From MedscapeCME Clinical Briefs
News Author: Pauline Anderson
CME Author: Charles P. Vega, MD
CME/CE Released: 08/17/2010;
Clinical Context
Estimates of the prevalence of ASD vary from study to study, according to the authors of the current systematic review. However, it appears that these estimates have been increasing during the last several years, with rates as high as 116 per 10,000 individuals.
ASD affects boys approximately 4 times more often than girls, and symptoms of ASD usually begin in early childhood.
ASD promotes chronic disability for many patients;
only 3% to 10% of adults with autism are able to live independently.
SSRIs are the most frequently prescribed psychotropic medications for patients with ASD, and they may help to reduce anxiety and obsessive-compulsive symptoms common to ASD.
The current systematic review examines the efficacy and safety of SSRI treatment among patients with ASD.
Study Highlights
•Researchers examined randomized, placebo-controlled trials of SSRIs for patients with ASD. Study outcomes could include core features of ASD or other aspects of behavior, function, or quality of life.
•Included studies were published before December 2009.
•46 studies were found on the original search. These titles were pared to 5 studies of children and 2 studies of adults for the final data analysis. The total number of patients in these 7 studies was 271.
•The 5 studies of children included participants between the ages of 3 and 17 years. These protocols tested fenfluramine, fluoxetine, fluvoxamine, and citalopram. 2 studies focused exclusively on children with autism and intellectual impairment, and the others included children with ASD.
•None of the included research in children suggested that SSRIs could significantly improve core features of ASD in this population. Likewise, SSRIs did not appear to significantly reduce the clinical global impression or obsessive-compulsive symptoms.
•There were only minor improvements in children's behavior with SSRIs vs placebo.
•Citalopram was associated with a higher rate of adverse events vs placebo among children. In 1 child, prolonged seizures developed from use of citalopram. However, in another study, fluoxetine was not associated with a higher rate of adverse events vs placebo among children.
•Among adults, a study of 30 patients focused on fluvoxamine, and another study examined fluoxetine among 6 patients.
•There was some suggestion of global clinical improvement with SSRIs vs placebo in adults. Fluoxetine improved a measure of anxiety, but not depression. Fluvoxamine improved a measure of aggression.
•Fluvoxamine was associated with a significant improvement in obsessive-compulsive behaviors vs placebo, whereas fluoxetine was not.
•SSRIs were not associated with significant adverse events among adults.
•The reviewers conclude that SSRIs appear not to be beneficial and, in fact, may be harmful to children with ASD. Small studies among adults with ASD have indicated some efficacy and better tolerability of SSRI.
Clinical Implications
•The prevalence of ASD appears to have increased during the last several years. ASD affects boys approximately 4 times more often than girls, and symptoms of ASD usually begin in early childhood. Only 3% to 10% of adults with autism are able to live independently.
•The current systematic review finds that SSRIs are not helpful for children with ASD but may have more efficacy among adults with ASD.
Tuesday, August 31, 2010
Sunday, August 29, 2010
Metabolic Syndrome in Children and Adolescents
From U.S. Pharmacist
Kirandeep Panesar, BPharmS(Hons), MRPharmS, RPh, CPh
Introduction
There has been a renewed interest in metabolic syndrome in children in recent years in association with increasing childhood obesity, and the origins of metabolic syndrome have been traced back to childhood.[1] This article attempts to collate the information available so far and to describe the challenges currently faced in diagnosing and treating metabolic syndrome in children.
Description
Metabolic syndrome is a group of risk factors that increase a patient's chance of developing heart disease and diabetes, including abdominal obesity, dyslipidemia, glucose intolerance, and hypertension.[2] However, health care providers do not commonly recognize that these components may coexist in children and may lead to future atherosclerotic cardiovascular disease in young adults.[3]
Various attempts have been made to define metabolic syndrome in adults. Ford and Li describe metabolic syndrome as "a cluster of anthropometric, physiological, and biochemical abnormalities tied together by incompletely understood underlying mechanisms that predisposes those affected to development of diabetes and cardiovascular disease."[3] Washington defines metabolic syndrome as "a cluster of a variable number of risk factors that exceed criterion values. These risk factors include an increased waist circumference (central adiposity), systemic hypertension, elevated fasting plasma triglyceride, and an elevated fasting glucose or insulin resistance."[3] Metabolic syndrome is described by Zimmet et al as a "cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus, which include abdominal obesity, dyslipidaemia, glucose intolerance, and hypertension."[4] According to the Third Report of the National Cholesterol Education Program Adult Treatment Panel (ATP III), metabolic (or insulin resistance) syndrome is "the presence in an individual of at least three of the following five risk factors: central or abdominal obesity, hypertriglyceridemia, hypertension, low HDL cholesterol, and high fasting glucose levels."[5]
There is currently no uniform definition for metabolic syndrome in children. This poses a challenge for measuring prevalence, setting up screening measures, and establishing treatment protocols.[6,7] Furthermore, it is not possible to accurately compare the results of different studies measuring prevalence in children since the studies' threshold values vary. What is known so far is that the prevalence of metabolic syndrome in children is much lower than in adults.[8]
Management
In addition to helping patients and caregivers identify metabolic syndrome and understand the complex matrix of underlying issues, pharmacists can provide support and training for appropriate management. A number of approaches have been used to manage metabolic syndrome in children and reduce risks later in life; however, the primary focus is on lifestyle intervention. Specifically, lifestyle changes involving diet and physical activity are recommended by several expert authors as first-line therapy for overweight, hypertension, insulin resistance, and dyslipidemia.[5] One paper proposes that focusing treatment strategies on improving insulin sensitivity may be more beneficial than focusing on obesity reduction for preventing or delaying the onset of cardiovascular disease and type 2 diabetes in high-risk youths.[8] TABLE 2 lists American Academy of Pediatrics (AAP)–recommended target BMIs for determining which children need to reduce weight to be healthy.[5]
Since there is increasing evidence to support insulin resistance as the underlying cause of metabolic syndrome, treatment strategies are being developed to improve insulin sensitivity.[4] The cornerstones of treatment are diet and exercise intervention, nutritional intervention, and pharmacologic intervention.
