Susan London

SEATTLE — Children prone to atopy are more likely to develop asthma if they frequently have moderate to severe respiratory illnesses in the first years of life, according to results of a prospective cohort study. Moreover, these illnesses do not protect against other atopic conditions.

Childhood respiratory illnesses cause considerable morbidity, contribute to parental absence from work, and are one of the most common causes for health care visits among the pediatric population, lead author Dr. Christine Virnig noted at the annual meeting of the American College of Allergy, Asthma, and Immunology.

“We sought to further understand the risk factors for and atopic consequences of having frequent respiratory illnesses during the first 3 years of life,” she said.

The investigators analyzed data from 277 children in the Childhood Origins of Asthma (COAST) study, which enrolled a birth cohort of infants who were at high risk for atopic conditions because at least one parent had allergies, asthma, or both.

During the children's first 3 years of life, parents completed a scorecard whenever their child had a respiratory illness to document the frequency and severity of these illnesses, said Dr. Virnig, who is an allergy and immunology fellow at the University of Wisconsin, Madison.

The children's personal, family, and environmental characteristics were assessed between birth and 6 years. Total IgE levels, levels of antigen-specific IgE to food and airborne allergens, eosinophil counts, and presence of atopic dermatitis were ascertained at 1, 3, and 6 years, and the presence of asthma was assessed at 6 years.

Scorecard results indicated that 8% of the children did not have any moderate to severe respiratory illnesses (MSIs) during the first 3 years of life, whereas 9% had frequent MSIs (12 or more), Dr. Virnig reported.

Not unexpectedly, she said, children who had MSIs frequently were significantly more likely to have attended day care in their first 6 months of life, compared with their counterparts who did not have any MSIs during those years (64% vs. 27%).

But in a finding that was very surprising, according to Dr. Virnig, children with frequent MSIs also were significantly more likely to have been exclusively breastfed for the first 6 months of life (52% vs. 18%).

This association remained significant when the number of MSIs was analyzed as a continuous variable, but the ranges of values overlapped considerably. “Therefore, the clinical significance of this finding is very uncertain,” Dr. Virnig commented, adding that it would not justify altering recommendations to breastfeed.

Children with frequent MSIs also were marginally more likely to have a mother who had asthma. A variety of other factors—sex, birth weight, presence of an older sibling, smoke exposure, a cat or dog in the home at birth, and paternal asthma—did not differ between groups.

The prevalence of asthma at age 6 was significantly higher among children having frequent MSIs relative to children having none of them (59% vs. 9%). This association also remained significant when the number of illnesses was analyzed as a continuous variable, although the ranges of values again overlapped.

There was no significant difference between the two groups in terms of other indicators of atopy—atopic dermatitis, the presence of food-specific IgE, or the presence of aeroallergen-specific IgE—or eosinophil counts at any of the ages studied.

Dr. Virnig acknowledged that the study's findings appear to be at odds with the hygiene hypothesis, which proposes that early infectious illnesses protect against subsequent allergic conditions. However, she noted, evidence supporting this hypothesis has generally been strongest for gastrointestinal illnesses, while several studies have in fact found an opposite pattern when it comes to respiratory illnesses, particularly those of the lower respiratory tract.

Dr. Virnig stated that she had no conflicts of interest relevant to the study.

SEATTLE — Children prone to atopy are more likely to develop asthma if they frequently have moderate to severe respiratory illnesses in the first years of life, according to results of a prospective cohort study. Moreover, these illnesses do not protect against other atopic conditions.

Childhood respiratory illnesses cause considerable morbidity, contribute to parental absence from work, and are one of the most common causes for health care visits among the pediatric population, lead author Dr. Christine Virnig noted at the annual meeting of the American College of Allergy, Asthma, and Immunology.

“We sought to further understand the risk factors for and atopic consequences of having frequent respiratory illnesses during the first 3 years of life,” she said.

The investigators analyzed data from 277 children in the Childhood Origins of Asthma (COAST) study, which enrolled a birth cohort of infants who were at high risk for atopic conditions because at least one parent had allergies, asthma, or both.

During the children's first 3 years of life, parents completed a scorecard whenever their child had a respiratory illness to document the frequency and severity of these illnesses, said Dr. Virnig, who is an allergy and immunology fellow at the University of Wisconsin, Madison.

The children's personal, family, and environmental characteristics were assessed between birth and 6 years. Total IgE levels, levels of antigen-specific IgE to food and airborne allergens, eosinophil counts, and presence of atopic dermatitis were ascertained at 1, 3, and 6 years, and the presence of asthma was assessed at 6 years.

Scorecard results indicated that 8% of the children did not have any moderate to severe respiratory illnesses (MSIs) during the first 3 years of life, whereas 9% had frequent MSIs (12 or more), Dr. Virnig reported.

Not unexpectedly, she said, children who had MSIs frequently were significantly more likely to have attended day care in their first 6 months of life, compared with their counterparts who did not have any MSIs during those years (64% vs. 27%).

But in a finding that was very surprising, according to Dr. Virnig, children with frequent MSIs also were significantly more likely to have been exclusively breastfed for the first 6 months of life (52% vs. 18%).

This association remained significant when the number of MSIs was analyzed as a continuous variable, but the ranges of values overlapped considerably. “Therefore, the clinical significance of this finding is very uncertain,” Dr. Virnig commented, adding that it would not justify altering recommendations to breastfeed.

Children with frequent MSIs also were marginally more likely to have a mother who had asthma. A variety of other factors—sex, birth weight, presence of an older sibling, smoke exposure, a cat or dog in the home at birth, and paternal asthma—did not differ between groups.

The prevalence of asthma at age 6 was significantly higher among children having frequent MSIs relative to children having none of them (59% vs. 9%). This association also remained significant when the number of illnesses was analyzed as a continuous variable, although the ranges of values again overlapped.

There was no significant difference between the two groups in terms of other indicators of atopy—atopic dermatitis, the presence of food-specific IgE, or the presence of aeroallergen-specific IgE—or eosinophil counts at any of the ages studied.

Dr. Virnig acknowledged that the study's findings appear to be at odds with the hygiene hypothesis, which proposes that early infectious illnesses protect against subsequent allergic conditions. However, she noted, evidence supporting this hypothesis has generally been strongest for gastrointestinal illnesses, while several studies have in fact found an opposite pattern when it comes to respiratory illnesses, particularly those of the lower respiratory tract.

Dr. Virnig stated that she had no conflicts of interest relevant to the study.

SEATTLE — Children prone to atopy are more likely to develop asthma if they frequently have moderate to severe respiratory illnesses in the first years of life, according to results of a prospective cohort study. Moreover, these illnesses do not protect against other atopic conditions.

Childhood respiratory illnesses cause considerable morbidity, contribute to parental absence from work, and are one of the most common causes for health care visits among the pediatric population, lead author Dr. Christine Virnig noted at the annual meeting of the American College of Allergy, Asthma, and Immunology.

“We sought to further understand the risk factors for and atopic consequences of having frequent respiratory illnesses during the first 3 years of life,” she said.

The investigators analyzed data from 277 children in the Childhood Origins of Asthma (COAST) study, which enrolled a birth cohort of infants who were at high risk for atopic conditions because at least one parent had allergies, asthma, or both.

During the children's first 3 years of life, parents completed a scorecard whenever their child had a respiratory illness to document the frequency and severity of these illnesses, said Dr. Virnig, who is an allergy and immunology fellow at the University of Wisconsin, Madison.

The children's personal, family, and environmental characteristics were assessed between birth and 6 years. Total IgE levels, levels of antigen-specific IgE to food and airborne allergens, eosinophil counts, and presence of atopic dermatitis were ascertained at 1, 3, and 6 years, and the presence of asthma was assessed at 6 years.

Scorecard results indicated that 8% of the children did not have any moderate to severe respiratory illnesses (MSIs) during the first 3 years of life, whereas 9% had frequent MSIs (12 or more), Dr. Virnig reported.

Not unexpectedly, she said, children who had MSIs frequently were significantly more likely to have attended day care in their first 6 months of life, compared with their counterparts who did not have any MSIs during those years (64% vs. 27%).

But in a finding that was very surprising, according to Dr. Virnig, children with frequent MSIs also were significantly more likely to have been exclusively breastfed for the first 6 months of life (52% vs. 18%).

This association remained significant when the number of MSIs was analyzed as a continuous variable, but the ranges of values overlapped considerably. “Therefore, the clinical significance of this finding is very uncertain,” Dr. Virnig commented, adding that it would not justify altering recommendations to breastfeed.

Children with frequent MSIs also were marginally more likely to have a mother who had asthma. A variety of other factors—sex, birth weight, presence of an older sibling, smoke exposure, a cat or dog in the home at birth, and paternal asthma—did not differ between groups.

The prevalence of asthma at age 6 was significantly higher among children having frequent MSIs relative to children having none of them (59% vs. 9%). This association also remained significant when the number of illnesses was analyzed as a continuous variable, although the ranges of values again overlapped.

There was no significant difference between the two groups in terms of other indicators of atopy—atopic dermatitis, the presence of food-specific IgE, or the presence of aeroallergen-specific IgE—or eosinophil counts at any of the ages studied.

