling, she said.
Studies show that such SCCs frequently drain to cervical nodes, 66% of which are positive at the time of diagnosis.
Although the precise cause of an uptick in cases is unknown, the theoretical involvement of HPV makes vaccination of young women all the more sensible, Dr. Smith said at a second lecture during a seminar held in Las Vegas and sponsored by Skin Disease Education Foundation.
"We are actually quite anxious to see that people get vaccinated," she said.
Dr. Smith reported no potential conflicts of interest regarding her lectures.
SDEF and this newspaper are owned by Elsevier.
GI Disorders Found Common in Autistic Children
Children with autism spectrum disorders had a 5.3-fold greater probability of having a gastrointestinal disorder than their nonautistic siblings in a large study of families enrolled in the Autism Genetic Resource Exchange Consortium.
Based on these findings, physicians should educate families that gastrointestinal problems do appear to be common in children with autism spectrum disorder, many of whom may not be able to communicate their discomfort, according to Dr. Lulu W. Wang, who reported the findings at the annual Western regional meeting of the American Federation for Medical Research held in Carmel, Calif.
Among 651 children with autism spectrum disorders, 43% had a gastrointestinal disorder or chronic gastrointestinal symptoms, compared with just 12% of 165 siblings, said Dr. Wang, a developmental behavioral pediatrics fellow at the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute of the University of California at Davis and University of California Davis Children's Hospital.
Constipation (20%) and chronic diarrhea (19%) were the most common GI diagnoses represented among children with autism spectrum disorders.
By contrast, gastroesophageal reflux disorder (4.9%) and constipation (3.7%) were the most common diagnoses among their siblings who did not have autism spectrum disorders, she found.
Children who met the full criteria for autistic disorder were quite low functioning and had few language skills. These children had the highest odds ratio for gastrointestinal disorders, 6.4.
Those who nearly met criteria for autism but were higher functioning had the next highest odds of having gastrointestinal problems, 4.5. Children with minimal deficits across the autism spectrum had a lower probability of having gastrointestinal disorders, at an odds ratio of 2.4, compared with siblings who had no autism spectrum disorder.
After controlling for possible confounders, a multivariate analysis showed that autism was significantly associated with GI disorders (OR = 5.3).
Genetic and dietary factors have been postulated as contributors to the high prevalence of gastrointestinal disturbances in children with autism spectrum disorders, but the problem remains largely a mystery, said Dr. Wang in a telephone interview following the meeting.
“We can only speculate, since we only found an association,” she said of the study, coauthored by Dr. Dan Thomas, chief of the division of pediatric gastroenterology and nutrition at Childrens Hospital Los Angeles.
Asked to comment on how diet may play a role in gastrointestinal symptoms, Dr. Wang pointed to a controlled dietary diary study that found association between stool consistency and dietary intake. Children with autism were not consuming greater amounts of carbohydrates than recommended RDA values (Biol. Psychiatry 2007;61:492-7).
Laboratory studies of a randomly selected subset of 35 children with autistic disorder from Dr. Wang's cohort showed none had celiac markers. The small numbers make that finding statistically inconclusive, but the results agree with mounting evidence that celiac disease is not a likely contributor to the gastrointestinal or autistic symptoms of a majority of children with the disease.
“There are now more genetic studies coming out that may help explain why a subset of children with autism have more gastrointestinal disorders,” she said.
Dr. Wang and Dr. Thomas reported no potential financial conflicts of interest concerning their study.
Among children with autism spectrum disorders, 43% had a GI disorder or chronic GI symptoms. DR. WANG
Children with autism spectrum disorders had a 5.3-fold greater probability of having a gastrointestinal disorder than their nonautistic siblings in a large study of families enrolled in the Autism Genetic Resource Exchange Consortium.
Based on these findings, physicians should educate families that gastrointestinal problems do appear to be common in children with autism spectrum disorder, many of whom may not be able to communicate their discomfort, according to Dr. Lulu W. Wang, who reported the findings at the annual Western regional meeting of the American Federation for Medical Research held in Carmel, Calif.
Among 651 children with autism spectrum disorders, 43% had a gastrointestinal disorder or chronic gastrointestinal symptoms, compared with just 12% of 165 siblings, said Dr. Wang, a developmental behavioral pediatrics fellow at the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute of the University of California at Davis and University of California Davis Children's Hospital.
Constipation (20%) and chronic diarrhea (19%) were the most common GI diagnoses represented among children with autism spectrum disorders.
By contrast, gastroesophageal reflux disorder (4.9%) and constipation (3.7%) were the most common diagnoses among their siblings who did not have autism spectrum disorders, she found.
Children who met the full criteria for autistic disorder were quite low functioning and had few language skills. These children had the highest odds ratio for gastrointestinal disorders, 6.4.
