Timothy F. Kirn

People who are uninsured or covered by Medicaid are more likely to be diagnosed with cancer later than those with private insurance, according to a review of more than 3 million cancer cases.

The cancers most likely to be diagnosed at a more advanced stage in this population were those that could be detected by screening or symptom assessment by a physician, according to the study.

Uninsured or Medicaid-covered patients were twice as likely to be diagnosed with stage III colorectal cancer as patients with private insurance, and 1.6 times more likely to be diagnosed with stage IV colorectal cancer, wrote Dr. Michael T. Halpern and colleagues, from the American Cancer Society, Atlanta.

The 5-year survival rate for colon cancer is 93% if it is diagnosed at stage I, 44% if diagnosed at stage IIIC, and only 8% if diagnosed at stage IV (Lancet Oncol. 2008 Feb. 18 [doi:10.1016/s1470–2045(08)70032–9]).

The review used information from the U.S. National Cancer Database, a hospital-based registry that collects information from 1,430 facilities, and included information from 3,742,407 patients diagnosed between 1998 and 2004. The database captures about 75% of all cancer cases diagnosed in the United States, Dr. Halpern and colleagues said.

The review included patients with 12 cancers: breast, colorectal, lung, prostate, urinary bladder, non-Hodgkin's lymphoma, uterus, kidney, melanoma, pancreas, thyroid, and ovary.

Uninsured patients had a significantly increased likelihood of presenting with stage II, III, or IV cancer at diagnosis, compared with insured patients. The largest odds ratio for diagnosis at stage II, compared with stage I disease was for colorectal cancer (odds ratio 1.9). For diagnosis at stage III or stage IV, compared with stage I, the largest odds ratio was for breast cancer (OR 2.9). In comparison to privately insured patients, the study found Medicaid patients had an increased risk of presenting with stage II vs. stage I disease for 6 of the 12 cancers, and with stage III or IV vs. stage I disease for 11 of the 12 cancers.

In comparison to whites, blacks were more likely to be diagnosed at stage III or stage IV for 10 of the 12 cancers regardless of insurance status.

Hispanic patients were more likely to present with more advanced-stage disease at diagnosis than were white patients. Odds ratios for presenting with more advanced-stage disease were generally lower for Hispanics than for black patients.

Because the findings of later diagnosis were found across all the types of cancer that can be detected early with screening or prompt medical attention, “These findings have important implications for screening programmes and access to medical care,” Dr. Halpern and colleagues wrote.

People who are uninsured or covered by Medicaid are more likely to be diagnosed with cancer later than those with private insurance, according to a review of more than 3 million cancer cases.

The cancers most likely to be diagnosed at a more advanced stage in this population were those that could be detected by screening or symptom assessment by a physician, according to the study.

Uninsured or Medicaid-covered patients were twice as likely to be diagnosed with stage III colorectal cancer as patients with private insurance, and 1.6 times more likely to be diagnosed with stage IV colorectal cancer, wrote Dr. Michael T. Halpern and colleagues, from the American Cancer Society, Atlanta.

The 5-year survival rate for colon cancer is 93% if it is diagnosed at stage I, 44% if diagnosed at stage IIIC, and only 8% if diagnosed at stage IV (Lancet Oncol. 2008 Feb. 18 [doi:10.1016/s1470–2045(08)70032–9]).

The review used information from the U.S. National Cancer Database, a hospital-based registry that collects information from 1,430 facilities, and included information from 3,742,407 patients diagnosed between 1998 and 2004. The database captures about 75% of all cancer cases diagnosed in the United States, Dr. Halpern and colleagues said.

The review included patients with 12 cancers: breast, colorectal, lung, prostate, urinary bladder, non-Hodgkin's lymphoma, uterus, kidney, melanoma, pancreas, thyroid, and ovary.

Uninsured patients had a significantly increased likelihood of presenting with stage II, III, or IV cancer at diagnosis, compared with insured patients. The largest odds ratio for diagnosis at stage II, compared with stage I disease was for colorectal cancer (odds ratio 1.9). For diagnosis at stage III or stage IV, compared with stage I, the largest odds ratio was for breast cancer (OR 2.9). In comparison to privately insured patients, the study found Medicaid patients had an increased risk of presenting with stage II vs. stage I disease for 6 of the 12 cancers, and with stage III or IV vs. stage I disease for 11 of the 12 cancers.

In comparison to whites, blacks were more likely to be diagnosed at stage III or stage IV for 10 of the 12 cancers regardless of insurance status.

Hispanic patients were more likely to present with more advanced-stage disease at diagnosis than were white patients. Odds ratios for presenting with more advanced-stage disease were generally lower for Hispanics than for black patients.

Because the findings of later diagnosis were found across all the types of cancer that can be detected early with screening or prompt medical attention, “These findings have important implications for screening programmes and access to medical care,” Dr. Halpern and colleagues wrote.

People who are uninsured or covered by Medicaid are more likely to be diagnosed with cancer later than those with private insurance, according to a review of more than 3 million cancer cases.

The cancers most likely to be diagnosed at a more advanced stage in this population were those that could be detected by screening or symptom assessment by a physician, according to the study.

Uninsured or Medicaid-covered patients were twice as likely to be diagnosed with stage III colorectal cancer as patients with private insurance, and 1.6 times more likely to be diagnosed with stage IV colorectal cancer, wrote Dr. Michael T. Halpern and colleagues, from the American Cancer Society, Atlanta.

The 5-year survival rate for colon cancer is 93% if it is diagnosed at stage I, 44% if diagnosed at stage IIIC, and only 8% if diagnosed at stage IV (Lancet Oncol. 2008 Feb. 18 [doi:10.1016/s1470–2045(08)70032–9]).

The review used information from the U.S. National Cancer Database, a hospital-based registry that collects information from 1,430 facilities, and included information from 3,742,407 patients diagnosed between 1998 and 2004. The database captures about 75% of all cancer cases diagnosed in the United States, Dr. Halpern and colleagues said.

The review included patients with 12 cancers: breast, colorectal, lung, prostate, urinary bladder, non-Hodgkin's lymphoma, uterus, kidney, melanoma, pancreas, thyroid, and ovary.

Uninsured patients had a significantly increased likelihood of presenting with stage II, III, or IV cancer at diagnosis, compared with insured patients. The largest odds ratio for diagnosis at stage II, compared with stage I disease was for colorectal cancer (odds ratio 1.9). For diagnosis at stage III or stage IV, compared with stage I, the largest odds ratio was for breast cancer (OR 2.9). In comparison to privately insured patients, the study found Medicaid patients had an increased risk of presenting with stage II vs. stage I disease for 6 of the 12 cancers, and with stage III or IV vs. stage I disease for 11 of the 12 cancers.

In comparison to whites, blacks were more likely to be diagnosed at stage III or stage IV for 10 of the 12 cancers regardless of insurance status.

Hispanic patients were more likely to present with more advanced-stage disease at diagnosis than were white patients. Odds ratios for presenting with more advanced-stage disease were generally lower for Hispanics than for black patients.

Because the findings of later diagnosis were found across all the types of cancer that can be detected early with screening or prompt medical attention, “These findings have important implications for screening programmes and access to medical care,” Dr. Halpern and colleagues wrote.

Bocavirus does not appear to be pathogenic in children, Canadian researchers reported.

Investigators in Sweden, Japan, Australia, and Thailand have previously reported bocavirus infections in children that appeared to be associated with bronchiolitis and viral pneumonia.

However, the Canadian group recently found human bocavirus in 43% of 100 children without symptoms undergoing surgery, but in only 14% of 225 symptomatic children hospitalized with an acute lower respiratory tract infection (RTI).

These findings suggest that the virus may not be pathogenic, and further studies are called for before any conclusions can be drawn, Dr. Jean Longtin of Laval University Hospital Center, Quebec City, and colleagues wrote (Emerg. Infect. Dis. 2008;14:217–21).

Human bocavirus, which is a parvovirus, was first identified by researchers at the Karolinska Institute, Stockholm. Those researchers had developed a virus-screening system and sought to test it; in the process of screening nasopharyngeal aspirates, they picked up the human bocavirus (Proc. Natl. Acad. Sci. 2005;102:12891–6).

Dr. Tobias Allander and associates then went back and screened for the bocavirus in 378 culture-negative, nasopharyngeal aspirate samples drawn in Karolinska clinics, and found 7 to be positive for the virus. All seven samples came from children.

When they screened samples taken from 540 hospitalized children, they found 17 patients (3%) who were positive for bocavirus, and 14 of those patients were negative for any other virus the researchers searched for. All 14 patients had been admitted to the hospital from home for respiratory distress; bilateral interstitial infiltrates were seen in six of seven patients who had chest radiography.

The Swedish investigators said it could be difficult to prove that bocavirus was indeed a pathogen. They noted that with the modern methods that now detect probable pathogens, it is often not possible to adhere to Koch's postulates. There often isn't a proper culture for the agent, or a suitable experimental animal model to test whether one can make the animal sick and transmit the pathogen, they said.

Other studies have found a similar incidence of bocavirus in about 3%–5% in children with RTI symptoms and no other significant, identified viral infection, although an incidence as high as 19% has been reported. Most cases appear to have fever, and the most common diagnosis tends to be bronchiolitis.

The Canadian researchers had nasopharyngeal samples on hand from two previous studies that they now tested for human bocavirus. Those cohorts included 126 adults with chronic obstructive pulmonary disease who were seen in the emergency department for an acute exacerbation of their symptoms, plus 225 symptomatic children admitted to the hospital with an upper RTI and their controls (100 symptomatic children entering the hospital for surgery).

Dr. Longtin and associates found bocavirus DNA in only one of the nasopharyngeal samples from the 126 adult patients (mean age, 71 years). They found bocavirus DNA in 31 samples from the 225 symptomatic children (mean age, 17 months). But human bocavirus DNA was found in the samples of 43 of the 100 asymptomatic controls (mean age, 22 months).

