John R. Bell

The hormones progesterone and estrogen might provoke allergic antibody reactions in some women, which might in turn help explain various menstrual disorders, according to a prospective study.

Dr. Russell R. Roby and colleagues from the Roby Institute in Austin, Tex., found increased reactions to both hormones, compared with women who served as controls, in patients with menstruation-related symptoms (Am. J. Reprod. Immunol. 2006;55:307–13).

“Our data presented in this paper are the first to show the presence of IgM and IgE against different steroid hormones,” the investigators wrote.

They noted that acne, asthma, epilepsy, allergic rhinitis, and several other disorders have been linked with menstrual cycle influences.

Their report “suggests the possibility of hormone allergy,” they wrote, citing earlier studies linking hormone reactions to endocrine disorders and periodic rashes.

The investigators sampled the blood of 270 patients from their clinic who reported a change in their menstrual symptoms over the course of 2 years and tested for IgM and IgG antibodies to progesterone.

They also obtained blood samples from 288 unaffected women from a commercial laboratory, to serve as a control group.

When blood was tested via enzyme-linked immunosorbent assay, the test patients had a mean optical density (OD; a measure of antibody levels) of 0.17 for IgG and 0.32 for IgM, vs. a mean OD in the control population of 0.08 for IgG and 0.13 for IgM—a statistically significant difference in both cases.

The investigators also tested another group of 98 patients for IgE antibodies against both progesterone and estrogen, using a control group of 320 patients (the same 288 from a commercial laboratory plus 32 from their clinic with possible hormone allergy).

For progesterone, test patients had a mean OD of 0.42, vs. a mean OD of 0.11 in the remote control group and 0.23 in the clinic-based control group—a highly significant increase, the investigators noted.

The hormones progesterone and estrogen might provoke allergic antibody reactions in some women, which might in turn help explain various menstrual disorders, according to a prospective study.

Dr. Russell R. Roby and colleagues from the Roby Institute in Austin, Tex., found increased reactions to both hormones, compared with women who served as controls, in patients with menstruation-related symptoms (Am. J. Reprod. Immunol. 2006;55:307–13).

“Our data presented in this paper are the first to show the presence of IgM and IgE against different steroid hormones,” the investigators wrote.

They noted that acne, asthma, epilepsy, allergic rhinitis, and several other disorders have been linked with menstrual cycle influences.

Their report “suggests the possibility of hormone allergy,” they wrote, citing earlier studies linking hormone reactions to endocrine disorders and periodic rashes.

The investigators sampled the blood of 270 patients from their clinic who reported a change in their menstrual symptoms over the course of 2 years and tested for IgM and IgG antibodies to progesterone.

They also obtained blood samples from 288 unaffected women from a commercial laboratory, to serve as a control group.

When blood was tested via enzyme-linked immunosorbent assay, the test patients had a mean optical density (OD; a measure of antibody levels) of 0.17 for IgG and 0.32 for IgM, vs. a mean OD in the control population of 0.08 for IgG and 0.13 for IgM—a statistically significant difference in both cases.

The investigators also tested another group of 98 patients for IgE antibodies against both progesterone and estrogen, using a control group of 320 patients (the same 288 from a commercial laboratory plus 32 from their clinic with possible hormone allergy).

For progesterone, test patients had a mean OD of 0.42, vs. a mean OD of 0.11 in the remote control group and 0.23 in the clinic-based control group—a highly significant increase, the investigators noted.

The hormones progesterone and estrogen might provoke allergic antibody reactions in some women, which might in turn help explain various menstrual disorders, according to a prospective study.

Dr. Russell R. Roby and colleagues from the Roby Institute in Austin, Tex., found increased reactions to both hormones, compared with women who served as controls, in patients with menstruation-related symptoms (Am. J. Reprod. Immunol. 2006;55:307–13).

“Our data presented in this paper are the first to show the presence of IgM and IgE against different steroid hormones,” the investigators wrote.

They noted that acne, asthma, epilepsy, allergic rhinitis, and several other disorders have been linked with menstrual cycle influences.

Their report “suggests the possibility of hormone allergy,” they wrote, citing earlier studies linking hormone reactions to endocrine disorders and periodic rashes.

The investigators sampled the blood of 270 patients from their clinic who reported a change in their menstrual symptoms over the course of 2 years and tested for IgM and IgG antibodies to progesterone.

They also obtained blood samples from 288 unaffected women from a commercial laboratory, to serve as a control group.

When blood was tested via enzyme-linked immunosorbent assay, the test patients had a mean optical density (OD; a measure of antibody levels) of 0.17 for IgG and 0.32 for IgM, vs. a mean OD in the control population of 0.08 for IgG and 0.13 for IgM—a statistically significant difference in both cases.

The investigators also tested another group of 98 patients for IgE antibodies against both progesterone and estrogen, using a control group of 320 patients (the same 288 from a commercial laboratory plus 32 from their clinic with possible hormone allergy).

For progesterone, test patients had a mean OD of 0.42, vs. a mean OD of 0.11 in the remote control group and 0.23 in the clinic-based control group—a highly significant increase, the investigators noted.

The American Academy of Otolaryngology's first-ever guidelines for the diagnosis and treatment of acute otitis externa—commonly known as swimmer's ear—include a recommendation to treat pain and to use antimicrobial drops, rather than oral antibiotics, as first-line treatment.

The clinical practice guidelines were derived from a metaanalysis of nearly 3,000 published reports and were written by a panel of otolaryngologists from various subspecialties.

The document notes that starting treatment of acute otitis externa (AOE) with drops can help prevent bacterial resistance—even though many drops contain antibiotics themselves.

“It's a concentration issue,” explained Dr. Richard Rosenfeld, who led the AAO guidelines writing committee. “You can achieve a concentration with a topical drop that's about 1,000 times higher [at the infection site] than with a systemic drug. Topical [medication] is so incredibly potent that it overwhelms any ability of resistance. … Dead bugs don't mutate—especially if you wipe them all out with a Scud missile of a drop.”

But drops don't have to even contain antibiotics to be effective, he noted.

“We tested many types of topical therapy out there—antiseptics, various types of antibiotics, and also steroid-containing preparations. And they all seemed to have very comparable efficacy. We saw only minor, clinically irrelevant differences in efficacy.

“That doesn't mean that it's at all irrelevant what you use—for example, quinolone drops are perhaps most suitable for severe infections, because they're the most potent—but that's only anecdotal,” added Dr. Rosenfeld, director of pediatric otolaryngology at Long Island College Hospital in New York.

As to prevention of swimmer's ear, Dr. Rosenfeld said that although there's no specific policy statement, in his opinion, the key is to avoid the things that trigger AOE.

Those include trauma or scratching of the ear canal and allowing excess water to build up in the ear canal and get trapped there. Trauma can be caused by cotton swabs or other objects inserted to remove wax or to scratch, or even by inserting foam ear plugs for swimming. Such earplugs are fine for preventing noise exposure because there is no water involved, he said. “But for swimming, just stuffing [foam] earplugs into your ears just does not work” and can lead to trauma, he said.

When water does get in the ear, Dr. Rosenfeld recommended eliminating it with a hair dryer on a low setting.

Administering a few drops of isopropyl alcohol also works, and it is considerably less expensive than over-the-counter swimmer's ear drops.

Alternatively, a few drops of white vinegar and rubbing alcohol combined in a 50/50 ratio also can prevent swimmer's ear if applied after swimming or bathing. This combination is similar to some of the commercially available preparations. Vinegar is 5% acetic acid, and mixing it with the alcohol gets it down to 2.5% acetic acid. The alcohol helps kill bacteria and is a drying agent.

“It's a poor man's version of some of the rather expensive prescription drops. I wouldn't recommend it as a mainstay of treatment, but for people who are prone to AOE, it should help prevent it,” he said.

“It's a lot simpler to use drops,” commented Dr. Roland Eavey, professor of otology and laryngology at Harvard University, Boston.

“Drops don't cause systemic side effects, such as diarrhea—and by using drops, you help keep down bacterial resistance.”

Dr. Eavey, who also is director of pediatric otolaryngology at Massachusetts Eye and Ear Infirmary in Boston, and who served on the AAO's guidelines panel for acute otitis media, agreed with the strong recommendation in favor of assessing and treating pain.

“Otitis externa can be very painful. On the assessment, when a child comes in with really bad external otitis externa, they first of all need pain relief,” Dr. Eavey said.