Those who nearly met criteria for autism but were higher functioning had the next highest odds of having gastrointestinal problems, 4.5. Children with minimal deficits across the autism spectrum had a lower probability of having gastrointestinal disorders, at an odds ratio of 2.4, compared with siblings who had no autism spectrum disorder.
After controlling for possible confounders, a multivariate analysis showed that autism was significantly associated with GI disorders (OR = 5.3).
Genetic and dietary factors have been postulated as contributors to the high prevalence of gastrointestinal disturbances in children with autism spectrum disorders, but the problem remains largely a mystery, said Dr. Wang in a telephone interview following the meeting.
“We can only speculate, since we only found an association,” she said of the study, coauthored by Dr. Dan Thomas, chief of the division of pediatric gastroenterology and nutrition at Childrens Hospital Los Angeles.
Asked to comment on how diet may play a role in gastrointestinal symptoms, Dr. Wang pointed to a controlled dietary diary study that found association between stool consistency and dietary intake. Children with autism were not consuming greater amounts of carbohydrates than recommended RDA values (Biol. Psychiatry 2007;61:492-7).
Laboratory studies of a randomly selected subset of 35 children with autistic disorder from Dr. Wang's cohort showed none had celiac markers. The small numbers make that finding statistically inconclusive, but the results agree with mounting evidence that celiac disease is not a likely contributor to the gastrointestinal or autistic symptoms of a majority of children with the disease.
“There are now more genetic studies coming out that may help explain why a subset of children with autism have more gastrointestinal disorders,” she said.
Dr. Wang and Dr. Thomas reported no potential financial conflicts of interest concerning their study.
Among children with autism spectrum disorders, 43% had a GI disorder or chronic GI symptoms. DR. WANG
Children with autism spectrum disorders had a 5.3-fold greater probability of having a gastrointestinal disorder than their nonautistic siblings in a large study of families enrolled in the Autism Genetic Resource Exchange Consortium.
Based on these findings, physicians should educate families that gastrointestinal problems do appear to be common in children with autism spectrum disorder, many of whom may not be able to communicate their discomfort, according to Dr. Lulu W. Wang, who reported the findings at the annual Western regional meeting of the American Federation for Medical Research held in Carmel, Calif.
Among 651 children with autism spectrum disorders, 43% had a gastrointestinal disorder or chronic gastrointestinal symptoms, compared with just 12% of 165 siblings, said Dr. Wang, a developmental behavioral pediatrics fellow at the M.I.N.D. (Medical Investigation of Neurodevelopmental Disorders) Institute of the University of California at Davis and University of California Davis Children's Hospital.
Constipation (20%) and chronic diarrhea (19%) were the most common GI diagnoses represented among children with autism spectrum disorders.
By contrast, gastroesophageal reflux disorder (4.9%) and constipation (3.7%) were the most common diagnoses among their siblings who did not have autism spectrum disorders, she found.
Children who met the full criteria for autistic disorder were quite low functioning and had few language skills. These children had the highest odds ratio for gastrointestinal disorders, 6.4.
Those who nearly met criteria for autism but were higher functioning had the next highest odds of having gastrointestinal problems, 4.5. Children with minimal deficits across the autism spectrum had a lower probability of having gastrointestinal disorders, at an odds ratio of 2.4, compared with siblings who had no autism spectrum disorder.
After controlling for possible confounders, a multivariate analysis showed that autism was significantly associated with GI disorders (OR = 5.3).
Genetic and dietary factors have been postulated as contributors to the high prevalence of gastrointestinal disturbances in children with autism spectrum disorders, but the problem remains largely a mystery, said Dr. Wang in a telephone interview following the meeting.
“We can only speculate, since we only found an association,” she said of the study, coauthored by Dr. Dan Thomas, chief of the division of pediatric gastroenterology and nutrition at Childrens Hospital Los Angeles.
Asked to comment on how diet may play a role in gastrointestinal symptoms, Dr. Wang pointed to a controlled dietary diary study that found association between stool consistency and dietary intake. Children with autism were not consuming greater amounts of carbohydrates than recommended RDA values (Biol. Psychiatry 2007;61:492-7).
Laboratory studies of a randomly selected subset of 35 children with autistic disorder from Dr. Wang's cohort showed none had celiac markers. The small numbers make that finding statistically inconclusive, but the results agree with mounting evidence that celiac disease is not a likely contributor to the gastrointestinal or autistic symptoms of a majority of children with the disease.
“There are now more genetic studies coming out that may help explain why a subset of children with autism have more gastrointestinal disorders,” she said.
Dr. Wang and Dr. Thomas reported no potential financial conflicts of interest concerning their study.