Moreover, 22 of the 31 symptomatic children (71%) who had bocavirus also had at least one other virus detected in their samples: respiratory syncytial virus (16 patients), influenza A/B virus (3 patients), metapneumovirus (3 patients), adenovirus (1 patient), and parainfluenza virus (1 patient). Two of the children were infected with two viruses in addition to bocavirus.

Hospital stay was not greatly different for the symptomatic children infected with bocavirus, compared with the uninfected symptomatic children (a mean of 5 days vs. 7 days), Dr. Longtin and colleagues said.

The lone adult found to harbor bocavirus was a 71-year-old smoker who ended up being hospitalized for 7 days with his chronic obstructive pulmonary disease exacerbation, but he was not found to have any other viruses or bacteria in his sputum or nasopharyngeal aspirate.

“Overall, these data do not support a pathogenic role for [human bocavirus] in acute RTIs in children,” Dr. Longtin and colleagues wrote.

Bocavirus does not appear to be pathogenic in children, Canadian researchers reported.

Investigators in Sweden, Japan, Australia, and Thailand have previously reported bocavirus infections in children that appeared to be associated with bronchiolitis and viral pneumonia.

However, the Canadian group recently found human bocavirus in 43% of 100 children without symptoms undergoing surgery, but in only 14% of 225 symptomatic children hospitalized with an acute lower respiratory tract infection (RTI).

These findings suggest that the virus may not be pathogenic, and further studies are called for before any conclusions can be drawn, Dr. Jean Longtin of Laval University Hospital Center, Quebec City, and colleagues wrote (Emerg. Infect. Dis. 2008;14:217–21).

Human bocavirus, which is a parvovirus, was first identified by researchers at the Karolinska Institute, Stockholm. Those researchers had developed a virus-screening system and sought to test it; in the process of screening nasopharyngeal aspirates, they picked up the human bocavirus (Proc. Natl. Acad. Sci. 2005;102:12891–6).

Dr. Tobias Allander and associates then went back and screened for the bocavirus in 378 culture-negative, nasopharyngeal aspirate samples drawn in Karolinska clinics, and found 7 to be positive for the virus. All seven samples came from children.

When they screened samples taken from 540 hospitalized children, they found 17 patients (3%) who were positive for bocavirus, and 14 of those patients were negative for any other virus the researchers searched for. All 14 patients had been admitted to the hospital from home for respiratory distress; bilateral interstitial infiltrates were seen in six of seven patients who had chest radiography.

The Swedish investigators said it could be difficult to prove that bocavirus was indeed a pathogen. They noted that with the modern methods that now detect probable pathogens, it is often not possible to adhere to Koch's postulates. There often isn't a proper culture for the agent, or a suitable experimental animal model to test whether one can make the animal sick and transmit the pathogen, they said.

Other studies have found a similar incidence of bocavirus in about 3%–5% in children with RTI symptoms and no other significant, identified viral infection, although an incidence as high as 19% has been reported. Most cases appear to have fever, and the most common diagnosis tends to be bronchiolitis.

The Canadian researchers had nasopharyngeal samples on hand from two previous studies that they now tested for human bocavirus. Those cohorts included 126 adults with chronic obstructive pulmonary disease who were seen in the emergency department for an acute exacerbation of their symptoms, plus 225 symptomatic children admitted to the hospital with an upper RTI and their controls (100 symptomatic children entering the hospital for surgery).

Dr. Longtin and associates found bocavirus DNA in only one of the nasopharyngeal samples from the 126 adult patients (mean age, 71 years). They found bocavirus DNA in 31 samples from the 225 symptomatic children (mean age, 17 months). But human bocavirus DNA was found in the samples of 43 of the 100 asymptomatic controls (mean age, 22 months).

Moreover, 22 of the 31 symptomatic children (71%) who had bocavirus also had at least one other virus detected in their samples: respiratory syncytial virus (16 patients), influenza A/B virus (3 patients), metapneumovirus (3 patients), adenovirus (1 patient), and parainfluenza virus (1 patient). Two of the children were infected with two viruses in addition to bocavirus.

Hospital stay was not greatly different for the symptomatic children infected with bocavirus, compared with the uninfected symptomatic children (a mean of 5 days vs. 7 days), Dr. Longtin and colleagues said.

The lone adult found to harbor bocavirus was a 71-year-old smoker who ended up being hospitalized for 7 days with his chronic obstructive pulmonary disease exacerbation, but he was not found to have any other viruses or bacteria in his sputum or nasopharyngeal aspirate.

“Overall, these data do not support a pathogenic role for [human bocavirus] in acute RTIs in children,” Dr. Longtin and colleagues wrote.

Bocavirus does not appear to be pathogenic in children, Canadian researchers reported.

Investigators in Sweden, Japan, Australia, and Thailand have previously reported bocavirus infections in children that appeared to be associated with bronchiolitis and viral pneumonia.

However, the Canadian group recently found human bocavirus in 43% of 100 children without symptoms undergoing surgery, but in only 14% of 225 symptomatic children hospitalized with an acute lower respiratory tract infection (RTI).

These findings suggest that the virus may not be pathogenic, and further studies are called for before any conclusions can be drawn, Dr. Jean Longtin of Laval University Hospital Center, Quebec City, and colleagues wrote (Emerg. Infect. Dis. 2008;14:217–21).

Human bocavirus, which is a parvovirus, was first identified by researchers at the Karolinska Institute, Stockholm. Those researchers had developed a virus-screening system and sought to test it; in the process of screening nasopharyngeal aspirates, they picked up the human bocavirus (Proc. Natl. Acad. Sci. 2005;102:12891–6).

Dr. Tobias Allander and associates then went back and screened for the bocavirus in 378 culture-negative, nasopharyngeal aspirate samples drawn in Karolinska clinics, and found 7 to be positive for the virus. All seven samples came from children.

When they screened samples taken from 540 hospitalized children, they found 17 patients (3%) who were positive for bocavirus, and 14 of those patients were negative for any other virus the researchers searched for. All 14 patients had been admitted to the hospital from home for respiratory distress; bilateral interstitial infiltrates were seen in six of seven patients who had chest radiography.

The Swedish investigators said it could be difficult to prove that bocavirus was indeed a pathogen. They noted that with the modern methods that now detect probable pathogens, it is often not possible to adhere to Koch's postulates. There often isn't a proper culture for the agent, or a suitable experimental animal model to test whether one can make the animal sick and transmit the pathogen, they said.

Other studies have found a similar incidence of bocavirus in about 3%–5% in children with RTI symptoms and no other significant, identified viral infection, although an incidence as high as 19% has been reported. Most cases appear to have fever, and the most common diagnosis tends to be bronchiolitis.

The Canadian researchers had nasopharyngeal samples on hand from two previous studies that they now tested for human bocavirus. Those cohorts included 126 adults with chronic obstructive pulmonary disease who were seen in the emergency department for an acute exacerbation of their symptoms, plus 225 symptomatic children admitted to the hospital with an upper RTI and their controls (100 symptomatic children entering the hospital for surgery).

Dr. Longtin and associates found bocavirus DNA in only one of the nasopharyngeal samples from the 126 adult patients (mean age, 71 years). They found bocavirus DNA in 31 samples from the 225 symptomatic children (mean age, 17 months). But human bocavirus DNA was found in the samples of 43 of the 100 asymptomatic controls (mean age, 22 months).

Moreover, 22 of the 31 symptomatic children (71%) who had bocavirus also had at least one other virus detected in their samples: respiratory syncytial virus (16 patients), influenza A/B virus (3 patients), metapneumovirus (3 patients), adenovirus (1 patient), and parainfluenza virus (1 patient). Two of the children were infected with two viruses in addition to bocavirus.

Hospital stay was not greatly different for the symptomatic children infected with bocavirus, compared with the uninfected symptomatic children (a mean of 5 days vs. 7 days), Dr. Longtin and colleagues said.

The lone adult found to harbor bocavirus was a 71-year-old smoker who ended up being hospitalized for 7 days with his chronic obstructive pulmonary disease exacerbation, but he was not found to have any other viruses or bacteria in his sputum or nasopharyngeal aspirate.

“Overall, these data do not support a pathogenic role for [human bocavirus] in acute RTIs in children,” Dr. Longtin and colleagues wrote.

Atomoxetine had no enduring effect on oppositional defiant disorder symptoms in a new report of manufacturer data from children with both ODD and attention-deficit/hyperactivity disorder.

The findings from the 8-week, multicenter, placebo-controlled trial run counter to the results of a previous study that suggested atomoxetine (Strattera) could improve symptoms in patients with both disorders. Atomoxetine, a norepinephrine reuptake inhibitor, was approved in 2002 as the first nonstimulant medication for attention-deficit/hyperactivity disorder (ADHD). ODD is thought to be present in 40%–60% of children with ADHD.

In the study, 156 children with both disorders received 1.2 mg/kg per day of atomoxetine for 8 weeks, and 70 received placebo. The subjects, aged 6–12 years, came from 17 centers in Europe. Improvement was measured on the Swanson, Nolan, and Pelham Rating Scale-Revised, which has 18 items used to grade ADHD symptoms and 8 used to grade ODD symptoms.

ADHD symptoms were significantly improved on the rating scale, but ODD symptoms were no better at week 8. Although those given the active treatment had improved ratings relative to placebo-treated children at weeks 2 and 5 of the trial, “it remains uncertain whether atomoxetine exerts a specific and enduring effect on ODD symptoms,” said Dr. Mark E. Bangs of Lilly Research Laboratories, Indianapolis, and his colleagues in the Atomoxetine ADHD/ODD Study Group (Pediatrics 2008;121:e314–20).