He also shared the AAO's recommendation regarding differential diagnosis. “For example, although rare in childhood, malignant external otitis is a serious bone infection which mimics acute external otitis and can occur in insulin-dependent diabetics,” he said.

He added his own specific recommendation: “You need to differentiate between a child with acute otitis and one with acute mastoiditis if there is swelling behind the ear. In that case, you need a clinical view of the eardrum and possibly a CT scan to make sure it's not mastoiditis.

But for garden-variety otitis externa, go with the ear drops, and the patient should get better—if they're not much improved in 2–3 days, the patient should be reassessed.

Dr. Eavey also shared a treatment pearl. “My recommendation is also to have Mom or Dad warm up the drops in their hand or carry them in their pocket, because drops are often colder than the ear canal—and so to a child, it can feel like having ice water poured into their ear.” He echoed a tip advocated in the guidelines that putting a wick in a severely swollen ear can help deliver the drops into the canal.

Dr. Seth Pransky, a pediatric otolaryngologist at Children's Hospital in San Diego, observed that although the guidelines are new, their advice is familiar to many physicians.

“Perhaps this might be considered new for primary care physicians, but the vast majority of otolaryngologists understand that this is a disease treated with topical rather than oral antibiotics,” Dr. Pransky said.

“There are cases where orals are necessary, and the guidelines point that out—but they're a lot less common than garden variety, run-of-the-mill swimmer's ear, which is very painful.”

Dr. Michael Pichichero, professor of microbiology and immunology at the University of Rochester (N.Y.) Medical Center, also approved of the recommendations. “I think the guidelines are very well written and comprehensive and appear to be evidence based—on as much evidence as we do have,” he said in an interview.

In particular Dr. Pichichero noted that distinguishing between patients who have an intact eardrum and those who don't has a sizeable impact on the antibiotic choice—because if the eardrum is not intact, “we really should move to preference for the chloroquinolone antibiotic preparations, which are not ototoxic.”

The document gave various treatment recommendations for specific AOE etiologies and advised against the use of alternative therapies such as ear candles.

The guidelines, which were published as a supplement to the journal Otolaryngology-Head and Neck Surgery, will be available free of charge at www.entnet.org

Drops don't cause systemic side effects, and you help keep down bacterial resistance. DR. EAVEY

The American Academy of Otolaryngology's first-ever guidelines for the diagnosis and treatment of acute otitis externa—commonly known as swimmer's ear—include a recommendation to treat pain and to use antimicrobial drops, rather than oral antibiotics, as first-line treatment.

The clinical practice guidelines were derived from a metaanalysis of nearly 3,000 published reports and were written by a panel of otolaryngologists from various subspecialties.

The document notes that starting treatment of acute otitis externa (AOE) with drops can help prevent bacterial resistance—even though many drops contain antibiotics themselves.

“It's a concentration issue,” explained Dr. Richard Rosenfeld, who led the AAO guidelines writing committee. “You can achieve a concentration with a topical drop that's about 1,000 times higher [at the infection site] than with a systemic drug. Topical [medication] is so incredibly potent that it overwhelms any ability of resistance. … Dead bugs don't mutate—especially if you wipe them all out with a Scud missile of a drop.”

But drops don't have to even contain antibiotics to be effective, he noted.

“We tested many types of topical therapy out there—antiseptics, various types of antibiotics, and also steroid-containing preparations. And they all seemed to have very comparable efficacy. We saw only minor, clinically irrelevant differences in efficacy.

“That doesn't mean that it's at all irrelevant what you use—for example, quinolone drops are perhaps most suitable for severe infections, because they're the most potent—but that's only anecdotal,” added Dr. Rosenfeld, director of pediatric otolaryngology at Long Island College Hospital in New York.

As to prevention of swimmer's ear, Dr. Rosenfeld said that although there's no specific policy statement, in his opinion, the key is to avoid the things that trigger AOE.

Those include trauma or scratching of the ear canal and allowing excess water to build up in the ear canal and get trapped there. Trauma can be caused by cotton swabs or other objects inserted to remove wax or to scratch, or even by inserting foam ear plugs for swimming. Such earplugs are fine for preventing noise exposure because there is no water involved, he said. “But for swimming, just stuffing [foam] earplugs into your ears just does not work” and can lead to trauma, he said.

When water does get in the ear, Dr. Rosenfeld recommended eliminating it with a hair dryer on a low setting.

Administering a few drops of isopropyl alcohol also works, and it is considerably less expensive than over-the-counter swimmer's ear drops.

Alternatively, a few drops of white vinegar and rubbing alcohol combined in a 50/50 ratio also can prevent swimmer's ear if applied after swimming or bathing. This combination is similar to some of the commercially available preparations. Vinegar is 5% acetic acid, and mixing it with the alcohol gets it down to 2.5% acetic acid. The alcohol helps kill bacteria and is a drying agent.

“It's a poor man's version of some of the rather expensive prescription drops. I wouldn't recommend it as a mainstay of treatment, but for people who are prone to AOE, it should help prevent it,” he said.

“It's a lot simpler to use drops,” commented Dr. Roland Eavey, professor of otology and laryngology at Harvard University, Boston.

“Drops don't cause systemic side effects, such as diarrhea—and by using drops, you help keep down bacterial resistance.”

Dr. Eavey, who also is director of pediatric otolaryngology at Massachusetts Eye and Ear Infirmary in Boston, and who served on the AAO's guidelines panel for acute otitis media, agreed with the strong recommendation in favor of assessing and treating pain.

“Otitis externa can be very painful. On the assessment, when a child comes in with really bad external otitis externa, they first of all need pain relief,” Dr. Eavey said.

He also shared the AAO's recommendation regarding differential diagnosis. “For example, although rare in childhood, malignant external otitis is a serious bone infection which mimics acute external otitis and can occur in insulin-dependent diabetics,” he said.

He added his own specific recommendation: “You need to differentiate between a child with acute otitis and one with acute mastoiditis if there is swelling behind the ear. In that case, you need a clinical view of the eardrum and possibly a CT scan to make sure it's not mastoiditis.

But for garden-variety otitis externa, go with the ear drops, and the patient should get better—if they're not much improved in 2–3 days, the patient should be reassessed.

Dr. Eavey also shared a treatment pearl. “My recommendation is also to have Mom or Dad warm up the drops in their hand or carry them in their pocket, because drops are often colder than the ear canal—and so to a child, it can feel like having ice water poured into their ear.” He echoed a tip advocated in the guidelines that putting a wick in a severely swollen ear can help deliver the drops into the canal.

Dr. Seth Pransky, a pediatric otolaryngologist at Children's Hospital in San Diego, observed that although the guidelines are new, their advice is familiar to many physicians.

“Perhaps this might be considered new for primary care physicians, but the vast majority of otolaryngologists understand that this is a disease treated with topical rather than oral antibiotics,” Dr. Pransky said.

“There are cases where orals are necessary, and the guidelines point that out—but they're a lot less common than garden variety, run-of-the-mill swimmer's ear, which is very painful.”

Dr. Michael Pichichero, professor of microbiology and immunology at the University of Rochester (N.Y.) Medical Center, also approved of the recommendations. “I think the guidelines are very well written and comprehensive and appear to be evidence based—on as much evidence as we do have,” he said in an interview.

In particular Dr. Pichichero noted that distinguishing between patients who have an intact eardrum and those who don't has a sizeable impact on the antibiotic choice—because if the eardrum is not intact, “we really should move to preference for the chloroquinolone antibiotic preparations, which are not ototoxic.”

The document gave various treatment recommendations for specific AOE etiologies and advised against the use of alternative therapies such as ear candles.

The guidelines, which were published as a supplement to the journal Otolaryngology-Head and Neck Surgery, will be available free of charge at www.entnet.org

Drops don't cause systemic side effects, and you help keep down bacterial resistance. DR. EAVEY

The American Academy of Otolaryngology's first-ever guidelines for the diagnosis and treatment of acute otitis externa—commonly known as swimmer's ear—include a recommendation to treat pain and to use antimicrobial drops, rather than oral antibiotics, as first-line treatment.

The clinical practice guidelines were derived from a metaanalysis of nearly 3,000 published reports and were written by a panel of otolaryngologists from various subspecialties.

The document notes that starting treatment of acute otitis externa (AOE) with drops can help prevent bacterial resistance—even though many drops contain antibiotics themselves.