Dr. Virnig acknowledged that the study's findings appear to be at odds with the hygiene hypothesis, which proposes that early infectious illnesses protect against subsequent allergic conditions. However, she noted, evidence supporting this hypothesis has generally been strongest for gastrointestinal illnesses, while several studies have in fact found an opposite pattern when it comes to respiratory illnesses, particularly those of the lower respiratory tract.

Dr. Virnig stated that she had no conflicts of interest relevant to the study.

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit, according to results of a study of 93 children and their parents.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination among children with asthma and reasons for receipt and nonreceipt of the vaccine, the investigators conducted a clinic-based study in the fall of 2004.

“During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. Given media coverage of the shortage and the resulting increased public awareness, Dr. Reddy and her colleagues hypothesized that vaccination rates would be high.

Study participants were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating.

Asthma was rated as mild in 55% and as moderate or severe in 45%.

Sixty-seven percent of the children received the flu vaccine. The leading reason that parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine on an annual basis (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

On the other hand, the leading reason parents gave for not vaccinating their children was lack of benefit of the vaccine, cited by 32%, which Dr. Reddy commented was surprising.

Other reasons included a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend vaccination (3%). (In all, 5% of the parents did not respond to this question.)

In terms of perceived benefits of the flu vaccine, 48% of parents overall believed that it prevented influenza illness, and 47% believed that it helped control asthma.

Among children who received the vaccine, the most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

The majority of parents (61%) said that their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

The investigators concluded that physicians remain the best source of information on the flu vaccine for most patients and should discuss the topic with patients at every opportunity for vaccination.

Dr. Reddy reported that she had no conflicts of interest in association with the study.

The leading reason parents gave for having their children vaccinated was recommendation by a physician. DR. REDDY

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit, according to results of a study of 93 children and their parents.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination among children with asthma and reasons for receipt and nonreceipt of the vaccine, the investigators conducted a clinic-based study in the fall of 2004.

“During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. Given media coverage of the shortage and the resulting increased public awareness, Dr. Reddy and her colleagues hypothesized that vaccination rates would be high.

Study participants were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating.

Asthma was rated as mild in 55% and as moderate or severe in 45%.

Sixty-seven percent of the children received the flu vaccine. The leading reason that parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine on an annual basis (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

On the other hand, the leading reason parents gave for not vaccinating their children was lack of benefit of the vaccine, cited by 32%, which Dr. Reddy commented was surprising.

Other reasons included a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend vaccination (3%). (In all, 5% of the parents did not respond to this question.)

In terms of perceived benefits of the flu vaccine, 48% of parents overall believed that it prevented influenza illness, and 47% believed that it helped control asthma.

Among children who received the vaccine, the most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

The majority of parents (61%) said that their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

The investigators concluded that physicians remain the best source of information on the flu vaccine for most patients and should discuss the topic with patients at every opportunity for vaccination.

Dr. Reddy reported that she had no conflicts of interest in association with the study.

The leading reason parents gave for having their children vaccinated was recommendation by a physician. DR. REDDY

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit, according to results of a study of 93 children and their parents.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination among children with asthma and reasons for receipt and nonreceipt of the vaccine, the investigators conducted a clinic-based study in the fall of 2004.

“During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. Given media coverage of the shortage and the resulting increased public awareness, Dr. Reddy and her colleagues hypothesized that vaccination rates would be high.

Study participants were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating.

Asthma was rated as mild in 55% and as moderate or severe in 45%.

Sixty-seven percent of the children received the flu vaccine. The leading reason that parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine on an annual basis (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

On the other hand, the leading reason parents gave for not vaccinating their children was lack of benefit of the vaccine, cited by 32%, which Dr. Reddy commented was surprising.

Other reasons included a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend vaccination (3%). (In all, 5% of the parents did not respond to this question.)

In terms of perceived benefits of the flu vaccine, 48% of parents overall believed that it prevented influenza illness, and 47% believed that it helped control asthma.

Among children who received the vaccine, the most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

The majority of parents (61%) said that their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

The investigators concluded that physicians remain the best source of information on the flu vaccine for most patients and should discuss the topic with patients at every opportunity for vaccination.

Dr. Reddy reported that she had no conflicts of interest in association with the study.

The leading reason parents gave for having their children vaccinated was recommendation by a physician. DR. REDDY

SEATTLE — Treating gastroesophageal reflux disease in children with persistent asthma improves lung function in the long term, new data show. Moreover, medical and surgical treatments appear to work equally well.

About two-thirds of nonatopic children with persistent asthma also have gastroesophageal reflux disease (GERD), and that disease appears to exacerbate the asthma, Dr. Aaron K. Kobernick said at the annual meeting of the American College of Allergy, Asthma, and Immunology. Studies of GERD treatment in this context have focused on asthma medication use and have been relatively short.

“With asthma, short-term studies are not as reliable,” said Dr. Kobernick. “Because [it] is a disease of exacerbation and remission, the longer we look at asthma and [its] outcomes, the better.”

In a prospective 2-year study, Dr. Kobernick and his colleagues enrolled 62 children aged between 6 and 11 years and who had moderate persistent asthma but did not have atopy or risk factors for wheezing. At baseline, all of the children underwent spirometry and extended esophageal pH monitoring. The latter testing revealed that most also had GERD.

Of those with asthma and GERD, 32 were treated with medical therapy for GERD consisting of proton pump inhibitors and prokinetic agents and 12 underwent surgical fundoplication; they also received asthma therapy. The 18 children who did not have comorbid GERD received asthma therapy only.

The three groups were similar with respect to age, sex, socioeconomic status, duration of illness, and initial spirometry findings, noted Dr. Kobernick, a medicine and pediatrics resident at Tulane University in New Orleans.

After 2 years of treatment, the average annual number of asthma exacerbations per child was significantly lower, by about 75%, in those with medically treated GERD (0.68) and those with surgically treated GERD (0.79), compared with their GERD-free counterparts treated for asthma alone (2.9). The difference between the medically and surgically treated GERD groups was not significant.

The percentage of children who had an improvement in forced expiratory volume in 1 second (FEV1) by more than 20% from baseline was significantly greater in the groups given medical GERD treatment (47%) and surgical GERD treatment (58%), compared with the group given asthma therapy alone (28%).

The percentage of children with an improvement in forced expiratory flow in mid-expiration (FEF25%-75%) of more than 20% from baseline was significantly greater with added medical GERD therapy (22%) and surgical GERD therapy (25%), versus asthma therapy alone (11%).

Dr. Kobernick said anatomy may explain why more children had an improvement in FEV1 (indicating large-airway function) than they did in FEF25%-75% (indicating small-airway function) with anti-GERD treatment. “Maybe the large airways… are most likely exposed to the onslaught of acid from the reflux, and those just tend to improve more quickly with anti-GERD treatment,” he said.

Spirometry testing done after only 1 year of treatment did not show any significant improvement in FEV1, he noted. That, combined with the apparent slower improvement of FEF25%-75%, reinforces the importance of long-term studies.

The results may underestimate the benefit of anti-GERD treatment because many children had been previously treated for asthma. “The average time a patient was treated for asthma before enrollment was about 11/2-2 years, so we think their lungs probably started looking a lot better before they enrolled,” said Dr. Kobernick, who reported no conflicts of interest related to the study.

Large airways are exposed to the reflux acid, and they tend to respond more quickly with anti-GERD treatment. DR. KOBERNICK

SEATTLE — Treating gastroesophageal reflux disease in children with persistent asthma improves lung function in the long term, new data show. Moreover, medical and surgical treatments appear to work equally well.

About two-thirds of nonatopic children with persistent asthma also have gastroesophageal reflux disease (GERD), and that disease appears to exacerbate the asthma, Dr. Aaron K. Kobernick said at the annual meeting of the American College of Allergy, Asthma, and Immunology. Studies of GERD treatment in this context have focused on asthma medication use and have been relatively short.

“With asthma, short-term studies are not as reliable,” said Dr. Kobernick. “Because [it] is a disease of exacerbation and remission, the longer we look at asthma and [its] outcomes, the better.”

In a prospective 2-year study, Dr. Kobernick and his colleagues enrolled 62 children aged between 6 and 11 years and who had moderate persistent asthma but did not have atopy or risk factors for wheezing. At baseline, all of the children underwent spirometry and extended esophageal pH monitoring. The latter testing revealed that most also had GERD.

Of those with asthma and GERD, 32 were treated with medical therapy for GERD consisting of proton pump inhibitors and prokinetic agents and 12 underwent surgical fundoplication; they also received asthma therapy. The 18 children who did not have comorbid GERD received asthma therapy only.

The three groups were similar with respect to age, sex, socioeconomic status, duration of illness, and initial spirometry findings, noted Dr. Kobernick, a medicine and pediatrics resident at Tulane University in New Orleans.

After 2 years of treatment, the average annual number of asthma exacerbations per child was significantly lower, by about 75%, in those with medically treated GERD (0.68) and those with surgically treated GERD (0.79), compared with their GERD-free counterparts treated for asthma alone (2.9). The difference between the medically and surgically treated GERD groups was not significant.

The percentage of children who had an improvement in forced expiratory volume in 1 second (FEV1) by more than 20% from baseline was significantly greater in the groups given medical GERD treatment (47%) and surgical GERD treatment (58%), compared with the group given asthma therapy alone (28%).