“Patients with ADHD and ODD will not be disadvantaged by treatment with atomoxetine, but additional pharmacologic or psychological strategies may be needed to address the ODD symptoms, they said. Dr. Bangs and several of his coinvestigators are employees and shareholders of Eli Lilly & Co., which funded the study and manufactures Strattera.

Atomoxetine had no enduring effect on oppositional defiant disorder symptoms in a new report of manufacturer data from children with both ODD and attention-deficit/hyperactivity disorder.

The findings from the 8-week, multicenter, placebo-controlled trial run counter to the results of a previous study that suggested atomoxetine (Strattera) could improve symptoms in patients with both disorders. Atomoxetine, a norepinephrine reuptake inhibitor, was approved in 2002 as the first nonstimulant medication for attention-deficit/hyperactivity disorder (ADHD). ODD is thought to be present in 40%–60% of children with ADHD.

In the study, 156 children with both disorders received 1.2 mg/kg per day of atomoxetine for 8 weeks, and 70 received placebo. The subjects, aged 6–12 years, came from 17 centers in Europe. Improvement was measured on the Swanson, Nolan, and Pelham Rating Scale-Revised, which has 18 items used to grade ADHD symptoms and 8 used to grade ODD symptoms.

ADHD symptoms were significantly improved on the rating scale, but ODD symptoms were no better at week 8. Although those given the active treatment had improved ratings relative to placebo-treated children at weeks 2 and 5 of the trial, “it remains uncertain whether atomoxetine exerts a specific and enduring effect on ODD symptoms,” said Dr. Mark E. Bangs of Lilly Research Laboratories, Indianapolis, and his colleagues in the Atomoxetine ADHD/ODD Study Group (Pediatrics 2008;121:e314–20).

“Patients with ADHD and ODD will not be disadvantaged by treatment with atomoxetine, but additional pharmacologic or psychological strategies may be needed to address the ODD symptoms, they said. Dr. Bangs and several of his coinvestigators are employees and shareholders of Eli Lilly & Co., which funded the study and manufactures Strattera.

Atomoxetine had no enduring effect on oppositional defiant disorder symptoms in a new report of manufacturer data from children with both ODD and attention-deficit/hyperactivity disorder.

The findings from the 8-week, multicenter, placebo-controlled trial run counter to the results of a previous study that suggested atomoxetine (Strattera) could improve symptoms in patients with both disorders. Atomoxetine, a norepinephrine reuptake inhibitor, was approved in 2002 as the first nonstimulant medication for attention-deficit/hyperactivity disorder (ADHD). ODD is thought to be present in 40%–60% of children with ADHD.

In the study, 156 children with both disorders received 1.2 mg/kg per day of atomoxetine for 8 weeks, and 70 received placebo. The subjects, aged 6–12 years, came from 17 centers in Europe. Improvement was measured on the Swanson, Nolan, and Pelham Rating Scale-Revised, which has 18 items used to grade ADHD symptoms and 8 used to grade ODD symptoms.

ADHD symptoms were significantly improved on the rating scale, but ODD symptoms were no better at week 8. Although those given the active treatment had improved ratings relative to placebo-treated children at weeks 2 and 5 of the trial, “it remains uncertain whether atomoxetine exerts a specific and enduring effect on ODD symptoms,” said Dr. Mark E. Bangs of Lilly Research Laboratories, Indianapolis, and his colleagues in the Atomoxetine ADHD/ODD Study Group (Pediatrics 2008;121:e314–20).

“Patients with ADHD and ODD will not be disadvantaged by treatment with atomoxetine, but additional pharmacologic or psychological strategies may be needed to address the ODD symptoms, they said. Dr. Bangs and several of his coinvestigators are employees and shareholders of Eli Lilly & Co., which funded the study and manufactures Strattera.

INCLINE VALLEY, NEV. — Urinary tract infection is so common in children younger than age 2 years that a physician should almost always get a urine culture when working up a fever in a child that age, Dr. Nathan Kuppermann said at an emergency medicine conference sponsored by the University of California, Davis.

That includes getting a urine culture for febrile children younger than age 2 years who have a clinically documented viral infection, he said.

“Urinary tract infections in young febrile infants, particularly, are very common, and these viral infections are very common, so overlap occurs not infrequently,” said Dr. Kuppermann, professor of emergency medicine and pediatrics and chair of the department of emergency medicine at the university.

Studies have looked at concurrence of bacterial infection and viral croup, varicella, stomatitis, bronchiolitis, and influenza infection, and they suggest that a urinary tract infection can also be present about 3% of the time, he said.

Urinary tract infection (UTI) is probably the most important bacterial infection in children 0–3 months of age, because it is so common and because of its serious consequences. Urinary tract infection occurs in 5%–10% of children aged 0–3 months who have a fever above 38° C.

About half the time, the normal routine urinalysis performed for a child of that age will be normal even when there is an infection, Dr. Kuppermann noted. So, one should have a culture done, with Gram staining.

In children younger than age 3 months, UTI is more common in boys than girls. It only switches when they get older. In children younger than age 2 years overall, UTI accounts for 7%–8% of infections in girls with a temperature of 39° C or higher, and 2%–3% of boys with a temperature of 39° C or higher. Most of those boys, however, are uncircumcised. The rate among circumcised boys is 0.2%–0.4%, Dr. Kuppermann said.

The reason for the UTI vigilance is that the kidney is so much more susceptible to damage in the young. It is estimated that most UTIs that lead to renal damage occur in children younger than age 4 years, and especially in those younger than 1 year.

Approximately 13%–15% of end-stage renal disease may be related to an unrecognized, and untreated, UTI in early childhood, Dr. Kuppermann said.

INCLINE VALLEY, NEV. — Urinary tract infection is so common in children younger than age 2 years that a physician should almost always get a urine culture when working up a fever in a child that age, Dr. Nathan Kuppermann said at an emergency medicine conference sponsored by the University of California, Davis.

That includes getting a urine culture for febrile children younger than age 2 years who have a clinically documented viral infection, he said.

“Urinary tract infections in young febrile infants, particularly, are very common, and these viral infections are very common, so overlap occurs not infrequently,” said Dr. Kuppermann, professor of emergency medicine and pediatrics and chair of the department of emergency medicine at the university.

Studies have looked at concurrence of bacterial infection and viral croup, varicella, stomatitis, bronchiolitis, and influenza infection, and they suggest that a urinary tract infection can also be present about 3% of the time, he said.

Urinary tract infection (UTI) is probably the most important bacterial infection in children 0–3 months of age, because it is so common and because of its serious consequences. Urinary tract infection occurs in 5%–10% of children aged 0–3 months who have a fever above 38° C.

About half the time, the normal routine urinalysis performed for a child of that age will be normal even when there is an infection, Dr. Kuppermann noted. So, one should have a culture done, with Gram staining.

In children younger than age 3 months, UTI is more common in boys than girls. It only switches when they get older. In children younger than age 2 years overall, UTI accounts for 7%–8% of infections in girls with a temperature of 39° C or higher, and 2%–3% of boys with a temperature of 39° C or higher. Most of those boys, however, are uncircumcised. The rate among circumcised boys is 0.2%–0.4%, Dr. Kuppermann said.

The reason for the UTI vigilance is that the kidney is so much more susceptible to damage in the young. It is estimated that most UTIs that lead to renal damage occur in children younger than age 4 years, and especially in those younger than 1 year.

Approximately 13%–15% of end-stage renal disease may be related to an unrecognized, and untreated, UTI in early childhood, Dr. Kuppermann said.

INCLINE VALLEY, NEV. — Urinary tract infection is so common in children younger than age 2 years that a physician should almost always get a urine culture when working up a fever in a child that age, Dr. Nathan Kuppermann said at an emergency medicine conference sponsored by the University of California, Davis.

That includes getting a urine culture for febrile children younger than age 2 years who have a clinically documented viral infection, he said.

“Urinary tract infections in young febrile infants, particularly, are very common, and these viral infections are very common, so overlap occurs not infrequently,” said Dr. Kuppermann, professor of emergency medicine and pediatrics and chair of the department of emergency medicine at the university.

Studies have looked at concurrence of bacterial infection and viral croup, varicella, stomatitis, bronchiolitis, and influenza infection, and they suggest that a urinary tract infection can also be present about 3% of the time, he said.

Urinary tract infection (UTI) is probably the most important bacterial infection in children 0–3 months of age, because it is so common and because of its serious consequences. Urinary tract infection occurs in 5%–10% of children aged 0–3 months who have a fever above 38° C.

About half the time, the normal routine urinalysis performed for a child of that age will be normal even when there is an infection, Dr. Kuppermann noted. So, one should have a culture done, with Gram staining.

In children younger than age 3 months, UTI is more common in boys than girls. It only switches when they get older. In children younger than age 2 years overall, UTI accounts for 7%–8% of infections in girls with a temperature of 39° C or higher, and 2%–3% of boys with a temperature of 39° C or higher. Most of those boys, however, are uncircumcised. The rate among circumcised boys is 0.2%–0.4%, Dr. Kuppermann said.

The reason for the UTI vigilance is that the kidney is so much more susceptible to damage in the young. It is estimated that most UTIs that lead to renal damage occur in children younger than age 4 years, and especially in those younger than 1 year.

Approximately 13%–15% of end-stage renal disease may be related to an unrecognized, and untreated, UTI in early childhood, Dr. Kuppermann said.

SACRAMENTO — California's family doctors are not waiting for health care reform to come to them.

For the first time, the California Academy of Family Physicians split its Congress of Delegates meeting from its scientific assembly in order to bring the delegates here to the state capital.

While policy issues were discussed and debated by the congress, the main reason for the Sacramento sojourn was to introduce delegates to the workings of state government and the current politics of health care, and to have them make contact with their individual legislators.