“It's a concentration issue,” explained Dr. Richard Rosenfeld, who led the AAO guidelines writing committee. “You can achieve a concentration with a topical drop that's about 1,000 times higher [at the infection site] than with a systemic drug. Topical [medication] is so incredibly potent that it overwhelms any ability of resistance. … Dead bugs don't mutate—especially if you wipe them all out with a Scud missile of a drop.”

But drops don't have to even contain antibiotics to be effective, he noted.

“We tested many types of topical therapy out there—antiseptics, various types of antibiotics, and also steroid-containing preparations. And they all seemed to have very comparable efficacy. We saw only minor, clinically irrelevant differences in efficacy.

“That doesn't mean that it's at all irrelevant what you use—for example, quinolone drops are perhaps most suitable for severe infections, because they're the most potent—but that's only anecdotal,” added Dr. Rosenfeld, director of pediatric otolaryngology at Long Island College Hospital in New York.

As to prevention of swimmer's ear, Dr. Rosenfeld said that although there's no specific policy statement, in his opinion, the key is to avoid the things that trigger AOE.

Those include trauma or scratching of the ear canal and allowing excess water to build up in the ear canal and get trapped there. Trauma can be caused by cotton swabs or other objects inserted to remove wax or to scratch, or even by inserting foam ear plugs for swimming. Such earplugs are fine for preventing noise exposure because there is no water involved, he said. “But for swimming, just stuffing [foam] earplugs into your ears just does not work” and can lead to trauma, he said.

When water does get in the ear, Dr. Rosenfeld recommended eliminating it with a hair dryer on a low setting.

Administering a few drops of isopropyl alcohol also works, and it is considerably less expensive than over-the-counter swimmer's ear drops.

Alternatively, a few drops of white vinegar and rubbing alcohol combined in a 50/50 ratio also can prevent swimmer's ear if applied after swimming or bathing. This combination is similar to some of the commercially available preparations. Vinegar is 5% acetic acid, and mixing it with the alcohol gets it down to 2.5% acetic acid. The alcohol helps kill bacteria and is a drying agent.

“It's a poor man's version of some of the rather expensive prescription drops. I wouldn't recommend it as a mainstay of treatment, but for people who are prone to AOE, it should help prevent it,” he said.

“It's a lot simpler to use drops,” commented Dr. Roland Eavey, professor of otology and laryngology at Harvard University, Boston.

“Drops don't cause systemic side effects, such as diarrhea—and by using drops, you help keep down bacterial resistance.”

Dr. Eavey, who also is director of pediatric otolaryngology at Massachusetts Eye and Ear Infirmary in Boston, and who served on the AAO's guidelines panel for acute otitis media, agreed with the strong recommendation in favor of assessing and treating pain.

“Otitis externa can be very painful. On the assessment, when a child comes in with really bad external otitis externa, they first of all need pain relief,” Dr. Eavey said.

He also shared the AAO's recommendation regarding differential diagnosis. “For example, although rare in childhood, malignant external otitis is a serious bone infection which mimics acute external otitis and can occur in insulin-dependent diabetics,” he said.

He added his own specific recommendation: “You need to differentiate between a child with acute otitis and one with acute mastoiditis if there is swelling behind the ear. In that case, you need a clinical view of the eardrum and possibly a CT scan to make sure it's not mastoiditis.

But for garden-variety otitis externa, go with the ear drops, and the patient should get better—if they're not much improved in 2–3 days, the patient should be reassessed.

Dr. Eavey also shared a treatment pearl. “My recommendation is also to have Mom or Dad warm up the drops in their hand or carry them in their pocket, because drops are often colder than the ear canal—and so to a child, it can feel like having ice water poured into their ear.” He echoed a tip advocated in the guidelines that putting a wick in a severely swollen ear can help deliver the drops into the canal.

Dr. Seth Pransky, a pediatric otolaryngologist at Children's Hospital in San Diego, observed that although the guidelines are new, their advice is familiar to many physicians.

“Perhaps this might be considered new for primary care physicians, but the vast majority of otolaryngologists understand that this is a disease treated with topical rather than oral antibiotics,” Dr. Pransky said.

“There are cases where orals are necessary, and the guidelines point that out—but they're a lot less common than garden variety, run-of-the-mill swimmer's ear, which is very painful.”

Dr. Michael Pichichero, professor of microbiology and immunology at the University of Rochester (N.Y.) Medical Center, also approved of the recommendations. “I think the guidelines are very well written and comprehensive and appear to be evidence based—on as much evidence as we do have,” he said in an interview.

In particular Dr. Pichichero noted that distinguishing between patients who have an intact eardrum and those who don't has a sizeable impact on the antibiotic choice—because if the eardrum is not intact, “we really should move to preference for the chloroquinolone antibiotic preparations, which are not ototoxic.”

The document gave various treatment recommendations for specific AOE etiologies and advised against the use of alternative therapies such as ear candles.

The guidelines, which were published as a supplement to the journal Otolaryngology-Head and Neck Surgery, will be available free of charge at www.entnet.org

Drops don't cause systemic side effects, and you help keep down bacterial resistance. DR. EAVEY

Outbreaks of community-associated methicillin-resistant Staphylococcus aureus among healthy, term newborns in Chicago and Los Angeles County hospitals probably originated in the newborn nursery and illustrate the critical importance of consistent hand hygiene, the Centers for Disease Control and Prevention reported.

The CDC helped local health departments in both locations conduct independent investigations into the outbreaks, both of which occurred in 2004. In both outbreaks, the MRSA was a community-acquired rather than a health care-acquired strain.

The Chicago hospital had a cluster of MRSA infections that led authorities to discover 11 cases, of which 9 (82%) were in infants delivered by cesarean section (MMWR 2006;55:329–32).

Nine of the infants were male.

Symptoms were pustules, vesicles, and/or blisters on areas including the neck, groin, perineum, ears, and legs; most patients had lesions on more than one site.

Median age at symptom onset was 7 days, and symptom onset occurred a median of 5 days post discharge from the newborn nursery. The infants were treated with topical antimicrobials in 10 cases, and 3 of those were treated with concomitant oral antimicrobials. One was hospitalized. All 11 infants recovered without incident, the CDC reported.

A subsequent investigation found that one physician and one nurse had nasal MRSA colonization.

Both were restricted from work and required to undergo a course of intranasal mupirocin and to then test negative for MRSA.

In the Los Angeles County hospital, 11 cases of infection were discovered in two clusters. All were male newborns, and 7 of the 11 (64%) were delivered via C-section. All the infants had pustular/vesicular lesions in the groin area occurring a median of 3 days after nursery discharge. The median postdelivery stay was 4 days, as in the Chicago cases.

In contrast to the Chicago outbreak, 8 of these 11 infants were hospitalized. They were treated with parenteral antimicrobials and recovered without incident. The remaining infants were either treated with topical antimicrobials or not treated. Laboratory tests showed that the MRSA strain was the same one as in the Chicago outbreak.

Unlike the Chicago hospital, however, the Los Angeles County hospital chose not to test its health care workers for MRSA, reasoning that no employee had more infant contact than the others.

Staff members were instructed regarding proper hand hygiene, and all patient contacts were subsequently required to wear gloves and gowns. A policy of bathing newborns with antibacterial soap before discharge also was begun, and the frequency and intensity of the environmental cleaning of the nursery was reportedly increased.

The editors noted that these cases were similar to cases in a New York City hospital in 2002, in which a community-acquired strain of MRSA was the source of infection in six newborns.

They also observed that male gender has been found to be a risk factor for staphylococcal infection in newborns and that most of the infants in this report were delivered via C-section, which requires a longer hospital stay—although they cautioned that the role of this factor is unclear.

They speculated that the moist environment and friction in the diaper area, where lesions were common, might be a breeding ground for S. aureus.

The CDC recommended that hospitals emphasize transmission-prevention methods and promote frequent dressing changes for infants with skin infections. The agency also advised that when MRSA appears, hospitals should review and reinforce infection-control measures in all newborn nurseries and consider requiring all persons coming into contact with the infants to be checked for skin lesions.

The need for universal use of gowns and gloves, antiseptic bathing of newborns, and surveillance cultures of health care workers and the environment is less clear, the CDC said.

Additional information regarding MRSA infections is available at http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Outbreaks of community-associated methicillin-resistant Staphylococcus aureus among healthy, term newborns in Chicago and Los Angeles County hospitals probably originated in the newborn nursery and illustrate the critical importance of consistent hand hygiene, the Centers for Disease Control and Prevention reported.