The percentage of children with an improvement in forced expiratory flow in mid-expiration (FEF25%-75%) of more than 20% from baseline was significantly greater with added medical GERD therapy (22%) and surgical GERD therapy (25%), versus asthma therapy alone (11%).

Dr. Kobernick said anatomy may explain why more children had an improvement in FEV1 (indicating large-airway function) than they did in FEF25%-75% (indicating small-airway function) with anti-GERD treatment. “Maybe the large airways… are most likely exposed to the onslaught of acid from the reflux, and those just tend to improve more quickly with anti-GERD treatment,” he said.

Spirometry testing done after only 1 year of treatment did not show any significant improvement in FEV1, he noted. That, combined with the apparent slower improvement of FEF25%-75%, reinforces the importance of long-term studies.

The results may underestimate the benefit of anti-GERD treatment because many children had been previously treated for asthma. “The average time a patient was treated for asthma before enrollment was about 11/2-2 years, so we think their lungs probably started looking a lot better before they enrolled,” said Dr. Kobernick, who reported no conflicts of interest related to the study.

Large airways are exposed to the reflux acid, and they tend to respond more quickly with anti-GERD treatment. DR. KOBERNICK

SEATTLE — Treating gastroesophageal reflux disease in children with persistent asthma improves lung function in the long term, new data show. Moreover, medical and surgical treatments appear to work equally well.

About two-thirds of nonatopic children with persistent asthma also have gastroesophageal reflux disease (GERD), and that disease appears to exacerbate the asthma, Dr. Aaron K. Kobernick said at the annual meeting of the American College of Allergy, Asthma, and Immunology. Studies of GERD treatment in this context have focused on asthma medication use and have been relatively short.

“With asthma, short-term studies are not as reliable,” said Dr. Kobernick. “Because [it] is a disease of exacerbation and remission, the longer we look at asthma and [its] outcomes, the better.”

In a prospective 2-year study, Dr. Kobernick and his colleagues enrolled 62 children aged between 6 and 11 years and who had moderate persistent asthma but did not have atopy or risk factors for wheezing. At baseline, all of the children underwent spirometry and extended esophageal pH monitoring. The latter testing revealed that most also had GERD.

Of those with asthma and GERD, 32 were treated with medical therapy for GERD consisting of proton pump inhibitors and prokinetic agents and 12 underwent surgical fundoplication; they also received asthma therapy. The 18 children who did not have comorbid GERD received asthma therapy only.

The three groups were similar with respect to age, sex, socioeconomic status, duration of illness, and initial spirometry findings, noted Dr. Kobernick, a medicine and pediatrics resident at Tulane University in New Orleans.

After 2 years of treatment, the average annual number of asthma exacerbations per child was significantly lower, by about 75%, in those with medically treated GERD (0.68) and those with surgically treated GERD (0.79), compared with their GERD-free counterparts treated for asthma alone (2.9). The difference between the medically and surgically treated GERD groups was not significant.

The percentage of children who had an improvement in forced expiratory volume in 1 second (FEV1) by more than 20% from baseline was significantly greater in the groups given medical GERD treatment (47%) and surgical GERD treatment (58%), compared with the group given asthma therapy alone (28%).

The percentage of children with an improvement in forced expiratory flow in mid-expiration (FEF25%-75%) of more than 20% from baseline was significantly greater with added medical GERD therapy (22%) and surgical GERD therapy (25%), versus asthma therapy alone (11%).

Dr. Kobernick said anatomy may explain why more children had an improvement in FEV1 (indicating large-airway function) than they did in FEF25%-75% (indicating small-airway function) with anti-GERD treatment. “Maybe the large airways… are most likely exposed to the onslaught of acid from the reflux, and those just tend to improve more quickly with anti-GERD treatment,” he said.

Spirometry testing done after only 1 year of treatment did not show any significant improvement in FEV1, he noted. That, combined with the apparent slower improvement of FEF25%-75%, reinforces the importance of long-term studies.

The results may underestimate the benefit of anti-GERD treatment because many children had been previously treated for asthma. “The average time a patient was treated for asthma before enrollment was about 11/2-2 years, so we think their lungs probably started looking a lot better before they enrolled,” said Dr. Kobernick, who reported no conflicts of interest related to the study.

Large airways are exposed to the reflux acid, and they tend to respond more quickly with anti-GERD treatment. DR. KOBERNICK

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.

SEATTLE – Defendants who are incompetent to stand trial are less likely to be restored to competence with treatment if they are older or have dementia, according to study results reported at the annual meeting of the American Academy of Psychiatry and the Law. Still, roughly half of them achieve this goal.

The U.S. Supreme Court has ruled that defendants thought to be permanently incompetent to stand trial or unlikely to be restored in the foreseeable future must either be released or evaluated for civil commitment, Dr. Douglas R. Morris noted in an interview. But it remains difficult for treating psychiatrists to predict which incompetent defendants have little probability of restoration.

Dr. Morris and his colleagues searched the Indiana forensic database for 1988–2004 to identify defendants hospitalized for treatment to restore competency to stand trial. They ascertained whether the defendants were restored to competence after 6 months (the state's statutory standard) and 1 year (the standard used in other states and published reports) and the clinical factors associated with restoration.

They identified 1,380 incompetent defendants. Some 3% had dementia, 2% were older (at least 65 years) and did not have dementia, and 95% had other diagnoses or reasons for admission.

About one-third of patients in the dementia group had Alzheimer's disease, one-third had dementia not otherwise specified, and the remaining third had dementia because of vascular causes or substance use, said Dr. Morris, a psychiatrist at the University of South Carolina, Columbia. Overall, about one-quarter had comorbid psychotic disorders.

Mean age differed significantly across groups: It was 50 years in the dementia group, 72 years in the older group without dementia, and 35 years in the group with other diagnoses. More than 85% of the defendants were male, with no difference across groups. Those with dementia were significantly more likely to be white than were their counterparts with other diagnoses (72% vs. 57%).

After 6 months of treatment, the percentage of defendants who remained incompetent to stand trial was significantly higher in the dementia group (49%) and the older group (55%) than in the other-diagnoses group (26%), Dr. Morris said. The finding was similar after 1 year of treatment (36% and 32% vs. 15%).

In a multivariate analysis adjusted for potential confounders (sex, race, treating hospital, psychotic disorder, mood disorder, and mental retardation), defendants with dementia were significantly less likely than were those with other diagnoses to be restored at 6 months (odds ratio 0.63) and at 1 year (OR 0.58).

The older defendants were on admission, the less likely they were to be restored to competence after adjustment for the above factors and dementia. The odds of restoration at 6 months were reduced by about 10% with a 5-year increment in age (OR 0.88) and by more than 50% with a 30-year increment (OR 0.46). Again, the findings were similar for restoration by 1 year (OR 0.85 and 0.36).

Dr. Morris said the link between older age and a decreased chance of restoration could be attributable to the impact of chronic mental illnesses, medical comorbidities, or both on cognitive function.

The link between dementia and reduced odds of restoration was not unexpected, he said, but it was noteworthy that almost half of demented defendants were restored to competence. Planned research might show which treatments and factors led to restoration in this group. In the end, “[prediction] will have to be done on a case-by-case basis–it will depend on the individual s specific deficits,” he said.

Dr. Morris reported no conflicts of interest in association with the study.

SEATTLE – Certain symptoms that are present up to month in advance herald psychosis-motivated assaults by psychiatric inpatients, according to a study reported at the annual meeting of the American Academy of Psychiatry and the Law.

Research on assaults by inpatients has focused on static factors and has not differentiated among assaults based on their motivation, lead author Dr. Cameron D. Quanbeck, a psychiatrist at the University of California, Davis, said in an interview.

In the retrospective study, he and his colleagues sought to identify dynamic factors–transient symptoms, behaviors, and situations–that predicted assaults specifically motivated by psychosis.

The investigators assessed the presence of symptom clusters among 26 long-term psychiatric inpatients at the Napa (Calif.) State Hospital (the state's largest forensic hospital) who had schizophrenia or major psychotic disorder, and had assaulted another patient or a staff member.

Nurses' notes were reviewed for the 6-month preassault period and a 6-month historical control period during which the patient had been clinically stable.

The symptom clusters assessed were psychomotor agitation; hostility/angry affect; staff intervention (e.g., seclusion, restraint); paranoid delusions; verbal aggression/attacks on objects; disinhibited, impulsive behaviors; internal preoccupation; anxiety; and depressed, isolative behavior.

Results showed that all nine symptom clusters were significantly more common in the preassault period than in the control period (odds ratios, 2.9–6.9), Dr. Quanbeck reported.

Within the preassault period, six of the clusters were more common in the month before the assault, compared with the preceding 5 months.

Specifically, patients were two to three times more likely to have psychomotor agitation (odds ratio, 1.8); hostility/angry affect (1.7); paranoid delusions (2.3); verbal aggression/attacks on objects (2.7); disinhibited, impulsive behavior (2.6); and the need for staff intervention (3.2) during this month.

Some of these symptoms became even more common and a new symptom (internal preoccupation) appeared as the assault grew yet closer, Dr. Quanbeck noted.

Patients were two to five times more likely to have psychomotor agitation (odds ratio, 3.2), hostility/angry affect (3.2), and internal preoccupation (3.2), and to need staff intervention (5.6) during the last week before the assault, compared with the preceding 3 weeks.