Such preparation will help CAFP be ready to affect health care reform proposals while they are being considered and specifically to help the academy to push greater acceptance of the medical home concept, said Tiffany Hasker, director of communications for CAFP.

“The more physicians that talk about a topic, the better the policy that comes out of it,” said Dr. Joseph F. Leonard, a delegate who practices in San Diego.

To bolster their efforts, delegates were trained by Tom Riley, CAFP chief lobbyist in Sacramento. Mr. Riley led delegates in a workshop on how to talk to legislators.

Delegates also heard from a member of the California State Assembly, Dave Jones (D-Sacramento). Mr. Jones told delegates that a recent proposal for universal health insurance coverage in California was similar to the mandate adopted by Massachusetts, a plan that required state residents to have insurance but did not impose caps on premiums. The Massachusetts plan is now in trouble as health care costs have continued to rise and more residents than expected have signed up for state-subsidized health plans, costing the state more than was anticipated, Mr. Jones said.

Regarding progress on getting the medical home concept integrated into medical payment, Sandy Newman, director of health policy for CAFP, told the delegates that the Medicaid pilot program in North Carolina has shown that a medical home can reduce costs, with an estimated $60 million saved by the program in 2003, and an estimated $124 million in 2004.

The program, which was launched in 1998, incorporates the medical home concept, and compensates designated medical home physicians $2.50 per member per month, and it now covers 74% of the Medicaid population in the state, Ms. Newman said. With success like that for encouragement, Medicare now plans to initiate medical-home pilot projects in eight states, she added. The Congress of Delegates also addressed other issues and resolutions. New positions that were adopted include the following:

▸ Medical marijuana. The delegates passed a resolution supporting availability of medical marijuana, used under the care of a physician, for patients with chronic pain, nausea, vomiting, or wasting syndromes, for whom other medications are ineffective or intolerable. The resolution also calls for more research.

The position updates a previous statement, passed in 1994, that called for expediting availability to medical marijuana.

One objection raised against the resolution as it was proposed came from a delegate who was apprehensive about any position that supported smoking.

Since the CAFP already supported access, the new policy actually does not broaden their support, but rather limits it somewhat by better defining when it might be appropriate, said Dr. Carol Havens, a member of the CAFP board of directors, who practices in Sacramento.

“We don't want to be supporting the practice of treating the patient with bipolar disorder with marijuana,” she said.

▸ Hyde Amendment. The delegates supported a resolution calling on the AAFP to work for repeal the federal Hyde Amendment, passed in 1976, which bans the use of federal funds for abortion.

“It's just outright discriminatory,” said Dr. Norma Jo Waxman, a delegate from San Francisco. “It discriminates against poor women. It discriminates against our military women. And, it is just plain wrong.”

▸ Contraceptive access. The delegates voted to encourage California insurers to compensate physicians when they provide contraceptive services such as fitting an intrauterine device, and for providing coverage for a full 12-month supply of a contraceptive except where it is medically contraindicated.

SACRAMENTO — California's family doctors are not waiting for health care reform to come to them.

For the first time, the California Academy of Family Physicians split its Congress of Delegates meeting from its scientific assembly in order to bring the delegates here to the state capital.

While policy issues were discussed and debated by the congress, the main reason for the Sacramento sojourn was to introduce delegates to the workings of state government and the current politics of health care, and to have them make contact with their individual legislators.

Such preparation will help CAFP be ready to affect health care reform proposals while they are being considered and specifically to help the academy to push greater acceptance of the medical home concept, said Tiffany Hasker, director of communications for CAFP.

“The more physicians that talk about a topic, the better the policy that comes out of it,” said Dr. Joseph F. Leonard, a delegate who practices in San Diego.

To bolster their efforts, delegates were trained by Tom Riley, CAFP chief lobbyist in Sacramento. Mr. Riley led delegates in a workshop on how to talk to legislators.

Delegates also heard from a member of the California State Assembly, Dave Jones (D-Sacramento). Mr. Jones told delegates that a recent proposal for universal health insurance coverage in California was similar to the mandate adopted by Massachusetts, a plan that required state residents to have insurance but did not impose caps on premiums. The Massachusetts plan is now in trouble as health care costs have continued to rise and more residents than expected have signed up for state-subsidized health plans, costing the state more than was anticipated, Mr. Jones said.

Regarding progress on getting the medical home concept integrated into medical payment, Sandy Newman, director of health policy for CAFP, told the delegates that the Medicaid pilot program in North Carolina has shown that a medical home can reduce costs, with an estimated $60 million saved by the program in 2003, and an estimated $124 million in 2004.

The program, which was launched in 1998, incorporates the medical home concept, and compensates designated medical home physicians $2.50 per member per month, and it now covers 74% of the Medicaid population in the state, Ms. Newman said. With success like that for encouragement, Medicare now plans to initiate medical-home pilot projects in eight states, she added. The Congress of Delegates also addressed other issues and resolutions. New positions that were adopted include the following:

▸ Medical marijuana. The delegates passed a resolution supporting availability of medical marijuana, used under the care of a physician, for patients with chronic pain, nausea, vomiting, or wasting syndromes, for whom other medications are ineffective or intolerable. The resolution also calls for more research.

The position updates a previous statement, passed in 1994, that called for expediting availability to medical marijuana.

One objection raised against the resolution as it was proposed came from a delegate who was apprehensive about any position that supported smoking.

Since the CAFP already supported access, the new policy actually does not broaden their support, but rather limits it somewhat by better defining when it might be appropriate, said Dr. Carol Havens, a member of the CAFP board of directors, who practices in Sacramento.

“We don't want to be supporting the practice of treating the patient with bipolar disorder with marijuana,” she said.

▸ Hyde Amendment. The delegates supported a resolution calling on the AAFP to work for repeal the federal Hyde Amendment, passed in 1976, which bans the use of federal funds for abortion.

“It's just outright discriminatory,” said Dr. Norma Jo Waxman, a delegate from San Francisco. “It discriminates against poor women. It discriminates against our military women. And, it is just plain wrong.”

▸ Contraceptive access. The delegates voted to encourage California insurers to compensate physicians when they provide contraceptive services such as fitting an intrauterine device, and for providing coverage for a full 12-month supply of a contraceptive except where it is medically contraindicated.

SACRAMENTO — California's family doctors are not waiting for health care reform to come to them.

For the first time, the California Academy of Family Physicians split its Congress of Delegates meeting from its scientific assembly in order to bring the delegates here to the state capital.

While policy issues were discussed and debated by the congress, the main reason for the Sacramento sojourn was to introduce delegates to the workings of state government and the current politics of health care, and to have them make contact with their individual legislators.

Such preparation will help CAFP be ready to affect health care reform proposals while they are being considered and specifically to help the academy to push greater acceptance of the medical home concept, said Tiffany Hasker, director of communications for CAFP.

“The more physicians that talk about a topic, the better the policy that comes out of it,” said Dr. Joseph F. Leonard, a delegate who practices in San Diego.

To bolster their efforts, delegates were trained by Tom Riley, CAFP chief lobbyist in Sacramento. Mr. Riley led delegates in a workshop on how to talk to legislators.

Delegates also heard from a member of the California State Assembly, Dave Jones (D-Sacramento). Mr. Jones told delegates that a recent proposal for universal health insurance coverage in California was similar to the mandate adopted by Massachusetts, a plan that required state residents to have insurance but did not impose caps on premiums. The Massachusetts plan is now in trouble as health care costs have continued to rise and more residents than expected have signed up for state-subsidized health plans, costing the state more than was anticipated, Mr. Jones said.

Regarding progress on getting the medical home concept integrated into medical payment, Sandy Newman, director of health policy for CAFP, told the delegates that the Medicaid pilot program in North Carolina has shown that a medical home can reduce costs, with an estimated $60 million saved by the program in 2003, and an estimated $124 million in 2004.

The program, which was launched in 1998, incorporates the medical home concept, and compensates designated medical home physicians $2.50 per member per month, and it now covers 74% of the Medicaid population in the state, Ms. Newman said. With success like that for encouragement, Medicare now plans to initiate medical-home pilot projects in eight states, she added. The Congress of Delegates also addressed other issues and resolutions. New positions that were adopted include the following:

▸ Medical marijuana. The delegates passed a resolution supporting availability of medical marijuana, used under the care of a physician, for patients with chronic pain, nausea, vomiting, or wasting syndromes, for whom other medications are ineffective or intolerable. The resolution also calls for more research.

The position updates a previous statement, passed in 1994, that called for expediting availability to medical marijuana.

One objection raised against the resolution as it was proposed came from a delegate who was apprehensive about any position that supported smoking.

Since the CAFP already supported access, the new policy actually does not broaden their support, but rather limits it somewhat by better defining when it might be appropriate, said Dr. Carol Havens, a member of the CAFP board of directors, who practices in Sacramento.

“We don't want to be supporting the practice of treating the patient with bipolar disorder with marijuana,” she said.

▸ Hyde Amendment. The delegates supported a resolution calling on the AAFP to work for repeal the federal Hyde Amendment, passed in 1976, which bans the use of federal funds for abortion.

“It's just outright discriminatory,” said Dr. Norma Jo Waxman, a delegate from San Francisco. “It discriminates against poor women. It discriminates against our military women. And, it is just plain wrong.”

▸ Contraceptive access. The delegates voted to encourage California insurers to compensate physicians when they provide contraceptive services such as fitting an intrauterine device, and for providing coverage for a full 12-month supply of a contraceptive except where it is medically contraindicated.

SALT LAKE CITY — Surgery is not needed for pediatric patients with gastroesophageal reflux disease to prevent the likelihood that the patient will go on to develop Barrett's esophagus or adenocarcinoma, Dr. David Gremse said.