The CDC helped local health departments in both locations conduct independent investigations into the outbreaks, both of which occurred in 2004. In both outbreaks, the MRSA was a community-acquired rather than a health care-acquired strain.

The Chicago hospital had a cluster of MRSA infections that led authorities to discover 11 cases, of which 9 (82%) were in infants delivered by cesarean section (MMWR 2006;55:329–32).

Nine of the infants were male.

Symptoms were pustules, vesicles, and/or blisters on areas including the neck, groin, perineum, ears, and legs; most patients had lesions on more than one site.

Median age at symptom onset was 7 days, and symptom onset occurred a median of 5 days post discharge from the newborn nursery. The infants were treated with topical antimicrobials in 10 cases, and 3 of those were treated with concomitant oral antimicrobials. One was hospitalized. All 11 infants recovered without incident, the CDC reported.

A subsequent investigation found that one physician and one nurse had nasal MRSA colonization.

Both were restricted from work and required to undergo a course of intranasal mupirocin and to then test negative for MRSA.

In the Los Angeles County hospital, 11 cases of infection were discovered in two clusters. All were male newborns, and 7 of the 11 (64%) were delivered via C-section. All the infants had pustular/vesicular lesions in the groin area occurring a median of 3 days after nursery discharge. The median postdelivery stay was 4 days, as in the Chicago cases.

In contrast to the Chicago outbreak, 8 of these 11 infants were hospitalized. They were treated with parenteral antimicrobials and recovered without incident. The remaining infants were either treated with topical antimicrobials or not treated. Laboratory tests showed that the MRSA strain was the same one as in the Chicago outbreak.

Unlike the Chicago hospital, however, the Los Angeles County hospital chose not to test its health care workers for MRSA, reasoning that no employee had more infant contact than the others.

Staff members were instructed regarding proper hand hygiene, and all patient contacts were subsequently required to wear gloves and gowns. A policy of bathing newborns with antibacterial soap before discharge also was begun, and the frequency and intensity of the environmental cleaning of the nursery was reportedly increased.

The editors noted that these cases were similar to cases in a New York City hospital in 2002, in which a community-acquired strain of MRSA was the source of infection in six newborns.

They also observed that male gender has been found to be a risk factor for staphylococcal infection in newborns and that most of the infants in this report were delivered via C-section, which requires a longer hospital stay—although they cautioned that the role of this factor is unclear.

They speculated that the moist environment and friction in the diaper area, where lesions were common, might be a breeding ground for S. aureus.

The CDC recommended that hospitals emphasize transmission-prevention methods and promote frequent dressing changes for infants with skin infections. The agency also advised that when MRSA appears, hospitals should review and reinforce infection-control measures in all newborn nurseries and consider requiring all persons coming into contact with the infants to be checked for skin lesions.

The need for universal use of gowns and gloves, antiseptic bathing of newborns, and surveillance cultures of health care workers and the environment is less clear, the CDC said.

Additional information regarding MRSA infections is available at http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Outbreaks of community-associated methicillin-resistant Staphylococcus aureus among healthy, term newborns in Chicago and Los Angeles County hospitals probably originated in the newborn nursery and illustrate the critical importance of consistent hand hygiene, the Centers for Disease Control and Prevention reported.

The CDC helped local health departments in both locations conduct independent investigations into the outbreaks, both of which occurred in 2004. In both outbreaks, the MRSA was a community-acquired rather than a health care-acquired strain.

The Chicago hospital had a cluster of MRSA infections that led authorities to discover 11 cases, of which 9 (82%) were in infants delivered by cesarean section (MMWR 2006;55:329–32).

Nine of the infants were male.

Symptoms were pustules, vesicles, and/or blisters on areas including the neck, groin, perineum, ears, and legs; most patients had lesions on more than one site.

Median age at symptom onset was 7 days, and symptom onset occurred a median of 5 days post discharge from the newborn nursery. The infants were treated with topical antimicrobials in 10 cases, and 3 of those were treated with concomitant oral antimicrobials. One was hospitalized. All 11 infants recovered without incident, the CDC reported.

A subsequent investigation found that one physician and one nurse had nasal MRSA colonization.

Both were restricted from work and required to undergo a course of intranasal mupirocin and to then test negative for MRSA.

In the Los Angeles County hospital, 11 cases of infection were discovered in two clusters. All were male newborns, and 7 of the 11 (64%) were delivered via C-section. All the infants had pustular/vesicular lesions in the groin area occurring a median of 3 days after nursery discharge. The median postdelivery stay was 4 days, as in the Chicago cases.

In contrast to the Chicago outbreak, 8 of these 11 infants were hospitalized. They were treated with parenteral antimicrobials and recovered without incident. The remaining infants were either treated with topical antimicrobials or not treated. Laboratory tests showed that the MRSA strain was the same one as in the Chicago outbreak.

Unlike the Chicago hospital, however, the Los Angeles County hospital chose not to test its health care workers for MRSA, reasoning that no employee had more infant contact than the others.

Staff members were instructed regarding proper hand hygiene, and all patient contacts were subsequently required to wear gloves and gowns. A policy of bathing newborns with antibacterial soap before discharge also was begun, and the frequency and intensity of the environmental cleaning of the nursery was reportedly increased.

The editors noted that these cases were similar to cases in a New York City hospital in 2002, in which a community-acquired strain of MRSA was the source of infection in six newborns.

They also observed that male gender has been found to be a risk factor for staphylococcal infection in newborns and that most of the infants in this report were delivered via C-section, which requires a longer hospital stay—although they cautioned that the role of this factor is unclear.

They speculated that the moist environment and friction in the diaper area, where lesions were common, might be a breeding ground for S. aureus.

The CDC recommended that hospitals emphasize transmission-prevention methods and promote frequent dressing changes for infants with skin infections. The agency also advised that when MRSA appears, hospitals should review and reinforce infection-control measures in all newborn nurseries and consider requiring all persons coming into contact with the infants to be checked for skin lesions.

The need for universal use of gowns and gloves, antiseptic bathing of newborns, and surveillance cultures of health care workers and the environment is less clear, the CDC said.

Additional information regarding MRSA infections is available at http://www.cdc.gov/ncidod/dhqp/ar_mrsa.html

Children vaccinated with three doses of pneumococcal conjugate vaccine had a reduced rate of human metapneumovirus-associated infections of the lower respiratory tract, as well as a lower rate of clinical pneumonia than children given placebo, researchers reported.

Dr. Shabir A. Madhi of the University of the Witwatersrand, Bertsham, South Africa, and colleagues performed an analysis of data from nearly 40,000 children—some of whom had been infected with HIV—who had been given three doses of a polysaccharide-protein conjugate vaccine (PCV) or placebo in an ongoing phase III study.

Dr. Madhi and coinvestigators tested nasopharyngeal aspirate samples of the children who had been hospitalized with lower respiratory tract infection (LRTI) for evidence of human metapneumovirus (hMPV), which was discovered only 5 years ago, as well as for HIV and C-reactive protein (J. Infect. Dis 2006;193:1236–43).

They found that for vaccinated children without HIV infection, the hospitalization rate was 46% lower than that of children who received placebo. For HIV-infected children, the reduction was 53% versus placebo. The incidence of clinical pneumonia also was reduced for both HIV-free and HIV-infected children who received vaccine (55% and 65%, respectively).

These results “suggest that bacterial coinfections, particularly pneumococcal infections, are an essential part of the pathogenesis of most severe hMPV infections progressing to pneumonia,” they said. This means that children hospitalized with hMPV-associated pneumonia “should be treated with antibiotics.”

Children vaccinated with three doses of pneumococcal conjugate vaccine had a reduced rate of human metapneumovirus-associated infections of the lower respiratory tract, as well as a lower rate of clinical pneumonia than children given placebo, researchers reported.

Dr. Shabir A. Madhi of the University of the Witwatersrand, Bertsham, South Africa, and colleagues performed an analysis of data from nearly 40,000 children—some of whom had been infected with HIV—who had been given three doses of a polysaccharide-protein conjugate vaccine (PCV) or placebo in an ongoing phase III study.

Dr. Madhi and coinvestigators tested nasopharyngeal aspirate samples of the children who had been hospitalized with lower respiratory tract infection (LRTI) for evidence of human metapneumovirus (hMPV), which was discovered only 5 years ago, as well as for HIV and C-reactive protein (J. Infect. Dis 2006;193:1236–43).