Among children with autism spectrum disorders, 43% had a GI disorder or chronic GI symptoms. DR. WANG
Quick ACR 20 Response Seen to Spleen Tyrosine Kinase Inhibitor
SAN FRANCISCO — Clinical disease activity lessened rapidly and persistently for 12 weeks in the first study of a spleen tyrosine kinase inhibitor in rheumatoid arthritis, based on findings from a phase II trial reported by Dr. Michael E. Weinblatt of the center for arthritis and joint disease at Brigham and Women's Hospital, Boston.
The double-blind, placebo-controlled study was a pivotal test of whether the novel oral molecule can inhibit inflammation by blocking activation signals in the complex kinase pathway, which serves as a facilitator of cellular activity involving neutrophils, B cells, mast cells, and microphages, he said at the annual meeting of the American College of Rheumatology.
Inhibition of the spleen tyrosine kinase (Syk) pathway is being studied in a variety of immune and inflammatory diseases, including asthma, lymphoma, and autoimmune thrombocytopenia.
In all, 189 patients who had long-standing, active RA and were on background methotrexate therapy, were randomized to receive the drug R788 at twice-daily dosages of 150 mg, 100 mg, 50 mg, or placebo at study sites in the United States and Mexico. An “adaptive” dosing regimen mandated dose reduction at any point that laboratory testing showed a decline in white blood cell count or a decline in liver function.
At 12 weeks, 84% of patients had completed the trial (122 patients who had received R788 and 36 in the placebo group). Any patient who withdrew from the study was treated as a “nonresponder” for the sake of data analysis, said Dr. Weinblatt, who is also professor of medicine at Harvard Medical School, Boston.
By week 1, significantly more patients on morning and evening 100-mg and 150-mg dosages showed an ACR 20 response versus those on a lower dose or placebo. A similar separation could be seen at week 1 and throughout the trial in interleukin-6 and metalloproteinase-3 levels, which were evaluated as surrogate biomarkers for inflammation and bone destruction. By week 12, the primary end point of an ACR 20 response rate was achieved by 72% of patients in the 150-mg group. (See box.) A higher bar, an ACR 70 response, was achieved in 40% of patients in the 150-mg cohort, 33% in the 100-mg group, and just 2% of the 50-mg group, versus 4% of the placebo group.
Remission, as defined by Disease Activity Score, occurred in 22 of 47 (47%) patients receiving the highest dosage, 17 of 49 (35%) patients in the 100-mg group, and 9 of 46 (20%) receiving the 50-mg, twice-daily dosage.
Diarrhea was experienced by 40% of patients receiving the highest dosage, causing one patient to withdraw from the trial. Dizziness, neutropenia, an increase in blood pressure, and a twofold increase in liver transaminases were also seen in patients receiving 150 mg twice daily, he said. Overall a “clear dose-response curve” pointed to an efficacious and safe dose of 100 mg twice daily, as opposed to relative ineffectiveness at 50 mg twice daily and unacceptable toxicity at 150 mg twice a day.
A future phase II study is planned to compare a 100-mg twice-daily dosage with a dosage of 150 mg once daily and placebo, he said.
The researchers disclosed research support from Rigel Pharmaceuticals Inc., the sponsor of the study.
ELSEVIER GLOBAL MEDICAL NEWS
SAN FRANCISCO — Clinical disease activity lessened rapidly and persistently for 12 weeks in the first study of a spleen tyrosine kinase inhibitor in rheumatoid arthritis, based on findings from a phase II trial reported by Dr. Michael E. Weinblatt of the center for arthritis and joint disease at Brigham and Women's Hospital, Boston.
The double-blind, placebo-controlled study was a pivotal test of whether the novel oral molecule can inhibit inflammation by blocking activation signals in the complex kinase pathway, which serves as a facilitator of cellular activity involving neutrophils, B cells, mast cells, and microphages, he said at the annual meeting of the American College of Rheumatology.
Inhibition of the spleen tyrosine kinase (Syk) pathway is being studied in a variety of immune and inflammatory diseases, including asthma, lymphoma, and autoimmune thrombocytopenia.
In all, 189 patients who had long-standing, active RA and were on background methotrexate therapy, were randomized to receive the drug R788 at twice-daily dosages of 150 mg, 100 mg, 50 mg, or placebo at study sites in the United States and Mexico. An “adaptive” dosing regimen mandated dose reduction at any point that laboratory testing showed a decline in white blood cell count or a decline in liver function.
At 12 weeks, 84% of patients had completed the trial (122 patients who had received R788 and 36 in the placebo group). Any patient who withdrew from the study was treated as a “nonresponder” for the sake of data analysis, said Dr. Weinblatt, who is also professor of medicine at Harvard Medical School, Boston.