“Since the healing rates of erosive esophagitis are high [with medical management, particularly proton pump inhibitor therapy], the decision for surgery should focus on symptom relief and quality of life,” said Dr. Gremse at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

In adults, the literature suggests that nonerosive esophagitis does not usually become erosive disease, and erosive esophagitis does not usually progress to Barrett's, said Dr. Gremse, the chair of pediatrics at the University of Nevada, Las Vegas.

It is not certain whether a young child with erosive esophagitis eventually will be at risk for adenocarcinoma because of a lifetime of acid exposure. But, at least in adults, there appears to be very little progression. In one study that followed 100 adults with erosive esophagitis for 10 years, only 1 patient went on to develop Barrett's, Dr. Gremse noted. Another 5-year study suggested a progression rate of 3% from erosive esophagitis to Barrett's.

In fact, gastroesophageal reflux disease (GERD) can probably be said to have three distinct phenotypes: nonerosive esophagitis, which is associated with reflux symptoms, erosive esophagitis, which can lead to esophageal bleeding, ulcers and/or strictures, and Barrett's esophagus, which can become adenocarcinoma, he said.

Pediatric patients with nonerosive esophagitis or low-grade erosive esophagitis can be treated with a histamine₂-receptor antagonist or a proton pump inhibitor (PPI), which is much more effective, on an on-demand or intermittent basis. Those patients do not need to be set up for screening for Barrett's esophagus.

Patients with erosive disease should be treated with a PPI, he added. Studies of the treatment of children with PPIs have shown healing rates that are similar to the rates reported in adults, with complete healing reported for around 80% of patients.

SALT LAKE CITY — Surgery is not needed for pediatric patients with gastroesophageal reflux disease to prevent the likelihood that the patient will go on to develop Barrett's esophagus or adenocarcinoma, Dr. David Gremse said.

“Since the healing rates of erosive esophagitis are high [with medical management, particularly proton pump inhibitor therapy], the decision for surgery should focus on symptom relief and quality of life,” said Dr. Gremse at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

In adults, the literature suggests that nonerosive esophagitis does not usually become erosive disease, and erosive esophagitis does not usually progress to Barrett's, said Dr. Gremse, the chair of pediatrics at the University of Nevada, Las Vegas.

It is not certain whether a young child with erosive esophagitis eventually will be at risk for adenocarcinoma because of a lifetime of acid exposure. But, at least in adults, there appears to be very little progression. In one study that followed 100 adults with erosive esophagitis for 10 years, only 1 patient went on to develop Barrett's, Dr. Gremse noted. Another 5-year study suggested a progression rate of 3% from erosive esophagitis to Barrett's.

In fact, gastroesophageal reflux disease (GERD) can probably be said to have three distinct phenotypes: nonerosive esophagitis, which is associated with reflux symptoms, erosive esophagitis, which can lead to esophageal bleeding, ulcers and/or strictures, and Barrett's esophagus, which can become adenocarcinoma, he said.

Pediatric patients with nonerosive esophagitis or low-grade erosive esophagitis can be treated with a histamine₂-receptor antagonist or a proton pump inhibitor (PPI), which is much more effective, on an on-demand or intermittent basis. Those patients do not need to be set up for screening for Barrett's esophagus.

Patients with erosive disease should be treated with a PPI, he added. Studies of the treatment of children with PPIs have shown healing rates that are similar to the rates reported in adults, with complete healing reported for around 80% of patients.

SALT LAKE CITY — Surgery is not needed for pediatric patients with gastroesophageal reflux disease to prevent the likelihood that the patient will go on to develop Barrett's esophagus or adenocarcinoma, Dr. David Gremse said.

“Since the healing rates of erosive esophagitis are high [with medical management, particularly proton pump inhibitor therapy], the decision for surgery should focus on symptom relief and quality of life,” said Dr. Gremse at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

In adults, the literature suggests that nonerosive esophagitis does not usually become erosive disease, and erosive esophagitis does not usually progress to Barrett's, said Dr. Gremse, the chair of pediatrics at the University of Nevada, Las Vegas.

It is not certain whether a young child with erosive esophagitis eventually will be at risk for adenocarcinoma because of a lifetime of acid exposure. But, at least in adults, there appears to be very little progression. In one study that followed 100 adults with erosive esophagitis for 10 years, only 1 patient went on to develop Barrett's, Dr. Gremse noted. Another 5-year study suggested a progression rate of 3% from erosive esophagitis to Barrett's.

In fact, gastroesophageal reflux disease (GERD) can probably be said to have three distinct phenotypes: nonerosive esophagitis, which is associated with reflux symptoms, erosive esophagitis, which can lead to esophageal bleeding, ulcers and/or strictures, and Barrett's esophagus, which can become adenocarcinoma, he said.

Pediatric patients with nonerosive esophagitis or low-grade erosive esophagitis can be treated with a histamine₂-receptor antagonist or a proton pump inhibitor (PPI), which is much more effective, on an on-demand or intermittent basis. Those patients do not need to be set up for screening for Barrett's esophagus.

Patients with erosive disease should be treated with a PPI, he added. Studies of the treatment of children with PPIs have shown healing rates that are similar to the rates reported in adults, with complete healing reported for around 80% of patients.

Dehydroepiandrosterone supplementation appears to have some benefit in patients with primary adrenal insufficiency. But it does not change fat mass, improve cognitive or sexual function, or necessarily alleviate physical fatigue, according to a 12-month placebo-controlled trial involving 100 patients.

Dehydroepiandrosterone (DHEA) therapy does improve lean body mass, some aspects of well-being, and bone mineral density at the femoral neck, investigators reported.

The findings support a previous study they conducted, which found DHEA improved patients' sense of well-being, said Dr. Eleanor M. Gurnell of the department of medicine, Addenbrooke's Hospital, Cambridge, England, and colleagues (J. Clin. Endocrinol. Metab. 2008;93:400–9).

They assumed the well-being finding would hold up, and designed the current study to be large enough to provide statistically significant data on whether long-term supplementation would prevent bone density loss, which most Addison's patients experience and which does not improve with glucocorticoid and mineralocorticoid treatment.

Of 106 patients (62 women) with primary adrenal insufficiency, 100 took DHEA (50 mg daily) or placebo for the full 12 months. The median age of the subjects was 46 years, their median duration of having Addison's was 10–11 years.

Serum DHEA levels monitored during the study indicated good compliance by those taking active drug, and raised DHEA levels from decidedly below normal to within the physiologic range for a young adult.

At the outset, bone mineral density was low in the subjects, with about 39% of the men and women having density T scores indicative of osteopenia in the lumbar spine and femoral neck. After 12 months of treatment, the placebo group had a continued mean loss in both the spine and femoral neck. The treated group, however, had a mean gain in the femoral neck (0.004 g/cm

The treatment did not produce any different changes in body mass index, though it improved total lean body mass and relative truncal lean mass. It did not change fat mass.

Cognitive function measures using the National Adult Reading Test showed no improvement relative to placebo, even when a subanalysis only looked at patients aged over 45 years. Psychological status of the study subjects was measured using three instruments, the Short Form-36, the General Health Questionnaire-30, and the Multidimensional Fatigue Inventory-20. Overall, the study subjects had scores that were worse than those of the general population at baseline, and scores generally improved with DHEA treatment when the subjects were tested again at 12 months. They declined after a 1-month drug washout period at the end of the study.

But only two parameters of psychological status showed a mean improvement that was statistically significant relative to placebo. One was the role-emotional dimension of health on the Short Form-36 when measured at 12 months, and the other was the mental fatigue portion of the Multidimensional Fatigue Inventory-20 when measured at 6 months. By 12 months, there was no significant difference in the mental fatigue portion, however.

The fact that the study documented improvement in psychological status with DHEA treatment, together with a decline when treatment had been stopped for a month, indicated that there probably was some definite improvement, even if it was not statistically significant.

One of the largest differences seen in a psychological parameter at the beginning of the study was in the self-esteem component, a pattern that has been documented in other studies. It suggests there may be a specific psychological abnormality profile associated with Addison's disease.

Regarding side effects, 64% of 31 women on DHEA developed skin spots, 45% noted greasy skin, and 58% reported an increase in axillary hair. There were no observed changes in libido or sexual function in either gender.

The study was supported financially by the National Osteoporosis Society, National Institute for Health Research Biomedical Research Centre, and Wellcome Trust.

Dehydroepiandrosterone supplementation appears to have some benefit in patients with primary adrenal insufficiency. But it does not change fat mass, improve cognitive or sexual function, or necessarily alleviate physical fatigue, according to a 12-month placebo-controlled trial involving 100 patients.

Dehydroepiandrosterone (DHEA) therapy does improve lean body mass, some aspects of well-being, and bone mineral density at the femoral neck, investigators reported.

The findings support a previous study they conducted, which found DHEA improved patients' sense of well-being, said Dr. Eleanor M. Gurnell of the department of medicine, Addenbrooke's Hospital, Cambridge, England, and colleagues (J. Clin. Endocrinol. Metab. 2008;93:400–9).

They assumed the well-being finding would hold up, and designed the current study to be large enough to provide statistically significant data on whether long-term supplementation would prevent bone density loss, which most Addison's patients experience and which does not improve with glucocorticoid and mineralocorticoid treatment.

Of 106 patients (62 women) with primary adrenal insufficiency, 100 took DHEA (50 mg daily) or placebo for the full 12 months. The median age of the subjects was 46 years, their median duration of having Addison's was 10–11 years.

Serum DHEA levels monitored during the study indicated good compliance by those taking active drug, and raised DHEA levels from decidedly below normal to within the physiologic range for a young adult.

At the outset, bone mineral density was low in the subjects, with about 39% of the men and women having density T scores indicative of osteopenia in the lumbar spine and femoral neck. After 12 months of treatment, the placebo group had a continued mean loss in both the spine and femoral neck. The treated group, however, had a mean gain in the femoral neck (0.004 g/cm

The treatment did not produce any different changes in body mass index, though it improved total lean body mass and relative truncal lean mass. It did not change fat mass.