They found that for vaccinated children without HIV infection, the hospitalization rate was 46% lower than that of children who received placebo. For HIV-infected children, the reduction was 53% versus placebo. The incidence of clinical pneumonia also was reduced for both HIV-free and HIV-infected children who received vaccine (55% and 65%, respectively).

These results “suggest that bacterial coinfections, particularly pneumococcal infections, are an essential part of the pathogenesis of most severe hMPV infections progressing to pneumonia,” they said. This means that children hospitalized with hMPV-associated pneumonia “should be treated with antibiotics.”

Children vaccinated with three doses of pneumococcal conjugate vaccine had a reduced rate of human metapneumovirus-associated infections of the lower respiratory tract, as well as a lower rate of clinical pneumonia than children given placebo, researchers reported.

Dr. Shabir A. Madhi of the University of the Witwatersrand, Bertsham, South Africa, and colleagues performed an analysis of data from nearly 40,000 children—some of whom had been infected with HIV—who had been given three doses of a polysaccharide-protein conjugate vaccine (PCV) or placebo in an ongoing phase III study.

Dr. Madhi and coinvestigators tested nasopharyngeal aspirate samples of the children who had been hospitalized with lower respiratory tract infection (LRTI) for evidence of human metapneumovirus (hMPV), which was discovered only 5 years ago, as well as for HIV and C-reactive protein (J. Infect. Dis 2006;193:1236–43).

They found that for vaccinated children without HIV infection, the hospitalization rate was 46% lower than that of children who received placebo. For HIV-infected children, the reduction was 53% versus placebo. The incidence of clinical pneumonia also was reduced for both HIV-free and HIV-infected children who received vaccine (55% and 65%, respectively).

These results “suggest that bacterial coinfections, particularly pneumococcal infections, are an essential part of the pathogenesis of most severe hMPV infections progressing to pneumonia,” they said. This means that children hospitalized with hMPV-associated pneumonia “should be treated with antibiotics.”

Pelvic disease, psychological morbidity, and a history of abuse are the factors most strongly associated with chronic pelvic pain in women, according to a metaanalysis including data on more than 90,000 patients.

Dr. Pallavi Latthe and colleagues at the University of Birmingham (England) evaluated 122 studies that examined dysmenorrhea, dyspareunia, and noncyclical pelvic pain, including recurrent pelvic pain. The reports included were published in six languages and were extracted from several large databases; a total of 94,927 women were assessed.

Studies were chosen based on inclusion of relevant clinical and statistical terms, as well as quality of the research design (BMJ 2006;332:749–55).

Patient characteristics associated with dysmenorrhea were being at least 30 years of age, having a body mass index of less than 20 kg/m

The factors associated with decreased risk were use of oral contraceptives, being married, having children, exercising, and including fish in the diet.

For dyspareunia, associated factors were having undergone female genital mutilation, having clinically suspected pelvic inflammatory disease, and being peri- or postmenopausal. Depression, anxiety, and history of sexual assault were more common in women with dyspareunia.

Those factors most strongly associated with noncyclical pelvic pain were childhood or adult physical, sexual, or other abuse; miscarriage; longer menstrual flow; presence of endometriosis; clinically suspected pelvic inflammatory disease; C-section scar; pelvic adhesions; anxiety; depression; and somatization.

The investigators concluded that “strong and consistent associations” existed “between chronic pelvic pain and presence of pelvic pathology, history of abuse, and coexistent psychological morbidity … [providing] potential targets for new therapeutic strategies for treating women with this disabling condition, for which current treatment options provide little relief.”

Pelvic disease, psychological morbidity, and a history of abuse are the factors most strongly associated with chronic pelvic pain in women, according to a metaanalysis including data on more than 90,000 patients.

Dr. Pallavi Latthe and colleagues at the University of Birmingham (England) evaluated 122 studies that examined dysmenorrhea, dyspareunia, and noncyclical pelvic pain, including recurrent pelvic pain. The reports included were published in six languages and were extracted from several large databases; a total of 94,927 women were assessed.

Studies were chosen based on inclusion of relevant clinical and statistical terms, as well as quality of the research design (BMJ 2006;332:749–55).

Patient characteristics associated with dysmenorrhea were being at least 30 years of age, having a body mass index of less than 20 kg/m

The factors associated with decreased risk were use of oral contraceptives, being married, having children, exercising, and including fish in the diet.

For dyspareunia, associated factors were having undergone female genital mutilation, having clinically suspected pelvic inflammatory disease, and being peri- or postmenopausal. Depression, anxiety, and history of sexual assault were more common in women with dyspareunia.

Those factors most strongly associated with noncyclical pelvic pain were childhood or adult physical, sexual, or other abuse; miscarriage; longer menstrual flow; presence of endometriosis; clinically suspected pelvic inflammatory disease; C-section scar; pelvic adhesions; anxiety; depression; and somatization.

The investigators concluded that “strong and consistent associations” existed “between chronic pelvic pain and presence of pelvic pathology, history of abuse, and coexistent psychological morbidity … [providing] potential targets for new therapeutic strategies for treating women with this disabling condition, for which current treatment options provide little relief.”

Pelvic disease, psychological morbidity, and a history of abuse are the factors most strongly associated with chronic pelvic pain in women, according to a metaanalysis including data on more than 90,000 patients.

Dr. Pallavi Latthe and colleagues at the University of Birmingham (England) evaluated 122 studies that examined dysmenorrhea, dyspareunia, and noncyclical pelvic pain, including recurrent pelvic pain. The reports included were published in six languages and were extracted from several large databases; a total of 94,927 women were assessed.

Studies were chosen based on inclusion of relevant clinical and statistical terms, as well as quality of the research design (BMJ 2006;332:749–55).

Patient characteristics associated with dysmenorrhea were being at least 30 years of age, having a body mass index of less than 20 kg/m

The factors associated with decreased risk were use of oral contraceptives, being married, having children, exercising, and including fish in the diet.

For dyspareunia, associated factors were having undergone female genital mutilation, having clinically suspected pelvic inflammatory disease, and being peri- or postmenopausal. Depression, anxiety, and history of sexual assault were more common in women with dyspareunia.

Those factors most strongly associated with noncyclical pelvic pain were childhood or adult physical, sexual, or other abuse; miscarriage; longer menstrual flow; presence of endometriosis; clinically suspected pelvic inflammatory disease; C-section scar; pelvic adhesions; anxiety; depression; and somatization.

The investigators concluded that “strong and consistent associations” existed “between chronic pelvic pain and presence of pelvic pathology, history of abuse, and coexistent psychological morbidity … [providing] potential targets for new therapeutic strategies for treating women with this disabling condition, for which current treatment options provide little relief.”

Claims of an autism “epidemic” are not backed by the data, which show evidence that diagnostic substitution accounts for reported increases in the disorder and that those increases are still short of epidemiologic estimates, according to one researcher.

Paul T. Shattuck, Ph.D., a research associate at the University of Wisconsin, Madison, conducted an analysis of disability data from the Department of Education for U.S. children aged 6–11 years from all 50 states and the District of Columbia from 1984 to 2003.

The data included the numbers of children categorized with any of 13 disabilities. He then used data from the U.S. Census to calculate incidence rates (Pediatrics 2006;117:1028–37).

He found that, according to logistic regression models, reported autism incidence met three criteria he established to determine that diagnostic substitution does, indeed, play a role: First, the nationwide incidence of reported autism has gone up, while the reported national incidence of other special-education categories (including mental retardation [MR] and learning disabilities [LD]) has gone down.

Second, within most states, increases in autism diagnoses are correlated with decreases in the number of children diagnosed with MR or LD. And third, the trajectories for the prevalence of various learning disorders have gone down at the same time that the administrative incidence of autism has gone up.

For the entire United States, the mean reported incidence of autism in children aged 3–10 years had gone from less than 1 case per 1,000 in 1994 to approximately 3 per 1,000 in 2003. However, this incidence rate was still short of the lower threshold of a reference range of expected incidence calculated by the Centers for Disease Control and Prevention. Thus, despite the marked increase in reported national incidence of autism over that time period, the incidence rate still did not meet the criteria required to be an epidemic, Dr. Shattuck wrote.

Moreover, the reported rates of learning disability and mental retardation decreased during the same period (odds ratio 0.98 and 0.97, respectively), while the overall incidence of all disabilities declined (by a non-statistically significant measure), discounting any claim that increased autism rates are a function of increased special education enrollment overall.