An additional study finding was that none of the patients were taking clozapine (Clozaril) in the preassault period, compared with 40% in the control period. “This suggests that Clozaril is a very effective medication for controlling aggression and the symptoms of psychosis,” Dr. Quanbeck said. The drug has some serious adverse effects, he acknowledged, but they may be an acceptable tradeoff for preventing violence.

The study's findings add to previous research on predicting violence among inpatients, most of which has focused on the day before an assault occurs, Dr. Quanbeck said. “This gives you a longer time frame in which to clinically intervene,” he explained.

In light of the complexity of human behavior, patterns of symptoms are likely more useful than individual ones in predicting assaults, he commented.

“Monitor these patients. Look for this pattern of symptoms that shows up (early),” he recommended. And if patients do become more symptomatic, reevaluate their medications and consider possible interventions (a medication revision, psychotherapy, and stepped-up observation).

“If you can intervene in the preassault period, maybe the assault will not happen,” he concluded.

Dr. Quanbeck reported that he had no conflicts of interest in association with the study.

SEATTLE – Certain symptoms that are present up to month in advance herald psychosis-motivated assaults by psychiatric inpatients, according to a study reported at the annual meeting of the American Academy of Psychiatry and the Law.

Research on assaults by inpatients has focused on static factors and has not differentiated among assaults based on their motivation, lead author Dr. Cameron D. Quanbeck, a psychiatrist at the University of California, Davis, said in an interview.

In the retrospective study, he and his colleagues sought to identify dynamic factors–transient symptoms, behaviors, and situations–that predicted assaults specifically motivated by psychosis.

The investigators assessed the presence of symptom clusters among 26 long-term psychiatric inpatients at the Napa (Calif.) State Hospital (the state's largest forensic hospital) who had schizophrenia or major psychotic disorder, and had assaulted another patient or a staff member.

Nurses' notes were reviewed for the 6-month preassault period and a 6-month historical control period during which the patient had been clinically stable.

The symptom clusters assessed were psychomotor agitation; hostility/angry affect; staff intervention (e.g., seclusion, restraint); paranoid delusions; verbal aggression/attacks on objects; disinhibited, impulsive behaviors; internal preoccupation; anxiety; and depressed, isolative behavior.

Results showed that all nine symptom clusters were significantly more common in the preassault period than in the control period (odds ratios, 2.9–6.9), Dr. Quanbeck reported.

Within the preassault period, six of the clusters were more common in the month before the assault, compared with the preceding 5 months.

Specifically, patients were two to three times more likely to have psychomotor agitation (odds ratio, 1.8); hostility/angry affect (1.7); paranoid delusions (2.3); verbal aggression/attacks on objects (2.7); disinhibited, impulsive behavior (2.6); and the need for staff intervention (3.2) during this month.

Some of these symptoms became even more common and a new symptom (internal preoccupation) appeared as the assault grew yet closer, Dr. Quanbeck noted.

Patients were two to five times more likely to have psychomotor agitation (odds ratio, 3.2), hostility/angry affect (3.2), and internal preoccupation (3.2), and to need staff intervention (5.6) during the last week before the assault, compared with the preceding 3 weeks.

An additional study finding was that none of the patients were taking clozapine (Clozaril) in the preassault period, compared with 40% in the control period. “This suggests that Clozaril is a very effective medication for controlling aggression and the symptoms of psychosis,” Dr. Quanbeck said. The drug has some serious adverse effects, he acknowledged, but they may be an acceptable tradeoff for preventing violence.

The study's findings add to previous research on predicting violence among inpatients, most of which has focused on the day before an assault occurs, Dr. Quanbeck said. “This gives you a longer time frame in which to clinically intervene,” he explained.

In light of the complexity of human behavior, patterns of symptoms are likely more useful than individual ones in predicting assaults, he commented.

“Monitor these patients. Look for this pattern of symptoms that shows up (early),” he recommended. And if patients do become more symptomatic, reevaluate their medications and consider possible interventions (a medication revision, psychotherapy, and stepped-up observation).

“If you can intervene in the preassault period, maybe the assault will not happen,” he concluded.

Dr. Quanbeck reported that he had no conflicts of interest in association with the study.

SEATTLE – Certain symptoms that are present up to month in advance herald psychosis-motivated assaults by psychiatric inpatients, according to a study reported at the annual meeting of the American Academy of Psychiatry and the Law.

Research on assaults by inpatients has focused on static factors and has not differentiated among assaults based on their motivation, lead author Dr. Cameron D. Quanbeck, a psychiatrist at the University of California, Davis, said in an interview.

In the retrospective study, he and his colleagues sought to identify dynamic factors–transient symptoms, behaviors, and situations–that predicted assaults specifically motivated by psychosis.

The investigators assessed the presence of symptom clusters among 26 long-term psychiatric inpatients at the Napa (Calif.) State Hospital (the state's largest forensic hospital) who had schizophrenia or major psychotic disorder, and had assaulted another patient or a staff member.

Nurses' notes were reviewed for the 6-month preassault period and a 6-month historical control period during which the patient had been clinically stable.

The symptom clusters assessed were psychomotor agitation; hostility/angry affect; staff intervention (e.g., seclusion, restraint); paranoid delusions; verbal aggression/attacks on objects; disinhibited, impulsive behaviors; internal preoccupation; anxiety; and depressed, isolative behavior.

Results showed that all nine symptom clusters were significantly more common in the preassault period than in the control period (odds ratios, 2.9–6.9), Dr. Quanbeck reported.

Within the preassault period, six of the clusters were more common in the month before the assault, compared with the preceding 5 months.

Specifically, patients were two to three times more likely to have psychomotor agitation (odds ratio, 1.8); hostility/angry affect (1.7); paranoid delusions (2.3); verbal aggression/attacks on objects (2.7); disinhibited, impulsive behavior (2.6); and the need for staff intervention (3.2) during this month.

Some of these symptoms became even more common and a new symptom (internal preoccupation) appeared as the assault grew yet closer, Dr. Quanbeck noted.

Patients were two to five times more likely to have psychomotor agitation (odds ratio, 3.2), hostility/angry affect (3.2), and internal preoccupation (3.2), and to need staff intervention (5.6) during the last week before the assault, compared with the preceding 3 weeks.

An additional study finding was that none of the patients were taking clozapine (Clozaril) in the preassault period, compared with 40% in the control period. “This suggests that Clozaril is a very effective medication for controlling aggression and the symptoms of psychosis,” Dr. Quanbeck said. The drug has some serious adverse effects, he acknowledged, but they may be an acceptable tradeoff for preventing violence.

The study's findings add to previous research on predicting violence among inpatients, most of which has focused on the day before an assault occurs, Dr. Quanbeck said. “This gives you a longer time frame in which to clinically intervene,” he explained.

In light of the complexity of human behavior, patterns of symptoms are likely more useful than individual ones in predicting assaults, he commented.

“Monitor these patients. Look for this pattern of symptoms that shows up (early),” he recommended. And if patients do become more symptomatic, reevaluate their medications and consider possible interventions (a medication revision, psychotherapy, and stepped-up observation).

“If you can intervene in the preassault period, maybe the assault will not happen,” he concluded.

Dr. Quanbeck reported that he had no conflicts of interest in association with the study.

VANCOUVER, B.C. — The best approach to managing neuropathic pain is to treat it early, when it is most likely to respond, according to Dr. Rob Hewko, a psychiatrist at Vancouver (B.C.) General Hospital.

“Neuropathic pain is common and extremely incapacitating,” said Dr. Hewko at the annual Canadian Hospitalist Conference. About 5%–10% of people will develop the condition in their lifetime.

And although this type of pain is classically associated with postherpetic neuralgia and diabetic neuropathy, it can arise from a diverse group of other illnesses and events, such as gallbladder and cardiac surgery, lupus, and chemotherapy.

Neuropathic pain has a complex pathogenesis that involves several mechanisms, he said at the conference, which was sponsored by the University of British Columbia. These include sensitization of peripheral nerves, activation of the dorsal horn nuclei in the spinal cord, and changes in descending inhibition from the brain.

Diagnosis can be challenging, for a variety of reasons: the diverse symptomatology, the numerous etiologies, patients' difficulty in articulating their symptoms, and the variable response to treatment.

A number of tools are available to help with diagnosis and assessment. “I would suggest that you choose one of these and use it exclusively, unless you have unlimited time,” Dr. Hewko advised. In cases in which the diagnosis is uncertain, he recommended the DN4 pain questionnaire (Pain 2005;114:29–36), which can be completed in about 10 minutes.

The best management of chronic neuropathic pain is effective management of acute neuropathic pain, Dr. Hewko said.

Most patients with acute neuropathic pain “will get better over time, so that's your backup position—do nothing and hope they get better,” he said. “But there's a downside to that, which is the longer you wait, the less likely they are to respond to treatment.”

Medication strategies can exploit the nature of neuropathic pain, by using agents with differing actions to target the different mechanisms and to potentiate each other. First-line agents include two of the tricyclic antidepressants (nortriptyline and desipramine), gabapentin, and pregabalin.

Opioids should not be used as first-line agents because patients rapidly develop tolerance to them in this setting, according to Dr. Hewko. And amitriptyline should not be used at all because of its many adverse effects.

National pain societies generally recommend a single-agent approach to the initial pharmacotherapy for neuropathic pain. However, he noted, “the likelihood of an excellent response to a single agent is really low in my experience.”