Cognitive function measures using the National Adult Reading Test showed no improvement relative to placebo, even when a subanalysis only looked at patients aged over 45 years. Psychological status of the study subjects was measured using three instruments, the Short Form-36, the General Health Questionnaire-30, and the Multidimensional Fatigue Inventory-20. Overall, the study subjects had scores that were worse than those of the general population at baseline, and scores generally improved with DHEA treatment when the subjects were tested again at 12 months. They declined after a 1-month drug washout period at the end of the study.

But only two parameters of psychological status showed a mean improvement that was statistically significant relative to placebo. One was the role-emotional dimension of health on the Short Form-36 when measured at 12 months, and the other was the mental fatigue portion of the Multidimensional Fatigue Inventory-20 when measured at 6 months. By 12 months, there was no significant difference in the mental fatigue portion, however.

The fact that the study documented improvement in psychological status with DHEA treatment, together with a decline when treatment had been stopped for a month, indicated that there probably was some definite improvement, even if it was not statistically significant.

One of the largest differences seen in a psychological parameter at the beginning of the study was in the self-esteem component, a pattern that has been documented in other studies. It suggests there may be a specific psychological abnormality profile associated with Addison's disease.

Regarding side effects, 64% of 31 women on DHEA developed skin spots, 45% noted greasy skin, and 58% reported an increase in axillary hair. There were no observed changes in libido or sexual function in either gender.

The study was supported financially by the National Osteoporosis Society, National Institute for Health Research Biomedical Research Centre, and Wellcome Trust.

Dehydroepiandrosterone supplementation appears to have some benefit in patients with primary adrenal insufficiency. But it does not change fat mass, improve cognitive or sexual function, or necessarily alleviate physical fatigue, according to a 12-month placebo-controlled trial involving 100 patients.

Dehydroepiandrosterone (DHEA) therapy does improve lean body mass, some aspects of well-being, and bone mineral density at the femoral neck, investigators reported.

The findings support a previous study they conducted, which found DHEA improved patients' sense of well-being, said Dr. Eleanor M. Gurnell of the department of medicine, Addenbrooke's Hospital, Cambridge, England, and colleagues (J. Clin. Endocrinol. Metab. 2008;93:400–9).

They assumed the well-being finding would hold up, and designed the current study to be large enough to provide statistically significant data on whether long-term supplementation would prevent bone density loss, which most Addison's patients experience and which does not improve with glucocorticoid and mineralocorticoid treatment.

Of 106 patients (62 women) with primary adrenal insufficiency, 100 took DHEA (50 mg daily) or placebo for the full 12 months. The median age of the subjects was 46 years, their median duration of having Addison's was 10–11 years.

Serum DHEA levels monitored during the study indicated good compliance by those taking active drug, and raised DHEA levels from decidedly below normal to within the physiologic range for a young adult.

At the outset, bone mineral density was low in the subjects, with about 39% of the men and women having density T scores indicative of osteopenia in the lumbar spine and femoral neck. After 12 months of treatment, the placebo group had a continued mean loss in both the spine and femoral neck. The treated group, however, had a mean gain in the femoral neck (0.004 g/cm

The treatment did not produce any different changes in body mass index, though it improved total lean body mass and relative truncal lean mass. It did not change fat mass.

Cognitive function measures using the National Adult Reading Test showed no improvement relative to placebo, even when a subanalysis only looked at patients aged over 45 years. Psychological status of the study subjects was measured using three instruments, the Short Form-36, the General Health Questionnaire-30, and the Multidimensional Fatigue Inventory-20. Overall, the study subjects had scores that were worse than those of the general population at baseline, and scores generally improved with DHEA treatment when the subjects were tested again at 12 months. They declined after a 1-month drug washout period at the end of the study.

But only two parameters of psychological status showed a mean improvement that was statistically significant relative to placebo. One was the role-emotional dimension of health on the Short Form-36 when measured at 12 months, and the other was the mental fatigue portion of the Multidimensional Fatigue Inventory-20 when measured at 6 months. By 12 months, there was no significant difference in the mental fatigue portion, however.

The fact that the study documented improvement in psychological status with DHEA treatment, together with a decline when treatment had been stopped for a month, indicated that there probably was some definite improvement, even if it was not statistically significant.

One of the largest differences seen in a psychological parameter at the beginning of the study was in the self-esteem component, a pattern that has been documented in other studies. It suggests there may be a specific psychological abnormality profile associated with Addison's disease.

Regarding side effects, 64% of 31 women on DHEA developed skin spots, 45% noted greasy skin, and 58% reported an increase in axillary hair. There were no observed changes in libido or sexual function in either gender.

The study was supported financially by the National Osteoporosis Society, National Institute for Health Research Biomedical Research Centre, and Wellcome Trust.

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not.

The mammography rates in those plans that adopted cost sharing declined by 5%.

In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375–83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65–69.

Among the 174 plans, only 3 had cost sharing in 2001; 9 had it in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks.

Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammogram within the past 2 years in 2000 (Cancer 2007;109:2405–9).

By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411–3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly.

But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach concluded.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not.

The mammography rates in those plans that adopted cost sharing declined by 5%.

In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375–83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65–69.

Among the 174 plans, only 3 had cost sharing in 2001; 9 had it in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks.

Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammogram within the past 2 years in 2000 (Cancer 2007;109:2405–9).

By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411–3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly.

But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach concluded.

ELSEVIER GLOBAL MEDICAL NEWS

Greater use of copayment and deductibles may be reducing the number of women seeking mammography, a new study of women enrolled in Medicare managed-care plans shows.

The investigators reviewed data from 174 plans and found that, on average, 77% of women in plans with full coverage had received their biennial screening, compared with 69% of women in plans with cost sharing for their health care visits.

In addition, the study reviewed seven plans that instituted a copayment or a deductible in 2003 and compared them with 14 plans that did not.

The mammography rates in those plans that adopted cost sharing declined by 5%.

In contrast, mammography rates increased 3% in 14 plans that did not institute cost sharing, reported Dr. Amal N. Trivedi of the department of community health at Brown University, Providence, R.I., and colleagues (N. Engl. J. Med. 2008;358:375–83).

The study used data from the Medicare Health Plan Employer Data and Information Set from 2001 to 2004, for 174 Medicare health plans and 366,475 women aged 65–69.

Among the 174 plans, only 3 had cost sharing in 2001; 9 had it in 2002, 10 in 2003, and 21 in 2004. The three plans with cost sharing in 2001 covered less than 1% of the women in the plans at that time. The 21 plans in 2004 covered 11%.

Copayments in the plans ranged from $12.50 to $35.

The study also found that black women and women with less education and lower incomes were more likely to be in cost-sharing plans. But the effect of cost sharing at reducing the rate of mammography was greater among whites than among blacks.

Among white patients, cost-sharing plans had an 8% lower mammography rate than did plans with no cost sharing. Among black patients, cost-sharing plans had a 4% lower mammography rate.

The adoption of cost sharing is increasing among health plans generally. Mammography rates appear to have declined since 2000, after increasing greatly throughout the 1990s, Dr. Trivedi wrote in the study, which was supported by a grant from the Agency for Healthcare Research and Quality.

One study that looked at mammography rates, conducted by researchers at the National Cancer Institute using a large, national database, reported that 70% of women had received a mammogram within the past 2 years in 2000 (Cancer 2007;109:2405–9).

By 2005, that figure had dropped to 66%.

In an accompanying editorial, Dr. Peter B. Bach said the study by Dr. Trivedi and colleagues showed a “large” impact relative to the “modest” copayments and deductibles imposed on the patients.

“Their findings are robust, with similar findings in unadjusted analyses and in multivariable analyses adjusted for potential demographic and regional confounders,” wrote Dr. Bach of the department of epidemiology and biostatistics, and the Health Outcomes Research Group, at Memorial Sloan-Kettering Cancer Center, New York (N. Engl. J. Med. 2008;358:411–3).

Noting that Dr. Trivedi and colleagues concluded that cost-sharing strategies apparently do more harm than good in mammography and should probably be waived for this important screening procedure, Dr. Bach said the study suggests a dilemma for insurers.

Deductibles and copayments are adopted by insurers to dissuade patients from using health care services extravagantly.

But in some cases, the strategy may backfire, resulting in higher costs and poorer health.

If, however, insurers choose to exempt some services from copayments or deductibles, they face the prospect of reconsidering all kinds of services and trusting that they can determine which ones are truly beneficial, he wrote.

It would be a very daunting task, he added.

The case of mammography is a particularly striking example, because mammography is a service that women tend to know is highly beneficial. Yet, the cost sharing kept 8% of consumers from seeking it out, Dr. Bach noted.

“This finding bodes poorly for the high-deductible movement, since one would expect that patients would make suboptimal decisions even more often in cases in which the health care service is more expensive, has received less publicity, has less rigorous quality control, or is more unpleasant or risky,” Dr. Bach concluded.

ELSEVIER GLOBAL MEDICAL NEWS

Acupuncture given with embryo transfer is associated with a significant 65% increase in the clinical pregnancy rate of women undergoing in vitro fertilization, according to a meta-analysis published online.

The number needed to treat to achieve an extra clinical pregnancy through acupuncture performed within 1 day of embryo transfer is 10; the odds ratio was 1.65. The number needed to treat to achieve an additional ongoing pregnancy (OR 1.87) or an additional live birth (OR 1.91) was 9 in both cases, reported Eric Manheimer, director of database and evaluation for the Center for Integrative Medicine at the University of Maryland, Baltimore, and his colleagues in a British Medical Journal report.