Dr. Shattuck also reported that LD and MR rates had declined in most states. The only states with increases in the learning disabilities category as well as autism were Oklahoma and Pennsylvania, and the only states with increases in mental retardation and autism were California, Michigan, New Jersey, and West Virginia. Increases in both disabilities were also found in the District of Columbia. He also observed that the historical trajectories for MR and LD prevalence were lower between 1984 and 1993 than between 1994 and 2003, with the advent of the autism diagnosis.

Dr. Shattuck noted that diagnostic substitution is suspected by many clinicians because the diagnostic criteria for autism have been expanded over the last few decades and that this phenomenon has been documented previously in special-education enrollment. He pointed out that the category of LD grew by 198% between 1976 and 1992, and the MR category shrank by 41%.

In an editorial accompanying the report, Craig J. Newschaffer, Ph.D., of Johns Hopkins University, Baltimore, conceded that diagnostic substitution is one factor that might contribute to increased autism prevalence. But Dr. Newschaffer added that not only the directions of classification trends but also their magnitudes should be incorporated into any statistical analysis thereof (Pediatrics 2006;117:1436–7).

Dr. Chris P. Johnson, medical director of the Village of Hope Center for Children With Disabilities at the University of Texas, San Antonio, and cochair of the American Academy of Pediatrics Autism Panel, offered qualified agreement with the theory of a diagnostic shift. She noted that before 1991, there was no label schools could use to give special education services to autistic children, other than MR, speech delayed, and LD. The “autism” label became available in 2003 with passage of the Improving Education Results for Children With Disabilities Act.

Moreover, because more services are often available to children with autism, including year-round schooling, behavioral management training, a home trainer, and funding for parental respite and/or recreation, parents and professionals may view the autism label as preferable to MR or LD. But despite this, “I certainly do not think [diagnostic substitution] is the only reason, and it may not even be the main reason, for the apparent rise in prevalence,” she added.

Good intentions on the part of administrators may also play a role, she explained. “I think when there's truly uncertainty as to whether the diagnosis in a particular child is autism or something close to it, a label of autism is sometimes given in a compassionate effort to entitle the child to additional services, which will also, in turn, benefit the family.”

She is not advocating for physicians to intentionally err on the side of an autism label, said Dr. Johnson, who disclosed that she had testified for the defense of vaccine manufacturers implicated in thimerosal lawsuits. Physicians must also weigh the possible negative consequences of labeling, particularly when the child might be on the mildest end of the spectrum. They also must look at the financial impact on early-intervention systems and school districts, she said.

Claims of an autism “epidemic” are not backed by the data, which show evidence that diagnostic substitution accounts for reported increases in the disorder and that those increases are still short of epidemiologic estimates, according to one researcher.

Paul T. Shattuck, Ph.D., a research associate at the University of Wisconsin, Madison, conducted an analysis of disability data from the Department of Education for U.S. children aged 6–11 years from all 50 states and the District of Columbia from 1984 to 2003.

The data included the numbers of children categorized with any of 13 disabilities. He then used data from the U.S. Census to calculate incidence rates (Pediatrics 2006;117:1028–37).

He found that, according to logistic regression models, reported autism incidence met three criteria he established to determine that diagnostic substitution does, indeed, play a role: First, the nationwide incidence of reported autism has gone up, while the reported national incidence of other special-education categories (including mental retardation [MR] and learning disabilities [LD]) has gone down.

Second, within most states, increases in autism diagnoses are correlated with decreases in the number of children diagnosed with MR or LD. And third, the trajectories for the prevalence of various learning disorders have gone down at the same time that the administrative incidence of autism has gone up.

For the entire United States, the mean reported incidence of autism in children aged 3–10 years had gone from less than 1 case per 1,000 in 1994 to approximately 3 per 1,000 in 2003. However, this incidence rate was still short of the lower threshold of a reference range of expected incidence calculated by the Centers for Disease Control and Prevention. Thus, despite the marked increase in reported national incidence of autism over that time period, the incidence rate still did not meet the criteria required to be an epidemic, Dr. Shattuck wrote.

Moreover, the reported rates of learning disability and mental retardation decreased during the same period (odds ratio 0.98 and 0.97, respectively), while the overall incidence of all disabilities declined (by a non-statistically significant measure), discounting any claim that increased autism rates are a function of increased special education enrollment overall.

Dr. Shattuck also reported that LD and MR rates had declined in most states. The only states with increases in the learning disabilities category as well as autism were Oklahoma and Pennsylvania, and the only states with increases in mental retardation and autism were California, Michigan, New Jersey, and West Virginia. Increases in both disabilities were also found in the District of Columbia. He also observed that the historical trajectories for MR and LD prevalence were lower between 1984 and 1993 than between 1994 and 2003, with the advent of the autism diagnosis.

Dr. Shattuck noted that diagnostic substitution is suspected by many clinicians because the diagnostic criteria for autism have been expanded over the last few decades and that this phenomenon has been documented previously in special-education enrollment. He pointed out that the category of LD grew by 198% between 1976 and 1992, and the MR category shrank by 41%.

In an editorial accompanying the report, Craig J. Newschaffer, Ph.D., of Johns Hopkins University, Baltimore, conceded that diagnostic substitution is one factor that might contribute to increased autism prevalence. But Dr. Newschaffer added that not only the directions of classification trends but also their magnitudes should be incorporated into any statistical analysis thereof (Pediatrics 2006;117:1436–7).

Dr. Chris P. Johnson, medical director of the Village of Hope Center for Children With Disabilities at the University of Texas, San Antonio, and cochair of the American Academy of Pediatrics Autism Panel, offered qualified agreement with the theory of a diagnostic shift. She noted that before 1991, there was no label schools could use to give special education services to autistic children, other than MR, speech delayed, and LD. The “autism” label became available in 2003 with passage of the Improving Education Results for Children With Disabilities Act.

Moreover, because more services are often available to children with autism, including year-round schooling, behavioral management training, a home trainer, and funding for parental respite and/or recreation, parents and professionals may view the autism label as preferable to MR or LD. But despite this, “I certainly do not think [diagnostic substitution] is the only reason, and it may not even be the main reason, for the apparent rise in prevalence,” she added.

Good intentions on the part of administrators may also play a role, she explained. “I think when there's truly uncertainty as to whether the diagnosis in a particular child is autism or something close to it, a label of autism is sometimes given in a compassionate effort to entitle the child to additional services, which will also, in turn, benefit the family.”

She is not advocating for physicians to intentionally err on the side of an autism label, said Dr. Johnson, who disclosed that she had testified for the defense of vaccine manufacturers implicated in thimerosal lawsuits. Physicians must also weigh the possible negative consequences of labeling, particularly when the child might be on the mildest end of the spectrum. They also must look at the financial impact on early-intervention systems and school districts, she said.

Claims of an autism “epidemic” are not backed by the data, which show evidence that diagnostic substitution accounts for reported increases in the disorder and that those increases are still short of epidemiologic estimates, according to one researcher.

Paul T. Shattuck, Ph.D., a research associate at the University of Wisconsin, Madison, conducted an analysis of disability data from the Department of Education for U.S. children aged 6–11 years from all 50 states and the District of Columbia from 1984 to 2003.

The data included the numbers of children categorized with any of 13 disabilities. He then used data from the U.S. Census to calculate incidence rates (Pediatrics 2006;117:1028–37).

He found that, according to logistic regression models, reported autism incidence met three criteria he established to determine that diagnostic substitution does, indeed, play a role: First, the nationwide incidence of reported autism has gone up, while the reported national incidence of other special-education categories (including mental retardation [MR] and learning disabilities [LD]) has gone down.

Second, within most states, increases in autism diagnoses are correlated with decreases in the number of children diagnosed with MR or LD. And third, the trajectories for the prevalence of various learning disorders have gone down at the same time that the administrative incidence of autism has gone up.

For the entire United States, the mean reported incidence of autism in children aged 3–10 years had gone from less than 1 case per 1,000 in 1994 to approximately 3 per 1,000 in 2003. However, this incidence rate was still short of the lower threshold of a reference range of expected incidence calculated by the Centers for Disease Control and Prevention. Thus, despite the marked increase in reported national incidence of autism over that time period, the incidence rate still did not meet the criteria required to be an epidemic, Dr. Shattuck wrote.

Moreover, the reported rates of learning disability and mental retardation decreased during the same period (odds ratio 0.98 and 0.97, respectively), while the overall incidence of all disabilities declined (by a non-statistically significant measure), discounting any claim that increased autism rates are a function of increased special education enrollment overall.