He therefore recommended combining two first-line agents—a tricyclic antidepressant plus either gabapentin or pregabalin—as initial therapy. The drugs should be started at low dosages and titrated every 24–48 hours.

This approach has the advantage of producing rapid relief. Fully 90%–95% of patients with acute neuropathic pain have a response within several days.

Third-line agents, such as opioids, cannabinoids, and topiramate, should be selected with consideration of the mechanism they target so that they complement other agents being used.

Among the opioids, which are more effective against peripheral than against central neuropathic pain, “methadone is the best option because it is the only narcotic that has an [N-methyl-D-aspartate] antagonistic effect,” he observed.

Measures such as cognitive-behavioral therapy and spinal cord stimulation can be useful when pain persists despite medical therapy.

Dr. Hewko is a member of a medical advisory board for Pfizer Canada.

'The longer you wait, the less likely [patients with neuropathic pain] are to respond to treatment.' DR. HEWKO

VANCOUVER, B.C. — The best approach to managing neuropathic pain is to treat it early, when it is most likely to respond, according to Dr. Rob Hewko, a psychiatrist at Vancouver (B.C.) General Hospital.

“Neuropathic pain is common and extremely incapacitating,” said Dr. Hewko at the annual Canadian Hospitalist Conference. About 5%–10% of people will develop the condition in their lifetime.

And although this type of pain is classically associated with postherpetic neuralgia and diabetic neuropathy, it can arise from a diverse group of other illnesses and events, such as gallbladder and cardiac surgery, lupus, and chemotherapy.

Neuropathic pain has a complex pathogenesis that involves several mechanisms, he said at the conference, which was sponsored by the University of British Columbia. These include sensitization of peripheral nerves, activation of the dorsal horn nuclei in the spinal cord, and changes in descending inhibition from the brain.

Diagnosis can be challenging, for a variety of reasons: the diverse symptomatology, the numerous etiologies, patients' difficulty in articulating their symptoms, and the variable response to treatment.

A number of tools are available to help with diagnosis and assessment. “I would suggest that you choose one of these and use it exclusively, unless you have unlimited time,” Dr. Hewko advised. In cases in which the diagnosis is uncertain, he recommended the DN4 pain questionnaire (Pain 2005;114:29–36), which can be completed in about 10 minutes.

The best management of chronic neuropathic pain is effective management of acute neuropathic pain, Dr. Hewko said.

Most patients with acute neuropathic pain “will get better over time, so that's your backup position—do nothing and hope they get better,” he said. “But there's a downside to that, which is the longer you wait, the less likely they are to respond to treatment.”

Medication strategies can exploit the nature of neuropathic pain, by using agents with differing actions to target the different mechanisms and to potentiate each other. First-line agents include two of the tricyclic antidepressants (nortriptyline and desipramine), gabapentin, and pregabalin.

Opioids should not be used as first-line agents because patients rapidly develop tolerance to them in this setting, according to Dr. Hewko. And amitriptyline should not be used at all because of its many adverse effects.

National pain societies generally recommend a single-agent approach to the initial pharmacotherapy for neuropathic pain. However, he noted, “the likelihood of an excellent response to a single agent is really low in my experience.”

He therefore recommended combining two first-line agents—a tricyclic antidepressant plus either gabapentin or pregabalin—as initial therapy. The drugs should be started at low dosages and titrated every 24–48 hours.

This approach has the advantage of producing rapid relief. Fully 90%–95% of patients with acute neuropathic pain have a response within several days.

Third-line agents, such as opioids, cannabinoids, and topiramate, should be selected with consideration of the mechanism they target so that they complement other agents being used.

Among the opioids, which are more effective against peripheral than against central neuropathic pain, “methadone is the best option because it is the only narcotic that has an [N-methyl-D-aspartate] antagonistic effect,” he observed.

Measures such as cognitive-behavioral therapy and spinal cord stimulation can be useful when pain persists despite medical therapy.

Dr. Hewko is a member of a medical advisory board for Pfizer Canada.

'The longer you wait, the less likely [patients with neuropathic pain] are to respond to treatment.' DR. HEWKO

VANCOUVER, B.C. — The best approach to managing neuropathic pain is to treat it early, when it is most likely to respond, according to Dr. Rob Hewko, a psychiatrist at Vancouver (B.C.) General Hospital.

“Neuropathic pain is common and extremely incapacitating,” said Dr. Hewko at the annual Canadian Hospitalist Conference. About 5%–10% of people will develop the condition in their lifetime.

And although this type of pain is classically associated with postherpetic neuralgia and diabetic neuropathy, it can arise from a diverse group of other illnesses and events, such as gallbladder and cardiac surgery, lupus, and chemotherapy.

Neuropathic pain has a complex pathogenesis that involves several mechanisms, he said at the conference, which was sponsored by the University of British Columbia. These include sensitization of peripheral nerves, activation of the dorsal horn nuclei in the spinal cord, and changes in descending inhibition from the brain.

Diagnosis can be challenging, for a variety of reasons: the diverse symptomatology, the numerous etiologies, patients' difficulty in articulating their symptoms, and the variable response to treatment.

A number of tools are available to help with diagnosis and assessment. “I would suggest that you choose one of these and use it exclusively, unless you have unlimited time,” Dr. Hewko advised. In cases in which the diagnosis is uncertain, he recommended the DN4 pain questionnaire (Pain 2005;114:29–36), which can be completed in about 10 minutes.

The best management of chronic neuropathic pain is effective management of acute neuropathic pain, Dr. Hewko said.

Most patients with acute neuropathic pain “will get better over time, so that's your backup position—do nothing and hope they get better,” he said. “But there's a downside to that, which is the longer you wait, the less likely they are to respond to treatment.”

Medication strategies can exploit the nature of neuropathic pain, by using agents with differing actions to target the different mechanisms and to potentiate each other. First-line agents include two of the tricyclic antidepressants (nortriptyline and desipramine), gabapentin, and pregabalin.

Opioids should not be used as first-line agents because patients rapidly develop tolerance to them in this setting, according to Dr. Hewko. And amitriptyline should not be used at all because of its many adverse effects.

National pain societies generally recommend a single-agent approach to the initial pharmacotherapy for neuropathic pain. However, he noted, “the likelihood of an excellent response to a single agent is really low in my experience.”

He therefore recommended combining two first-line agents—a tricyclic antidepressant plus either gabapentin or pregabalin—as initial therapy. The drugs should be started at low dosages and titrated every 24–48 hours.

This approach has the advantage of producing rapid relief. Fully 90%–95% of patients with acute neuropathic pain have a response within several days.

Third-line agents, such as opioids, cannabinoids, and topiramate, should be selected with consideration of the mechanism they target so that they complement other agents being used.

Among the opioids, which are more effective against peripheral than against central neuropathic pain, “methadone is the best option because it is the only narcotic that has an [N-methyl-D-aspartate] antagonistic effect,” he observed.

Measures such as cognitive-behavioral therapy and spinal cord stimulation can be useful when pain persists despite medical therapy.

Dr. Hewko is a member of a medical advisory board for Pfizer Canada.

'The longer you wait, the less likely [patients with neuropathic pain] are to respond to treatment.' DR. HEWKO

SEATTLE — More than half of adults with asthma who visit their primary care provider for any reason have disease that is not well controlled, indicate findings from a cross-sectional study involving more than 2,200 patients in practices across the United States.

The findings suggest that “primary care providers should probably be taking the opportunity to assess asthma control in all of their asthma patients, regardless of the reason for their visit,” according to the study's lead author, Richard H. Stanford, Pharm.D.

The Asthma Control Characteristics and Prevalence Survey Study was conducted in 35 non-research-based primary care practices in the United States in the first half of 2008. None of the practices had an allergy specialist on staff, Dr. Stanford said at the annual meeting of the American College of Allergy, Asthma, and Immunology.

The 2,238 adult patients (mean age, 47 years) were making scheduled visits and reported having provider-diagnosed asthma and having used asthma medication (including albuterol) in the past year. Patients with chronic obstructive pulmonary disease, chronic bronchitis, or emphysema were excluded. The patient-completed questionnaire included the Asthma Control Test (ACT) and questions about demographics, health behaviors, medical history, asthma exacerbation history, and reason for the visit.

Patients were classified as having asthma that was not well controlled if they had an ACT score less than 20.

The surveyed group was predominantly female (72%); 66% were white, 12% were black, 11% were Hispanic, and 9% were of other races. In all, 40% of patients were visiting their provider for respiratory reasons.

Of those surveyed, 58% had asthma that was not well controlled. The prevalence of uncontrolled asthma was 72% among patients who were visiting for respiratory reasons, but it was also high (48%) among patients visiting for nonrespiratory reasons, noted Dr. Stanford, an investigator with GlaxoSmithKline in Research Triangle Park, N.C.

Within the group visiting for nonrespiratory reasons, blacks were more likely to have asthma that was not well controlled (55%) than were whites (46%) and Hispanics (42%). And not surprisingly, Dr. Stanford noted, the prevalence was high among patients with self-reported severe asthma (82%) and moderate asthma (68%); however, it was also substantial among patients with self-reported mild asthma (31%).