The researchers reviewed data from seven controlled trials they deemed to have been properly conducted, with a total of 1,366 women undergoing in vitro fertilization (IVF). In all trials, the acupuncture was performed within 1 day of embryo transfer, usually 25 minutes before transfer. In some trials, control women received sham acupuncture. In others, they received nothing (BMJ 2008 [doi:10.1136/bmj.39471.430451.BE]).

The way in which the acupuncture was performed varied somewhat among the trials, though in all but one trial the fixed selection of acupuncture points was similar. In all trials, the acupuncture sessions lasted 25–30 minutes.

Three trials also included one additional acupuncture session in addition to the sessions immediately before and after transfer; six trials also used ear acupuncture to supplement body acupuncture.

The analysis should not be construed as the last word on the subject, however, according to Dr. LaTasha B. Craig of the department of obstetrics and gynecology at Oklahoma University, Oklahoma City. Dr. Craig was not involved with the meta-analysis. “I think more research needs to be done,” she said in an interview.

Most of the studies used in the review, and in the medical literature generally, have used different protocols and had different types of control groups, making it difficult to compare or combine them, she noted.

In addition, Dr. Craig herself reported a trial at the American Society for Reproductive Medicine last October in which she found acupuncture was associated with a reduction in clinical pregnancies and live births. Her study comprised 113 subjects randomized to receive acupuncture before and after embryo transfer, using the same acupuncture points used in the trials in the review plus two additional points, or to a control group. The control subjects received no treatment.

The difference in her trial was that the acupuncturist was not on site at the fertility clinic, and so study participants had to drive back and forth between the acupuncturist and the clinic, a requirement that might have been stressful.

Her study recorded a clinical pregnancy rate of 46% in the acupuncture group vs. 72% in the control group, and a live birth rate of 39% with acupuncture versus 65% without treatment.

Dr. Craig also said that, given the way Chinese acupuncture is usually performed, it might be better to do it one or two times in the week before transfer rather than on the same day, and that approach needs to be explored.

According to Mr. Manheimer and his colleagues, the strengths of their review include the number of trials they were able to include and each of the trial's relatively large sample size. In addition, his group contacted the studies' investigators to get supplemental information and to ensure they were handling the data properly.

Regarding the fact that not all trials in the analysis included sham acupuncture, Mr. Manheimer and colleagues argued that sham procedures are not considered important in trials where there is an objective outcome.

On the other hand, one limitation of their review is that there were big differences in the baseline pregnancy and birth rates, they acknowledged.

If acupuncture does indeed increase the likelihood of pregnancy, and therefore reduces the need for costly repeat cycles, then it probably is cost effective, they added. Each IVF cycle costs an average of $12,400 in the United States.

Mr. Manheimer and his colleagues reported no financial conflicts of interest.

Acupuncture given with embryo transfer is associated with a significant 65% increase in the clinical pregnancy rate of women undergoing in vitro fertilization, according to a meta-analysis published online.

The number needed to treat to achieve an extra clinical pregnancy through acupuncture performed within 1 day of embryo transfer is 10; the odds ratio was 1.65. The number needed to treat to achieve an additional ongoing pregnancy (OR 1.87) or an additional live birth (OR 1.91) was 9 in both cases, reported Eric Manheimer, director of database and evaluation for the Center for Integrative Medicine at the University of Maryland, Baltimore, and his colleagues in a British Medical Journal report.

The researchers reviewed data from seven controlled trials they deemed to have been properly conducted, with a total of 1,366 women undergoing in vitro fertilization (IVF). In all trials, the acupuncture was performed within 1 day of embryo transfer, usually 25 minutes before transfer. In some trials, control women received sham acupuncture. In others, they received nothing (BMJ 2008 [doi:10.1136/bmj.39471.430451.BE]).

The way in which the acupuncture was performed varied somewhat among the trials, though in all but one trial the fixed selection of acupuncture points was similar. In all trials, the acupuncture sessions lasted 25–30 minutes.

Three trials also included one additional acupuncture session in addition to the sessions immediately before and after transfer; six trials also used ear acupuncture to supplement body acupuncture.

The analysis should not be construed as the last word on the subject, however, according to Dr. LaTasha B. Craig of the department of obstetrics and gynecology at Oklahoma University, Oklahoma City. Dr. Craig was not involved with the meta-analysis. “I think more research needs to be done,” she said in an interview.

Most of the studies used in the review, and in the medical literature generally, have used different protocols and had different types of control groups, making it difficult to compare or combine them, she noted.

In addition, Dr. Craig herself reported a trial at the American Society for Reproductive Medicine last October in which she found acupuncture was associated with a reduction in clinical pregnancies and live births. Her study comprised 113 subjects randomized to receive acupuncture before and after embryo transfer, using the same acupuncture points used in the trials in the review plus two additional points, or to a control group. The control subjects received no treatment.

The difference in her trial was that the acupuncturist was not on site at the fertility clinic, and so study participants had to drive back and forth between the acupuncturist and the clinic, a requirement that might have been stressful.

Her study recorded a clinical pregnancy rate of 46% in the acupuncture group vs. 72% in the control group, and a live birth rate of 39% with acupuncture versus 65% without treatment.

Dr. Craig also said that, given the way Chinese acupuncture is usually performed, it might be better to do it one or two times in the week before transfer rather than on the same day, and that approach needs to be explored.

According to Mr. Manheimer and his colleagues, the strengths of their review include the number of trials they were able to include and each of the trial's relatively large sample size. In addition, his group contacted the studies' investigators to get supplemental information and to ensure they were handling the data properly.

Regarding the fact that not all trials in the analysis included sham acupuncture, Mr. Manheimer and colleagues argued that sham procedures are not considered important in trials where there is an objective outcome.

On the other hand, one limitation of their review is that there were big differences in the baseline pregnancy and birth rates, they acknowledged.

If acupuncture does indeed increase the likelihood of pregnancy, and therefore reduces the need for costly repeat cycles, then it probably is cost effective, they added. Each IVF cycle costs an average of $12,400 in the United States.

Mr. Manheimer and his colleagues reported no financial conflicts of interest.

Acupuncture given with embryo transfer is associated with a significant 65% increase in the clinical pregnancy rate of women undergoing in vitro fertilization, according to a meta-analysis published online.

The number needed to treat to achieve an extra clinical pregnancy through acupuncture performed within 1 day of embryo transfer is 10; the odds ratio was 1.65. The number needed to treat to achieve an additional ongoing pregnancy (OR 1.87) or an additional live birth (OR 1.91) was 9 in both cases, reported Eric Manheimer, director of database and evaluation for the Center for Integrative Medicine at the University of Maryland, Baltimore, and his colleagues in a British Medical Journal report.

The researchers reviewed data from seven controlled trials they deemed to have been properly conducted, with a total of 1,366 women undergoing in vitro fertilization (IVF). In all trials, the acupuncture was performed within 1 day of embryo transfer, usually 25 minutes before transfer. In some trials, control women received sham acupuncture. In others, they received nothing (BMJ 2008 [doi:10.1136/bmj.39471.430451.BE]).

The way in which the acupuncture was performed varied somewhat among the trials, though in all but one trial the fixed selection of acupuncture points was similar. In all trials, the acupuncture sessions lasted 25–30 minutes.

Three trials also included one additional acupuncture session in addition to the sessions immediately before and after transfer; six trials also used ear acupuncture to supplement body acupuncture.

The analysis should not be construed as the last word on the subject, however, according to Dr. LaTasha B. Craig of the department of obstetrics and gynecology at Oklahoma University, Oklahoma City. Dr. Craig was not involved with the meta-analysis. “I think more research needs to be done,” she said in an interview.

Most of the studies used in the review, and in the medical literature generally, have used different protocols and had different types of control groups, making it difficult to compare or combine them, she noted.

In addition, Dr. Craig herself reported a trial at the American Society for Reproductive Medicine last October in which she found acupuncture was associated with a reduction in clinical pregnancies and live births. Her study comprised 113 subjects randomized to receive acupuncture before and after embryo transfer, using the same acupuncture points used in the trials in the review plus two additional points, or to a control group. The control subjects received no treatment.

The difference in her trial was that the acupuncturist was not on site at the fertility clinic, and so study participants had to drive back and forth between the acupuncturist and the clinic, a requirement that might have been stressful.

Her study recorded a clinical pregnancy rate of 46% in the acupuncture group vs. 72% in the control group, and a live birth rate of 39% with acupuncture versus 65% without treatment.

Dr. Craig also said that, given the way Chinese acupuncture is usually performed, it might be better to do it one or two times in the week before transfer rather than on the same day, and that approach needs to be explored.

According to Mr. Manheimer and his colleagues, the strengths of their review include the number of trials they were able to include and each of the trial's relatively large sample size. In addition, his group contacted the studies' investigators to get supplemental information and to ensure they were handling the data properly.

Regarding the fact that not all trials in the analysis included sham acupuncture, Mr. Manheimer and colleagues argued that sham procedures are not considered important in trials where there is an objective outcome.

On the other hand, one limitation of their review is that there were big differences in the baseline pregnancy and birth rates, they acknowledged.

If acupuncture does indeed increase the likelihood of pregnancy, and therefore reduces the need for costly repeat cycles, then it probably is cost effective, they added. Each IVF cycle costs an average of $12,400 in the United States.

Mr. Manheimer and his colleagues reported no financial conflicts of interest.

A new study of children with epilepsy has found that their bone mineral density declines steadily relative to controls, starting perhaps even in the first year of treatment.

The study compared 82 children with epilepsy with 32 age- and sex-matched, first-degree cousins, measuring their bone mineral density (BMD) with dual-energy x-ray absorptiometry. The 82 patients were all ambulatory and without any other conditions that might affect bone density, investigators reported. Their ages ranged from 6 to 18 years, with a mean age of 12 years.