By week 1, significantly more patients on morning and evening 100-mg and 150-mg dosages showed an ACR 20 response versus those on a lower dose or placebo. A similar separation could be seen at week 1 and throughout the trial in interleukin-6 and metalloproteinase-3 levels, which were evaluated as surrogate biomarkers for inflammation and bone destruction. By week 12, the primary end point of an ACR 20 response rate was achieved by 72% of patients in the 150-mg group. (See box.) A higher bar, an ACR 70 response, was achieved in 40% of patients in the 150-mg cohort, 33% in the 100-mg group, and just 2% of the 50-mg group, versus 4% of the placebo group.
Remission, as defined by Disease Activity Score, occurred in 22 of 47 (47%) patients receiving the highest dosage, 17 of 49 (35%) patients in the 100-mg group, and 9 of 46 (20%) receiving the 50-mg, twice-daily dosage.
Diarrhea was experienced by 40% of patients receiving the highest dosage, causing one patient to withdraw from the trial. Dizziness, neutropenia, an increase in blood pressure, and a twofold increase in liver transaminases were also seen in patients receiving 150 mg twice daily, he said. Overall a “clear dose-response curve” pointed to an efficacious and safe dose of 100 mg twice daily, as opposed to relative ineffectiveness at 50 mg twice daily and unacceptable toxicity at 150 mg twice a day.
A future phase II study is planned to compare a 100-mg twice-daily dosage with a dosage of 150 mg once daily and placebo, he said.
The researchers disclosed research support from Rigel Pharmaceuticals Inc., the sponsor of the study.
ELSEVIER GLOBAL MEDICAL NEWS
SAN FRANCISCO — Clinical disease activity lessened rapidly and persistently for 12 weeks in the first study of a spleen tyrosine kinase inhibitor in rheumatoid arthritis, based on findings from a phase II trial reported by Dr. Michael E. Weinblatt of the center for arthritis and joint disease at Brigham and Women's Hospital, Boston.
The double-blind, placebo-controlled study was a pivotal test of whether the novel oral molecule can inhibit inflammation by blocking activation signals in the complex kinase pathway, which serves as a facilitator of cellular activity involving neutrophils, B cells, mast cells, and microphages, he said at the annual meeting of the American College of Rheumatology.
Inhibition of the spleen tyrosine kinase (Syk) pathway is being studied in a variety of immune and inflammatory diseases, including asthma, lymphoma, and autoimmune thrombocytopenia.
In all, 189 patients who had long-standing, active RA and were on background methotrexate therapy, were randomized to receive the drug R788 at twice-daily dosages of 150 mg, 100 mg, 50 mg, or placebo at study sites in the United States and Mexico. An “adaptive” dosing regimen mandated dose reduction at any point that laboratory testing showed a decline in white blood cell count or a decline in liver function.
At 12 weeks, 84% of patients had completed the trial (122 patients who had received R788 and 36 in the placebo group). Any patient who withdrew from the study was treated as a “nonresponder” for the sake of data analysis, said Dr. Weinblatt, who is also professor of medicine at Harvard Medical School, Boston.
By week 1, significantly more patients on morning and evening 100-mg and 150-mg dosages showed an ACR 20 response versus those on a lower dose or placebo. A similar separation could be seen at week 1 and throughout the trial in interleukin-6 and metalloproteinase-3 levels, which were evaluated as surrogate biomarkers for inflammation and bone destruction. By week 12, the primary end point of an ACR 20 response rate was achieved by 72% of patients in the 150-mg group. (See box.) A higher bar, an ACR 70 response, was achieved in 40% of patients in the 150-mg cohort, 33% in the 100-mg group, and just 2% of the 50-mg group, versus 4% of the placebo group.
Remission, as defined by Disease Activity Score, occurred in 22 of 47 (47%) patients receiving the highest dosage, 17 of 49 (35%) patients in the 100-mg group, and 9 of 46 (20%) receiving the 50-mg, twice-daily dosage.
Diarrhea was experienced by 40% of patients receiving the highest dosage, causing one patient to withdraw from the trial. Dizziness, neutropenia, an increase in blood pressure, and a twofold increase in liver transaminases were also seen in patients receiving 150 mg twice daily, he said. Overall a “clear dose-response curve” pointed to an efficacious and safe dose of 100 mg twice daily, as opposed to relative ineffectiveness at 50 mg twice daily and unacceptable toxicity at 150 mg twice a day.
A future phase II study is planned to compare a 100-mg twice-daily dosage with a dosage of 150 mg once daily and placebo, he said.
The researchers disclosed research support from Rigel Pharmaceuticals Inc., the sponsor of the study.
ELSEVIER GLOBAL MEDICAL NEWS