Also within the group visiting for nonrespiratory reasons, compared with their counterparts having controlled asthma, patients having asthma that was not well controlled were more likely to have had an exacerbation, used asthma-related steroids, and made an asthma-related visit to the emergency department or urgent care facility in the past year.

“What was most surprising to us was that among the patients with well-controlled asthma, a fourth of them had had an asthma exacerbation in the previous year,” Dr. Stanford commented.

He noted that the prevalence of asthma that was not well controlled may have been underestimated in the study because the participating primary care practices did not use spirometry.

The study was sponsored by GlaxoSmithKline in collaboration with the Research Triangle Institute.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — More than half of adults with asthma who visit their primary care provider for any reason have disease that is not well controlled, indicate findings from a cross-sectional study involving more than 2,200 patients in practices across the United States.

The findings suggest that “primary care providers should probably be taking the opportunity to assess asthma control in all of their asthma patients, regardless of the reason for their visit,” according to the study's lead author, Richard H. Stanford, Pharm.D.

The Asthma Control Characteristics and Prevalence Survey Study was conducted in 35 non-research-based primary care practices in the United States in the first half of 2008. None of the practices had an allergy specialist on staff, Dr. Stanford said at the annual meeting of the American College of Allergy, Asthma, and Immunology.

The 2,238 adult patients (mean age, 47 years) were making scheduled visits and reported having provider-diagnosed asthma and having used asthma medication (including albuterol) in the past year. Patients with chronic obstructive pulmonary disease, chronic bronchitis, or emphysema were excluded. The patient-completed questionnaire included the Asthma Control Test (ACT) and questions about demographics, health behaviors, medical history, asthma exacerbation history, and reason for the visit.

Patients were classified as having asthma that was not well controlled if they had an ACT score less than 20.

The surveyed group was predominantly female (72%); 66% were white, 12% were black, 11% were Hispanic, and 9% were of other races. In all, 40% of patients were visiting their provider for respiratory reasons.

Of those surveyed, 58% had asthma that was not well controlled. The prevalence of uncontrolled asthma was 72% among patients who were visiting for respiratory reasons, but it was also high (48%) among patients visiting for nonrespiratory reasons, noted Dr. Stanford, an investigator with GlaxoSmithKline in Research Triangle Park, N.C.

Within the group visiting for nonrespiratory reasons, blacks were more likely to have asthma that was not well controlled (55%) than were whites (46%) and Hispanics (42%). And not surprisingly, Dr. Stanford noted, the prevalence was high among patients with self-reported severe asthma (82%) and moderate asthma (68%); however, it was also substantial among patients with self-reported mild asthma (31%).

Also within the group visiting for nonrespiratory reasons, compared with their counterparts having controlled asthma, patients having asthma that was not well controlled were more likely to have had an exacerbation, used asthma-related steroids, and made an asthma-related visit to the emergency department or urgent care facility in the past year.

“What was most surprising to us was that among the patients with well-controlled asthma, a fourth of them had had an asthma exacerbation in the previous year,” Dr. Stanford commented.

He noted that the prevalence of asthma that was not well controlled may have been underestimated in the study because the participating primary care practices did not use spirometry.

The study was sponsored by GlaxoSmithKline in collaboration with the Research Triangle Institute.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — More than half of adults with asthma who visit their primary care provider for any reason have disease that is not well controlled, indicate findings from a cross-sectional study involving more than 2,200 patients in practices across the United States.

The findings suggest that “primary care providers should probably be taking the opportunity to assess asthma control in all of their asthma patients, regardless of the reason for their visit,” according to the study's lead author, Richard H. Stanford, Pharm.D.

The Asthma Control Characteristics and Prevalence Survey Study was conducted in 35 non-research-based primary care practices in the United States in the first half of 2008. None of the practices had an allergy specialist on staff, Dr. Stanford said at the annual meeting of the American College of Allergy, Asthma, and Immunology.

The 2,238 adult patients (mean age, 47 years) were making scheduled visits and reported having provider-diagnosed asthma and having used asthma medication (including albuterol) in the past year. Patients with chronic obstructive pulmonary disease, chronic bronchitis, or emphysema were excluded. The patient-completed questionnaire included the Asthma Control Test (ACT) and questions about demographics, health behaviors, medical history, asthma exacerbation history, and reason for the visit.

Patients were classified as having asthma that was not well controlled if they had an ACT score less than 20.

The surveyed group was predominantly female (72%); 66% were white, 12% were black, 11% were Hispanic, and 9% were of other races. In all, 40% of patients were visiting their provider for respiratory reasons.

Of those surveyed, 58% had asthma that was not well controlled. The prevalence of uncontrolled asthma was 72% among patients who were visiting for respiratory reasons, but it was also high (48%) among patients visiting for nonrespiratory reasons, noted Dr. Stanford, an investigator with GlaxoSmithKline in Research Triangle Park, N.C.

Within the group visiting for nonrespiratory reasons, blacks were more likely to have asthma that was not well controlled (55%) than were whites (46%) and Hispanics (42%). And not surprisingly, Dr. Stanford noted, the prevalence was high among patients with self-reported severe asthma (82%) and moderate asthma (68%); however, it was also substantial among patients with self-reported mild asthma (31%).

Also within the group visiting for nonrespiratory reasons, compared with their counterparts having controlled asthma, patients having asthma that was not well controlled were more likely to have had an exacerbation, used asthma-related steroids, and made an asthma-related visit to the emergency department or urgent care facility in the past year.

“What was most surprising to us was that among the patients with well-controlled asthma, a fourth of them had had an asthma exacerbation in the previous year,” Dr. Stanford commented.

He noted that the prevalence of asthma that was not well controlled may have been underestimated in the study because the participating primary care practices did not use spirometry.

The study was sponsored by GlaxoSmithKline in collaboration with the Research Triangle Institute.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — The cost of allergy immunotherapy among children with allergic rhinitis is quickly surpassed by savings in other health care costs, new data suggest.

“I am often asked by payers to justify the cost of allergy symptom treatments, allergy medications, and asthma medications,” said investigator Cheryl Hankin, Ph.D., president and chief scientific officer of BioMedEcon LLC, in Moss Beach, Calif. “It's amazing to me that payers rarely know that allergy immunotherapy is the only disease-modifying treatment available for children and patients with allergies.”

Research on the cost impact of this therapy in patients with asthma and allergic rhinitis in the United States has been limited, Dr. Hankin noted. Previous studies on the topic have yielded conflicting results.

In the retrospective study reported at the annual meeting of the American College of Allergy, Asthma, and Immunology, Dr. Hankin and her colleagues used a Florida Medicaid database to identify children younger than age 18 years given a new diagnosis of allergic rhinitis during a 9-year period (1997-2006). Children who received immunotherapy and had 18 months of follow-up data after starting the therapy were matched with children who did not receive immunotherapy according to age, comorbidities (atopic dermatitis, asthma, and conjunctivitis), sex, and race.

The investigators used Medicaid claims records to ascertain health care costs. Total health care costs were calculated as the sum of inpatient, outpatient, and medication costs.

Study results were based on 2,481 children who received immunotherapy and 150,615 children who did not. Analyses indicated that the median total cost of a course of immunotherapy over the 18-month period was $565, or about $35 per administration, Dr. Hankin said.

The median total health care costs per patient, including the cost of immunotherapy in the children who received it, were $1,809 or 29% lower in the immunotherapy group ($4,329 vs. $6,138).

In addition, the benefit began to emerge soon after the initiation of immunotherapy, according to Dr. Hankin. “At each time point, we were very surprised to find a highly significant effect, starting at 3 months, that continued to grow.” The cost of the immunotherapy was offset by savings in other health care costs after only 6 months.

When costs were broken down by type, children who did and did not receive immunotherapy had similar median inpatient costs. However, those receiving the therapy had significantly lower median medication costs ($1,469 vs. $1,698) and outpatient costs, including the cost of the immunotherapy itself ($2,391 vs. $3,329).

Discussing the study's findings, Dr. Hankin noted that they may not necessarily be generalizable to patients with private insurance or to adults. At the same time, she pointed out, the nature of the study permits an assessment of immunotherapy under real-world conditions.

Innovations such as sublingual allergy immunotherapy could reduce or remove barriers to accessing treatment, Dr. Hankin commented. “Reducing barriers to treatment may in fact reduce the cost of negative outcomes of allergic rhinitis, so we would expect that possibly this would reduce health care costs further, and further improve the health of children with allergic rhinitis.”

Dr. Hankin disclosed that she is a consultant for Greer Laboratories Inc., which also funded the study, and for Asthmatx Inc.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — The cost of allergy immunotherapy among children with allergic rhinitis is quickly surpassed by savings in other health care costs, new data suggest.

“I am often asked by payers to justify the cost of allergy symptom treatments, allergy medications, and asthma medications,” said investigator Cheryl Hankin, Ph.D., president and chief scientific officer of BioMedEcon LLC, in Moss Beach, Calif. “It's amazing to me that payers rarely know that allergy immunotherapy is the only disease-modifying treatment available for children and patients with allergies.”

Research on the cost impact of this therapy in patients with asthma and allergic rhinitis in the United States has been limited, Dr. Hankin noted. Previous studies on the topic have yielded conflicting results.