The investigators found that the 18 subjects who had had epilepsy less than 1 year had a mean BMD z score of 0.23. The 37 subjects who had epilepsy for 1–5 years had a mean BMD z score of 0.13. And the 27 subjects who had epilepsy for 6 years or longer had a mean BMD z score of 0.06, reported Dr. Raj D. Sheth, director of the comprehensive epilepsy program at the University of Wisconsin, Madison, and colleagues.

By comparison, the control subjects had a mean BMD z score of 0.57.

The difference between the mean score of the control group and the mean score of the subjects who had had epilepsy for less than a year did not reach statistical significance; however, the difference between the controls and the other subjects did.

“These findings suggest that as little as 2 years of treatment could result in significant reductions in BMD,” Dr. Sheth wrote (Neurology 2008;70:170–6).

The study was not able to investigate the role of specific medications in the bone density loss observed, in part because many of the patients had been on more than one drug at some time in their treatment.

Information from adults suggests medication plays a role in bone density loss, but the cause is probably multifactorial, Dr. Sheth said.

The study did compare subjects with partial epilepsy with those with generalized epilepsy, however. The investigators found that while those with generalized epilepsy for longer than 1 year had a significantly lower mean z score than controls, those with partial epilepsy had a mean score that was only slightly lower. The difference was not statistically significant.

Interestingly, the study found that calcium intake for the study subjects was somewhat higher than national averages.

Two patients actually experienced a pathological fracture while the study was underway. The evidence suggests that 40% of fractures that occur in individuals with epilepsy are pathological; among children with epilepsy, it's 20%, Dr. Sheth said.

One of the fracture patients was a 17-year-old female who fractured her clavicle during a seizure and fractured her leg while walking. She had experienced epilepsy for 15 years and her z score was −3.5. The other patient had had epilepsy for 12 years and had a z score of −2.5. She fractured her arm during a fall.

In an editorial accompanying the study report, Dr. Edwin Trevathan noted that most physicians consider osteopenia and BMD loss to be a problem for white, postmenopausal women, and for patients who smoke, have renal disease, or take corticosteroids (Neurology 2008;70:166–7).

But a previous study found that young adults who have epilepsy have a risk of BMD loss or fracture that is 2–6 times greater than the general population.

“We can probably prevent epilepsy-associated [BMD] loss, and the published data now demand that we make this a priority in epilepsy research and clinical practice,” wrote Dr. Trevathan, director of the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention, Atlanta. “Early intervention shortly after starting treatment for epilepsy among children, adolescents, and young adults should probably be a focus of screening and prevention efforts. Among the elderly with new-onset epilepsy, screening and prevention efforts may need to be started as soon as antiseizure medications are initiated.”

Prophylactic treatment with calcium and vitamin D of children with epilepsy may be useful, but the correct dosage has never yet been determined, Dr. Sheth said.

The study was funded in part by an investigator-initiated grant from GlaxoSmithKline Inc., which makes treatments for epilepsy and osteoporosis. Dr. Trevathan previously served as an investigator for a GSK epilepsy treatment.

A new study of children with epilepsy has found that their bone mineral density declines steadily relative to controls, starting perhaps even in the first year of treatment.

The study compared 82 children with epilepsy with 32 age- and sex-matched, first-degree cousins, measuring their bone mineral density (BMD) with dual-energy x-ray absorptiometry. The 82 patients were all ambulatory and without any other conditions that might affect bone density, investigators reported. Their ages ranged from 6 to 18 years, with a mean age of 12 years.

The investigators found that the 18 subjects who had had epilepsy less than 1 year had a mean BMD z score of 0.23. The 37 subjects who had epilepsy for 1–5 years had a mean BMD z score of 0.13. And the 27 subjects who had epilepsy for 6 years or longer had a mean BMD z score of 0.06, reported Dr. Raj D. Sheth, director of the comprehensive epilepsy program at the University of Wisconsin, Madison, and colleagues.

By comparison, the control subjects had a mean BMD z score of 0.57.

The difference between the mean score of the control group and the mean score of the subjects who had had epilepsy for less than a year did not reach statistical significance; however, the difference between the controls and the other subjects did.

“These findings suggest that as little as 2 years of treatment could result in significant reductions in BMD,” Dr. Sheth wrote (Neurology 2008;70:170–6).

The study was not able to investigate the role of specific medications in the bone density loss observed, in part because many of the patients had been on more than one drug at some time in their treatment.

Information from adults suggests medication plays a role in bone density loss, but the cause is probably multifactorial, Dr. Sheth said.

The study did compare subjects with partial epilepsy with those with generalized epilepsy, however. The investigators found that while those with generalized epilepsy for longer than 1 year had a significantly lower mean z score than controls, those with partial epilepsy had a mean score that was only slightly lower. The difference was not statistically significant.

Interestingly, the study found that calcium intake for the study subjects was somewhat higher than national averages.

Two patients actually experienced a pathological fracture while the study was underway. The evidence suggests that 40% of fractures that occur in individuals with epilepsy are pathological; among children with epilepsy, it's 20%, Dr. Sheth said.

One of the fracture patients was a 17-year-old female who fractured her clavicle during a seizure and fractured her leg while walking. She had experienced epilepsy for 15 years and her z score was −3.5. The other patient had had epilepsy for 12 years and had a z score of −2.5. She fractured her arm during a fall.

In an editorial accompanying the study report, Dr. Edwin Trevathan noted that most physicians consider osteopenia and BMD loss to be a problem for white, postmenopausal women, and for patients who smoke, have renal disease, or take corticosteroids (Neurology 2008;70:166–7).

But a previous study found that young adults who have epilepsy have a risk of BMD loss or fracture that is 2–6 times greater than the general population.

“We can probably prevent epilepsy-associated [BMD] loss, and the published data now demand that we make this a priority in epilepsy research and clinical practice,” wrote Dr. Trevathan, director of the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention, Atlanta. “Early intervention shortly after starting treatment for epilepsy among children, adolescents, and young adults should probably be a focus of screening and prevention efforts. Among the elderly with new-onset epilepsy, screening and prevention efforts may need to be started as soon as antiseizure medications are initiated.”

Prophylactic treatment with calcium and vitamin D of children with epilepsy may be useful, but the correct dosage has never yet been determined, Dr. Sheth said.

The study was funded in part by an investigator-initiated grant from GlaxoSmithKline Inc., which makes treatments for epilepsy and osteoporosis. Dr. Trevathan previously served as an investigator for a GSK epilepsy treatment.

A new study of children with epilepsy has found that their bone mineral density declines steadily relative to controls, starting perhaps even in the first year of treatment.

The study compared 82 children with epilepsy with 32 age- and sex-matched, first-degree cousins, measuring their bone mineral density (BMD) with dual-energy x-ray absorptiometry. The 82 patients were all ambulatory and without any other conditions that might affect bone density, investigators reported. Their ages ranged from 6 to 18 years, with a mean age of 12 years.

The investigators found that the 18 subjects who had had epilepsy less than 1 year had a mean BMD z score of 0.23. The 37 subjects who had epilepsy for 1–5 years had a mean BMD z score of 0.13. And the 27 subjects who had epilepsy for 6 years or longer had a mean BMD z score of 0.06, reported Dr. Raj D. Sheth, director of the comprehensive epilepsy program at the University of Wisconsin, Madison, and colleagues.

By comparison, the control subjects had a mean BMD z score of 0.57.

The difference between the mean score of the control group and the mean score of the subjects who had had epilepsy for less than a year did not reach statistical significance; however, the difference between the controls and the other subjects did.

“These findings suggest that as little as 2 years of treatment could result in significant reductions in BMD,” Dr. Sheth wrote (Neurology 2008;70:170–6).

The study was not able to investigate the role of specific medications in the bone density loss observed, in part because many of the patients had been on more than one drug at some time in their treatment.

Information from adults suggests medication plays a role in bone density loss, but the cause is probably multifactorial, Dr. Sheth said.

The study did compare subjects with partial epilepsy with those with generalized epilepsy, however. The investigators found that while those with generalized epilepsy for longer than 1 year had a significantly lower mean z score than controls, those with partial epilepsy had a mean score that was only slightly lower. The difference was not statistically significant.

Interestingly, the study found that calcium intake for the study subjects was somewhat higher than national averages.

Two patients actually experienced a pathological fracture while the study was underway. The evidence suggests that 40% of fractures that occur in individuals with epilepsy are pathological; among children with epilepsy, it's 20%, Dr. Sheth said.

One of the fracture patients was a 17-year-old female who fractured her clavicle during a seizure and fractured her leg while walking. She had experienced epilepsy for 15 years and her z score was −3.5. The other patient had had epilepsy for 12 years and had a z score of −2.5. She fractured her arm during a fall.

In an editorial accompanying the study report, Dr. Edwin Trevathan noted that most physicians consider osteopenia and BMD loss to be a problem for white, postmenopausal women, and for patients who smoke, have renal disease, or take corticosteroids (Neurology 2008;70:166–7).

But a previous study found that young adults who have epilepsy have a risk of BMD loss or fracture that is 2–6 times greater than the general population.

“We can probably prevent epilepsy-associated [BMD] loss, and the published data now demand that we make this a priority in epilepsy research and clinical practice,” wrote Dr. Trevathan, director of the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention, Atlanta. “Early intervention shortly after starting treatment for epilepsy among children, adolescents, and young adults should probably be a focus of screening and prevention efforts. Among the elderly with new-onset epilepsy, screening and prevention efforts may need to be started as soon as antiseizure medications are initiated.”

Prophylactic treatment with calcium and vitamin D of children with epilepsy may be useful, but the correct dosage has never yet been determined, Dr. Sheth said.

The study was funded in part by an investigator-initiated grant from GlaxoSmithKline Inc., which makes treatments for epilepsy and osteoporosis. Dr. Trevathan previously served as an investigator for a GSK epilepsy treatment.