Dr. Shattuck also reported that LD and MR rates had declined in most states. The only states with increases in the learning disabilities category as well as autism were Oklahoma and Pennsylvania, and the only states with increases in mental retardation and autism were California, Michigan, New Jersey, and West Virginia. Increases in both disabilities were also found in the District of Columbia. He also observed that the historical trajectories for MR and LD prevalence were lower between 1984 and 1993 than between 1994 and 2003, with the advent of the autism diagnosis.

Dr. Shattuck noted that diagnostic substitution is suspected by many clinicians because the diagnostic criteria for autism have been expanded over the last few decades and that this phenomenon has been documented previously in special-education enrollment. He pointed out that the category of LD grew by 198% between 1976 and 1992, and the MR category shrank by 41%.

In an editorial accompanying the report, Craig J. Newschaffer, Ph.D., of Johns Hopkins University, Baltimore, conceded that diagnostic substitution is one factor that might contribute to increased autism prevalence. But Dr. Newschaffer added that not only the directions of classification trends but also their magnitudes should be incorporated into any statistical analysis thereof (Pediatrics 2006;117:1436–7).

Dr. Chris P. Johnson, medical director of the Village of Hope Center for Children With Disabilities at the University of Texas, San Antonio, and cochair of the American Academy of Pediatrics Autism Panel, offered qualified agreement with the theory of a diagnostic shift. She noted that before 1991, there was no label schools could use to give special education services to autistic children, other than MR, speech delayed, and LD. The “autism” label became available in 2003 with passage of the Improving Education Results for Children With Disabilities Act.

Moreover, because more services are often available to children with autism, including year-round schooling, behavioral management training, a home trainer, and funding for parental respite and/or recreation, parents and professionals may view the autism label as preferable to MR or LD. But despite this, “I certainly do not think [diagnostic substitution] is the only reason, and it may not even be the main reason, for the apparent rise in prevalence,” she added.

Good intentions on the part of administrators may also play a role, she explained. “I think when there's truly uncertainty as to whether the diagnosis in a particular child is autism or something close to it, a label of autism is sometimes given in a compassionate effort to entitle the child to additional services, which will also, in turn, benefit the family.”

She is not advocating for physicians to intentionally err on the side of an autism label, said Dr. Johnson, who disclosed that she had testified for the defense of vaccine manufacturers implicated in thimerosal lawsuits. Physicians must also weigh the possible negative consequences of labeling, particularly when the child might be on the mildest end of the spectrum. They also must look at the financial impact on early-intervention systems and school districts, she said.

Doppler myocardial imaging to assess systolic activation delay can help determine whether a condition is hypertrophic cardiomyopathy or merely the result of athletic training—and help predict serious adverse cardiac events, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes with enlarged left ventricles and interventricular septa thicker than 12 mm (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up, the study's primary end point was cardiovascular mortality. Eight HCM patients died during follow-up; none of the athletes had a cardiovascular event. The participants were aged 29 years on average and were matched for blood pressure. Eighty percent of them were male. All had standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging in six myocardial segments. HCM patients showed a “significant global Doppler interventricular delay,” the authors said. One-fifth of the HCM patients had a relative who had died from an HCM-related cardiac event.

Doppler myocardial imaging to assess systolic activation delay can help determine whether a condition is hypertrophic cardiomyopathy or merely the result of athletic training—and help predict serious adverse cardiac events, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes with enlarged left ventricles and interventricular septa thicker than 12 mm (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up, the study's primary end point was cardiovascular mortality. Eight HCM patients died during follow-up; none of the athletes had a cardiovascular event. The participants were aged 29 years on average and were matched for blood pressure. Eighty percent of them were male. All had standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging in six myocardial segments. HCM patients showed a “significant global Doppler interventricular delay,” the authors said. One-fifth of the HCM patients had a relative who had died from an HCM-related cardiac event.

Doppler myocardial imaging to assess systolic activation delay can help determine whether a condition is hypertrophic cardiomyopathy or merely the result of athletic training—and help predict serious adverse cardiac events, Italian researchers reported.

Dr. Antonello D'Andrea of the Second University of Naples (Italy) and colleagues followed 70 patients with hypertrophic cardiomyopathy (HCM) and 85 age- and sex-matched competitive athletes with enlarged left ventricles and interventricular septa thicker than 12 mm (Br. J. Sports Med. 2006;40:244–50).

During the 4-year follow-up, the study's primary end point was cardiovascular mortality. Eight HCM patients died during follow-up; none of the athletes had a cardiovascular event. The participants were aged 29 years on average and were matched for blood pressure. Eighty percent of them were male. All had standard pulsed Doppler echocardiography and pulsed Doppler myocardial imaging in six myocardial segments. HCM patients showed a “significant global Doppler interventricular delay,” the authors said. One-fifth of the HCM patients had a relative who had died from an HCM-related cardiac event.

Anxiety and depression increase a child's likelihood of eventually using ecstasy, according to the findings of a longitudinal investigation.

Anja C. Huizink, Ph.D., and coinvestigators at Erasmus Medical Center in Rotterdam, the Netherlands, interviewed 1,580 individuals who had been participating in an ongoing investigation that had begun 14 years earlier in one Dutch province. They hypothesized that behavioral and emotional problems in children or adolescents would be associated with later use of ectasy, clinically known as 3,4-methylenedioxymethamphetamine (MDMA).

Participants were initially assessed in 1983 with the Child Behavior Checklist, a 120-question survey aimed at probing into mood disorders, including anxiety and depression. The 1997 follow-up analysis included 76% of the initial group of 2,076 individuals.

Mean patient age in 1983 was 10 years (range 4–17 years) and 25 years at study follow-up in 1997. There were slightly more female than male participants.

A total of 98 participants (6.2%) reported ever using ectasy. MDMA use was more prevalent among those with deviant scores on the “anxious or depressed” scale of the child behavior checklist in 1983 (hazard ratio 2.22).

There were no associations between MDMA use and the other scales. The authors noted that their study showed this association in both sexes, in contrast to previous studies showing the association only for females.

Ecstasy, they noted, would be attractive to those suffering anxiety and depression because of its euphoric and relaxing effects. However, they added, “It has been found … that in the long run, exposure to MDMA may result in increased depressive symptoms” borne of neurotoxic effects. Thus, depression might be a cause and an effect of using MDMA. “Links between emotional problems and MDMA use may run in both directions,” they said.

Other documented risk factors for ectasy use include drug use among peers, a “desire to party,” novelty seeking, and bad parenting practices.

The authors concluded that results support the idea that there is a temporal pathway linking childhood anxiety and depression to MDMA use. Future research should focus on children with such symptoms to better understand how psychological factors play into MDMA use.

Anxiety and depression increase a child's likelihood of eventually using ecstasy, according to the findings of a longitudinal investigation.

Anja C. Huizink, Ph.D., and coinvestigators at Erasmus Medical Center in Rotterdam, the Netherlands, interviewed 1,580 individuals who had been participating in an ongoing investigation that had begun 14 years earlier in one Dutch province. They hypothesized that behavioral and emotional problems in children or adolescents would be associated with later use of ectasy, clinically known as 3,4-methylenedioxymethamphetamine (MDMA).

Participants were initially assessed in 1983 with the Child Behavior Checklist, a 120-question survey aimed at probing into mood disorders, including anxiety and depression. The 1997 follow-up analysis included 76% of the initial group of 2,076 individuals.

Mean patient age in 1983 was 10 years (range 4–17 years) and 25 years at study follow-up in 1997. There were slightly more female than male participants.

A total of 98 participants (6.2%) reported ever using ectasy. MDMA use was more prevalent among those with deviant scores on the “anxious or depressed” scale of the child behavior checklist in 1983 (hazard ratio 2.22).

There were no associations between MDMA use and the other scales. The authors noted that their study showed this association in both sexes, in contrast to previous studies showing the association only for females.

Ecstasy, they noted, would be attractive to those suffering anxiety and depression because of its euphoric and relaxing effects. However, they added, “It has been found … that in the long run, exposure to MDMA may result in increased depressive symptoms” borne of neurotoxic effects. Thus, depression might be a cause and an effect of using MDMA. “Links between emotional problems and MDMA use may run in both directions,” they said.

Other documented risk factors for ectasy use include drug use among peers, a “desire to party,” novelty seeking, and bad parenting practices.