In the retrospective study reported at the annual meeting of the American College of Allergy, Asthma, and Immunology, Dr. Hankin and her colleagues used a Florida Medicaid database to identify children younger than age 18 years given a new diagnosis of allergic rhinitis during a 9-year period (1997-2006). Children who received immunotherapy and had 18 months of follow-up data after starting the therapy were matched with children who did not receive immunotherapy according to age, comorbidities (atopic dermatitis, asthma, and conjunctivitis), sex, and race.

The investigators used Medicaid claims records to ascertain health care costs. Total health care costs were calculated as the sum of inpatient, outpatient, and medication costs.

Study results were based on 2,481 children who received immunotherapy and 150,615 children who did not. Analyses indicated that the median total cost of a course of immunotherapy over the 18-month period was $565, or about $35 per administration, Dr. Hankin said.

The median total health care costs per patient, including the cost of immunotherapy in the children who received it, were $1,809 or 29% lower in the immunotherapy group ($4,329 vs. $6,138).

In addition, the benefit began to emerge soon after the initiation of immunotherapy, according to Dr. Hankin. “At each time point, we were very surprised to find a highly significant effect, starting at 3 months, that continued to grow.” The cost of the immunotherapy was offset by savings in other health care costs after only 6 months.

When costs were broken down by type, children who did and did not receive immunotherapy had similar median inpatient costs. However, those receiving the therapy had significantly lower median medication costs ($1,469 vs. $1,698) and outpatient costs, including the cost of the immunotherapy itself ($2,391 vs. $3,329).

Discussing the study's findings, Dr. Hankin noted that they may not necessarily be generalizable to patients with private insurance or to adults. At the same time, she pointed out, the nature of the study permits an assessment of immunotherapy under real-world conditions.

Innovations such as sublingual allergy immunotherapy could reduce or remove barriers to accessing treatment, Dr. Hankin commented. “Reducing barriers to treatment may in fact reduce the cost of negative outcomes of allergic rhinitis, so we would expect that possibly this would reduce health care costs further, and further improve the health of children with allergic rhinitis.”

Dr. Hankin disclosed that she is a consultant for Greer Laboratories Inc., which also funded the study, and for Asthmatx Inc.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — The cost of allergy immunotherapy among children with allergic rhinitis is quickly surpassed by savings in other health care costs, new data suggest.

“I am often asked by payers to justify the cost of allergy symptom treatments, allergy medications, and asthma medications,” said investigator Cheryl Hankin, Ph.D., president and chief scientific officer of BioMedEcon LLC, in Moss Beach, Calif. “It's amazing to me that payers rarely know that allergy immunotherapy is the only disease-modifying treatment available for children and patients with allergies.”

Research on the cost impact of this therapy in patients with asthma and allergic rhinitis in the United States has been limited, Dr. Hankin noted. Previous studies on the topic have yielded conflicting results.

In the retrospective study reported at the annual meeting of the American College of Allergy, Asthma, and Immunology, Dr. Hankin and her colleagues used a Florida Medicaid database to identify children younger than age 18 years given a new diagnosis of allergic rhinitis during a 9-year period (1997-2006). Children who received immunotherapy and had 18 months of follow-up data after starting the therapy were matched with children who did not receive immunotherapy according to age, comorbidities (atopic dermatitis, asthma, and conjunctivitis), sex, and race.

The investigators used Medicaid claims records to ascertain health care costs. Total health care costs were calculated as the sum of inpatient, outpatient, and medication costs.

Study results were based on 2,481 children who received immunotherapy and 150,615 children who did not. Analyses indicated that the median total cost of a course of immunotherapy over the 18-month period was $565, or about $35 per administration, Dr. Hankin said.

The median total health care costs per patient, including the cost of immunotherapy in the children who received it, were $1,809 or 29% lower in the immunotherapy group ($4,329 vs. $6,138).

In addition, the benefit began to emerge soon after the initiation of immunotherapy, according to Dr. Hankin. “At each time point, we were very surprised to find a highly significant effect, starting at 3 months, that continued to grow.” The cost of the immunotherapy was offset by savings in other health care costs after only 6 months.

When costs were broken down by type, children who did and did not receive immunotherapy had similar median inpatient costs. However, those receiving the therapy had significantly lower median medication costs ($1,469 vs. $1,698) and outpatient costs, including the cost of the immunotherapy itself ($2,391 vs. $3,329).

Discussing the study's findings, Dr. Hankin noted that they may not necessarily be generalizable to patients with private insurance or to adults. At the same time, she pointed out, the nature of the study permits an assessment of immunotherapy under real-world conditions.

Innovations such as sublingual allergy immunotherapy could reduce or remove barriers to accessing treatment, Dr. Hankin commented. “Reducing barriers to treatment may in fact reduce the cost of negative outcomes of allergic rhinitis, so we would expect that possibly this would reduce health care costs further, and further improve the health of children with allergic rhinitis.”

Dr. Hankin disclosed that she is a consultant for Greer Laboratories Inc., which also funded the study, and for Asthmatx Inc.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination in children with asthma and reasons for receipt and nonreceipt of the vaccine, they conducted a clinic-based study of 93 children and their parents in the fall of 2004. “During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. She and her colleagues hypothesized that vaccination rates would be high given media coverage of the shortage and the resulting increased public awareness.

The children were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating. Asthma was rated as mild in 55% and as moderate or severe in 45%.

Of the total, 67% of the children received the flu vaccine. The leading reason parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

The leading reason for not vaccinating children was lack of benefit of the vaccine (32%). Other reasons were: a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend it (3%). In all, 5% of parents didn't answer this question.

In terms of perceived benefits of the vaccine, 48% of parents believed it prevented influenza illness, and 47% believed it helped control asthma. The most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

Most of the parents (61%) said their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

“Influenza immunization is inadequate even in a high-risk group like [children with] asthma,” Dr. Reddy said, adding that more research is needed to determine if findings are similar in larger samples and other settings. The researchers concluded that physicians are the best source of information on the flu vaccine for most patients and should discuss vaccination with patients at every opportunity.

Dr. Reddy reported that she had no conflicts of interest.

Physicians are the best source of information on the flu vaccine and should discuss it with patients at every opportunity. DR. REDDY

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination in children with asthma and reasons for receipt and nonreceipt of the vaccine, they conducted a clinic-based study of 93 children and their parents in the fall of 2004. “During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. She and her colleagues hypothesized that vaccination rates would be high given media coverage of the shortage and the resulting increased public awareness.

The children were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating. Asthma was rated as mild in 55% and as moderate or severe in 45%.

Of the total, 67% of the children received the flu vaccine. The leading reason parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

The leading reason for not vaccinating children was lack of benefit of the vaccine (32%). Other reasons were: a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend it (3%). In all, 5% of parents didn't answer this question.

In terms of perceived benefits of the vaccine, 48% of parents believed it prevented influenza illness, and 47% believed it helped control asthma. The most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

Most of the parents (61%) said their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

“Influenza immunization is inadequate even in a high-risk group like [children with] asthma,” Dr. Reddy said, adding that more research is needed to determine if findings are similar in larger samples and other settings. The researchers concluded that physicians are the best source of information on the flu vaccine for most patients and should discuss vaccination with patients at every opportunity.

Dr. Reddy reported that she had no conflicts of interest.

Physicians are the best source of information on the flu vaccine and should discuss it with patients at every opportunity. DR. REDDY

SEATTLE — In one-third of children with asthma who are not vaccinated against influenza, the vaccine is withheld because parents believe it has no benefit.

Influenza exacerbates asthma, and annual flu vaccination is recommended for high-risk children, including those with chronic asthma, Dr. Sudha Reddy, a fellow at the Children's Hospital of Michigan in Detroit, and her colleagues reported at the annual meeting of the American College of Allergy, Asthma, and Immunology.

To determine the prevalence of flu vaccination in children with asthma and reasons for receipt and nonreceipt of the vaccine, they conducted a clinic-based study of 93 children and their parents in the fall of 2004. “During that year, there was a nationwide shortage of flu vaccine due to manufacturing problems,” Dr. Reddy noted in an interview. She and her colleagues hypothesized that vaccination rates would be high given media coverage of the shortage and the resulting increased public awareness.

The children were aged 5-18 years, had established asthma, and were visiting an allergy clinic in a university-affiliated hospital. They and their parents completed questionnaires asking about demographics, the severity of their asthma, their influenza vaccination status, and reasons for vaccinating or not vaccinating. Asthma was rated as mild in 55% and as moderate or severe in 45%.

Of the total, 67% of the children received the flu vaccine. The leading reason parents gave for vaccinating was that a physician recommended it (44%). Other reasons were: routinely getting the vaccine (21%), hearing about it through school (15%), being aware of the vaccine (12%), and news of the vaccine shortage (8%).

The leading reason for not vaccinating children was lack of benefit of the vaccine (32%). Other reasons were: a previous experience of vaccine-related adverse events (22%), a perception that the children would not get the flu (16%), a preference that the children would become ill rather than receive the vaccine (10%), an allergy to eggs (6%), a preference to not vaccinate (6%), and failure of the physician to recommend it (3%). In all, 5% of parents didn't answer this question.

In terms of perceived benefits of the vaccine, 48% of parents believed it prevented influenza illness, and 47% believed it helped control asthma. The most common adverse events were local pain (44%) and fever (13%). Only 2% experienced a worsening of their asthma.

Most of the parents (61%) said their physician was their source of information about flu vaccination. Other sources included the media generally (23%), news regarding the vaccine shortage specifically (13%), and family members (3%).

“Influenza immunization is inadequate even in a high-risk group like [children with] asthma,” Dr. Reddy said, adding that more research is needed to determine if findings are similar in larger samples and other settings. The researchers concluded that physicians are the best source of information on the flu vaccine for most patients and should discuss vaccination with patients at every opportunity.

Dr. Reddy reported that she had no conflicts of interest.

Physicians are the best source of information on the flu vaccine and should discuss it with patients at every opportunity. DR. REDDY

VANCOUVER, B.C. – Hospitalists are ideally qualified and positioned to drive hospital quality improvement initiatives, Dr. Larry Wellikson said at the annual Canadian Hospitalist Conference.

“We are owners, not renters,” he said, contrasting hospitalists with house staff and other physicians. Not only do hospitalists know their institutions inside and out, they often have more clout to effect change than do allied health professionals. And hospitalists are intrinsically involved in overarching issues of care, such as drug safety and patient education.

Hospital care today leaves much room for improvement, Dr. Wellikson said.

“We are virtually the only industry where you pay exactly the same thing whether you get the worst care or the best care.” Moreover, limited measurement of quality outcomes makes it difficult to compare the caliber of care across hospitals.

The Society of Hospital Medicine has taken a leading role in supporting hospitalists in working to change the status quo, according to Dr. Wellikson, CEO of the society.

The many guidelines for standards of care that have been written are merely an initial step in quality improvement (QI), and implementation is a key focus of SHM, he said. The society has brought together multidisciplinary groups of experts to create virtual resource rooms on its Web site (www.hospitalmedicine.org

In addition, because physicians seldom learn how to conduct QI projects during their medical education, the society offers QI training at its annual and chapter meetings, Dr. Wellikson noted.

SHM also has defined core competencies for hospital care and secured funding to pursue mentored implementation projects, whereby hospitalist leaders trained in QI mentor others involved in projects to improve quality outcomes. One project, conducted at a University of California, San Diego, hospital, led to a near doubling of the rate of adequate prophylaxis for venous thromboembolism and reduced the annual number of venous thromboembolic events from 50 to 4, he said.

SHM also is leading efforts to set standards for transitions of care at hospital admission and discharge, in part because hospitalists have often been criticized as contributing to a lack of continuity of care, according to Dr. Wellikson.

The society's long-term strategy for QI includes an emphasis on teamwork and efforts to bring together allied health professionals, Dr. Wellikson explained at the conference, which was sponsored by the University of British Columbia.

“We need to move toward a world where health care is a team sport,” he said, noting that empowering nurses, pharmacists, and other professionals can have benefits all around.

Dr. Wellikson cautioned against pursuing an illusion of improvement in place of the real thing. “The idea of a bunch of people running around with clipboards satisfying some regulations that will grow from 10 to 20 to 100 is really not having a culture of quality,” he said. SHM is also evaluating how information technology can best be harnessed to support QI, and is seeking to raise funds for research on the best ways to conduct QI.

He urged hospitalists not to view QI as a burdensome task undertaken at the end of the day. “You need to look at performance improvement as part of your DNA, as part of your job, as the gift or the differentiator that you bring to the marketplace,” he advised. “It isn't that [others don't] care about quality or performance–it's just that you have the opportunity to seize this, own this, and be the agents of change.”

Dr. Wellikson reported that he had no conflicts of interest in association with his presentation.

'You need to look at performance improvement as part of your DNA, as part of your job.' DR. WELLIKSON

VANCOUVER, B.C. – Hospitalists are ideally qualified and positioned to drive hospital quality improvement initiatives, Dr. Larry Wellikson said at the annual Canadian Hospitalist Conference.

“We are owners, not renters,” he said, contrasting hospitalists with house staff and other physicians. Not only do hospitalists know their institutions inside and out, they often have more clout to effect change than do allied health professionals. And hospitalists are intrinsically involved in overarching issues of care, such as drug safety and patient education.

Hospital care today leaves much room for improvement, Dr. Wellikson said.

“We are virtually the only industry where you pay exactly the same thing whether you get the worst care or the best care.” Moreover, limited measurement of quality outcomes makes it difficult to compare the caliber of care across hospitals.

The Society of Hospital Medicine has taken a leading role in supporting hospitalists in working to change the status quo, according to Dr. Wellikson, CEO of the society.

The many guidelines for standards of care that have been written are merely an initial step in quality improvement (QI), and implementation is a key focus of SHM, he said. The society has brought together multidisciplinary groups of experts to create virtual resource rooms on its Web site (www.hospitalmedicine.org

In addition, because physicians seldom learn how to conduct QI projects during their medical education, the society offers QI training at its annual and chapter meetings, Dr. Wellikson noted.

SHM also has defined core competencies for hospital care and secured funding to pursue mentored implementation projects, whereby hospitalist leaders trained in QI mentor others involved in projects to improve quality outcomes. One project, conducted at a University of California, San Diego, hospital, led to a near doubling of the rate of adequate prophylaxis for venous thromboembolism and reduced the annual number of venous thromboembolic events from 50 to 4, he said.

SHM also is leading efforts to set standards for transitions of care at hospital admission and discharge, in part because hospitalists have often been criticized as contributing to a lack of continuity of care, according to Dr. Wellikson.

The society's long-term strategy for QI includes an emphasis on teamwork and efforts to bring together allied health professionals, Dr. Wellikson explained at the conference, which was sponsored by the University of British Columbia.

“We need to move toward a world where health care is a team sport,” he said, noting that empowering nurses, pharmacists, and other professionals can have benefits all around.

Dr. Wellikson cautioned against pursuing an illusion of improvement in place of the real thing. “The idea of a bunch of people running around with clipboards satisfying some regulations that will grow from 10 to 20 to 100 is really not having a culture of quality,” he said. SHM is also evaluating how information technology can best be harnessed to support QI, and is seeking to raise funds for research on the best ways to conduct QI.

He urged hospitalists not to view QI as a burdensome task undertaken at the end of the day. “You need to look at performance improvement as part of your DNA, as part of your job, as the gift or the differentiator that you bring to the marketplace,” he advised. “It isn't that [others don't] care about quality or performance–it's just that you have the opportunity to seize this, own this, and be the agents of change.”

Dr. Wellikson reported that he had no conflicts of interest in association with his presentation.

'You need to look at performance improvement as part of your DNA, as part of your job.' DR. WELLIKSON

VANCOUVER, B.C. – Hospitalists are ideally qualified and positioned to drive hospital quality improvement initiatives, Dr. Larry Wellikson said at the annual Canadian Hospitalist Conference.

“We are owners, not renters,” he said, contrasting hospitalists with house staff and other physicians. Not only do hospitalists know their institutions inside and out, they often have more clout to effect change than do allied health professionals. And hospitalists are intrinsically involved in overarching issues of care, such as drug safety and patient education.

Hospital care today leaves much room for improvement, Dr. Wellikson said.

“We are virtually the only industry where you pay exactly the same thing whether you get the worst care or the best care.” Moreover, limited measurement of quality outcomes makes it difficult to compare the caliber of care across hospitals.

The Society of Hospital Medicine has taken a leading role in supporting hospitalists in working to change the status quo, according to Dr. Wellikson, CEO of the society.

The many guidelines for standards of care that have been written are merely an initial step in quality improvement (QI), and implementation is a key focus of SHM, he said. The society has brought together multidisciplinary groups of experts to create virtual resource rooms on its Web site (www.hospitalmedicine.org

In addition, because physicians seldom learn how to conduct QI projects during their medical education, the society offers QI training at its annual and chapter meetings, Dr. Wellikson noted.

SHM also has defined core competencies for hospital care and secured funding to pursue mentored implementation projects, whereby hospitalist leaders trained in QI mentor others involved in projects to improve quality outcomes. One project, conducted at a University of California, San Diego, hospital, led to a near doubling of the rate of adequate prophylaxis for venous thromboembolism and reduced the annual number of venous thromboembolic events from 50 to 4, he said.

SHM also is leading efforts to set standards for transitions of care at hospital admission and discharge, in part because hospitalists have often been criticized as contributing to a lack of continuity of care, according to Dr. Wellikson.

The society's long-term strategy for QI includes an emphasis on teamwork and efforts to bring together allied health professionals, Dr. Wellikson explained at the conference, which was sponsored by the University of British Columbia.

“We need to move toward a world where health care is a team sport,” he said, noting that empowering nurses, pharmacists, and other professionals can have benefits all around.

Dr. Wellikson cautioned against pursuing an illusion of improvement in place of the real thing. “The idea of a bunch of people running around with clipboards satisfying some regulations that will grow from 10 to 20 to 100 is really not having a culture of quality,” he said. SHM is also evaluating how information technology can best be harnessed to support QI, and is seeking to raise funds for research on the best ways to conduct QI.

He urged hospitalists not to view QI as a burdensome task undertaken at the end of the day. “You need to look at performance improvement as part of your DNA, as part of your job, as the gift or the differentiator that you bring to the marketplace,” he advised. “It isn't that [others don't] care about quality or performance–it's just that you have the opportunity to seize this, own this, and be the agents of change.”

Dr. Wellikson reported that he had no conflicts of interest in association with his presentation.

'You need to look at performance improvement as part of your DNA, as part of your job.' DR. WELLIKSON