The authors concluded that results support the idea that there is a temporal pathway linking childhood anxiety and depression to MDMA use. Future research should focus on children with such symptoms to better understand how psychological factors play into MDMA use.

Anxiety and depression increase a child's likelihood of eventually using ecstasy, according to the findings of a longitudinal investigation.

Anja C. Huizink, Ph.D., and coinvestigators at Erasmus Medical Center in Rotterdam, the Netherlands, interviewed 1,580 individuals who had been participating in an ongoing investigation that had begun 14 years earlier in one Dutch province. They hypothesized that behavioral and emotional problems in children or adolescents would be associated with later use of ectasy, clinically known as 3,4-methylenedioxymethamphetamine (MDMA).

Participants were initially assessed in 1983 with the Child Behavior Checklist, a 120-question survey aimed at probing into mood disorders, including anxiety and depression. The 1997 follow-up analysis included 76% of the initial group of 2,076 individuals.

Mean patient age in 1983 was 10 years (range 4–17 years) and 25 years at study follow-up in 1997. There were slightly more female than male participants.

A total of 98 participants (6.2%) reported ever using ectasy. MDMA use was more prevalent among those with deviant scores on the “anxious or depressed” scale of the child behavior checklist in 1983 (hazard ratio 2.22).

There were no associations between MDMA use and the other scales. The authors noted that their study showed this association in both sexes, in contrast to previous studies showing the association only for females.

Ecstasy, they noted, would be attractive to those suffering anxiety and depression because of its euphoric and relaxing effects. However, they added, “It has been found … that in the long run, exposure to MDMA may result in increased depressive symptoms” borne of neurotoxic effects. Thus, depression might be a cause and an effect of using MDMA. “Links between emotional problems and MDMA use may run in both directions,” they said.

Other documented risk factors for ectasy use include drug use among peers, a “desire to party,” novelty seeking, and bad parenting practices.

The authors concluded that results support the idea that there is a temporal pathway linking childhood anxiety and depression to MDMA use. Future research should focus on children with such symptoms to better understand how psychological factors play into MDMA use.

Evidence on the overall impact of low-carbohydrate diets on cardiovascular health is insufficient for making general recommendations to patients seeking weight loss advice, according to the findings of a metaanalysis.

Based on a review of five randomized controlled trials comparing low-fat and low-carb diets, Dr. Alain J. Nordmann of the Basel (Switzerland) Institute for Clinical Epidemiology and his colleagues concluded that while low-carb diets lead to greater short-term weight loss, their effect on lipid levels and other cardiovascular risk factors appeared to be mixed.

Across all studies, the 222 participants in the low-carb diet groups were permitted a carbohydrate intake of no more than 60 g/day but had no calorie restrictions. The 225 participants in the low-fat diet groups were allowed no more than 30% of daily calories from fats, and those with a body mass index of 25 kg/m

The 447 participants had a mean age range of 42–49 years. All five trials were unblinded.

At 6 months' follow-up, patients on low-carbohydrate diets had lost more weight than those on low-fat diets and were more likely to have completed the trial than were their low-fat diet counterparts (weighted mean difference −5.3 kg vs. − 1.4 kg). The investigators also noted a trend toward lower systolic and diastolic blood pressure among low-carb dieters.

In addition, compared with low-fat dieters, low-carb participants had better HDL and triglyceride levels. However, they also had less favorable total cholesterol and LDL-cholesterol values.

Differences in weight loss between the groups diminished in the three studies with 12-month follow-up (weighted mean difference −3.5 kg vs. −1.5 kg). Also, the attrition advantage for the low-carb group had become statistically insignificant, and the low-carb group's blood pressure advantage over the low-fat group was no longer detectable.

Moreover, the low-fat dieters' more favorable serum LDL and total-cholesterol profile remained favorable at the 12-month mark, as did their more favorable change in serum triglyceride, while the HDL-level advantage seen at 6 months for the low-carb group was no longer definitive at 12 months.

The authors concluded that “there is still insufficient evidence to make recommendations for or against” low-carb diets, “especially for durations longer than 6 months.” It's uncertain whether the positive effects of a low-carb diet on HDL cholesterol and triglyceride levels outweigh its less favorable effects on serum LDL cholesterol levels, they said.

Evidence on the overall impact of low-carbohydrate diets on cardiovascular health is insufficient for making general recommendations to patients seeking weight loss advice, according to the findings of a metaanalysis.

Based on a review of five randomized controlled trials comparing low-fat and low-carb diets, Dr. Alain J. Nordmann of the Basel (Switzerland) Institute for Clinical Epidemiology and his colleagues concluded that while low-carb diets lead to greater short-term weight loss, their effect on lipid levels and other cardiovascular risk factors appeared to be mixed.

Across all studies, the 222 participants in the low-carb diet groups were permitted a carbohydrate intake of no more than 60 g/day but had no calorie restrictions. The 225 participants in the low-fat diet groups were allowed no more than 30% of daily calories from fats, and those with a body mass index of 25 kg/m

The 447 participants had a mean age range of 42–49 years. All five trials were unblinded.

At 6 months' follow-up, patients on low-carbohydrate diets had lost more weight than those on low-fat diets and were more likely to have completed the trial than were their low-fat diet counterparts (weighted mean difference −5.3 kg vs. − 1.4 kg). The investigators also noted a trend toward lower systolic and diastolic blood pressure among low-carb dieters.

In addition, compared with low-fat dieters, low-carb participants had better HDL and triglyceride levels. However, they also had less favorable total cholesterol and LDL-cholesterol values.

Differences in weight loss between the groups diminished in the three studies with 12-month follow-up (weighted mean difference −3.5 kg vs. −1.5 kg). Also, the attrition advantage for the low-carb group had become statistically insignificant, and the low-carb group's blood pressure advantage over the low-fat group was no longer detectable.

Moreover, the low-fat dieters' more favorable serum LDL and total-cholesterol profile remained favorable at the 12-month mark, as did their more favorable change in serum triglyceride, while the HDL-level advantage seen at 6 months for the low-carb group was no longer definitive at 12 months.

The authors concluded that “there is still insufficient evidence to make recommendations for or against” low-carb diets, “especially for durations longer than 6 months.” It's uncertain whether the positive effects of a low-carb diet on HDL cholesterol and triglyceride levels outweigh its less favorable effects on serum LDL cholesterol levels, they said.

Evidence on the overall impact of low-carbohydrate diets on cardiovascular health is insufficient for making general recommendations to patients seeking weight loss advice, according to the findings of a metaanalysis.

Based on a review of five randomized controlled trials comparing low-fat and low-carb diets, Dr. Alain J. Nordmann of the Basel (Switzerland) Institute for Clinical Epidemiology and his colleagues concluded that while low-carb diets lead to greater short-term weight loss, their effect on lipid levels and other cardiovascular risk factors appeared to be mixed.

Across all studies, the 222 participants in the low-carb diet groups were permitted a carbohydrate intake of no more than 60 g/day but had no calorie restrictions. The 225 participants in the low-fat diet groups were allowed no more than 30% of daily calories from fats, and those with a body mass index of 25 kg/m

The 447 participants had a mean age range of 42–49 years. All five trials were unblinded.

At 6 months' follow-up, patients on low-carbohydrate diets had lost more weight than those on low-fat diets and were more likely to have completed the trial than were their low-fat diet counterparts (weighted mean difference −5.3 kg vs. − 1.4 kg). The investigators also noted a trend toward lower systolic and diastolic blood pressure among low-carb dieters.

In addition, compared with low-fat dieters, low-carb participants had better HDL and triglyceride levels. However, they also had less favorable total cholesterol and LDL-cholesterol values.

Differences in weight loss between the groups diminished in the three studies with 12-month follow-up (weighted mean difference −3.5 kg vs. −1.5 kg). Also, the attrition advantage for the low-carb group had become statistically insignificant, and the low-carb group's blood pressure advantage over the low-fat group was no longer detectable.

Moreover, the low-fat dieters' more favorable serum LDL and total-cholesterol profile remained favorable at the 12-month mark, as did their more favorable change in serum triglyceride, while the HDL-level advantage seen at 6 months for the low-carb group was no longer definitive at 12 months.

The authors concluded that “there is still insufficient evidence to make recommendations for or against” low-carb diets, “especially for durations longer than 6 months.” It's uncertain whether the positive effects of a low-carb diet on HDL cholesterol and triglyceride levels outweigh its less favorable effects on serum LDL cholesterol levels, they said.