Diet and Exercise Intervention
It is well established that lifestyle changes, such as diet and level of physical activity, are fundamental to prevention. Regular exercise not only improves response to a 2-hour glucose tolerance test, but also improves insulin sensitivity, even without weight loss.[5] It is thought that this action occurs through the activation of cellular glucose uptake independent of insulin.[5] Additionally, exercise is associated with lower blood pressure.
A recent study examining the effect of diet and exercise intervention on metabolic syndrome in overweight children indicated that metabolic syndrome can be reversed even with short-term lifestyle intervention.[16] The 16 study participants, aged 10 to 17 years, were given a complete physical examination and then underwent underwent a 14-day diet and exercise program. In addition to attending daily cooking classes and talks about nutrition, exercise, and general wellness, the subjects consumed a healthy, balanced diet containing less than 100 mg cholesterol and less than 1,600 mg sodium per day. Caffeinated beverages were not permitted. To meet the goal of increased physical activity and energy expenditure, the subjects engaged in 2 to 2.5 hours of supervised activity, including tennis, beach games, and gym-based exercises, each day. Before the intervention, seven subjects had metabolic syndrome based on parameters of insulin level, insulin resistance, body weight, cholesterol, and triglycerides, as well as blood pressure. In all subjects, all values except body weight were reduced post-intervention.
In an earlier study, high-intensity physical training for 8 months in overweight adolescents resulted in improvements in fasting plasma triglycerides, LDL particle size, and diastolic blood pressure, despite little change in body weight.[17] Non–weight-bearing activities, in particular, have been shown to be more acceptable to overweight children and to promote long-term health. Therefore, youthful patients should be directed to concentrate on cardiovascular training activities that are more enjoyable for children and adolescents.[18]
Similarly, a 12-week program based on the Kids N Fitness lifestyle intervention program had a positive effect on reducing risk factors for metabolic syndrome and insulin resistance in overweight children.[19] Parents and caregivers attended educational sessions about the comorbidities of obesity, and the children took part in an exercise program. The exercise sessions included cardiovascular training activities such as dodgeball, volleyball, jump rope, and running.[19] This was followed by family-centered educational sessions for both children and caregivers. Statistically significant improvements in BMI, systolic blood pressure, cholesterol and triglycerides, postprandial glucose, and leptin levels were seen in all children who completed the program.[19]
The CASPIAN study discovered an association between physical activity and metabolic syndrome in children that was independent of BMI and age.[1] The researchers used questionnaires to collect data regarding the children's level of physical activity.[1] The level of physical activity was assessed and categorized, and the measurements for metabolic syndrome were based on the criteria set forth by ATP III.[1]
In addition to providing advice on healthy eating and exercise, pharmacists can assist children and adolescents who need to lose weight by discouraging them from spending long periods of time in front of the television, supporting physical-education programs in schools, and helping create safe neighborhoods that promote physical activity.
Different authorities have proposed guidelines for healthy eating habits. The U.S. Department of Health and Human Services recommends that children and adolescents consume at least five fruits and vegetables a day and that no more than 30% of total calories per day comes from dietary fat. This program encourages increased consumption of whole grains and advises the avoidance of sweets, sodas, and other empty-calorie foods.[5]
The "stoplight diet," created by Epstein and Squires, divides foods into three categories: green (foods that can be eaten at any time), yellow (foods that are eaten within limits), and red (foods that should be avoided).[5] The AAP takes a slightly different approach, guiding parents and families to make lifestyle changes by teaching them strategies to promote and maintain healthy eating habits and physical activity.[20] While the majority of patients should be referred to a dietitian when making drastic changes to their diet, pharmacists should have a basic understanding of healthy eating habits to better guide their patients.
Nutritional Intervention
Grains, fiber, and phytoestrogens are the primary nutrients that have beneficial effects on insulin sensitivity.[8] Pharmacists and dietitians should encourage patients to regularly consume foods such as soy, flaxseed, whole-grain cereals, fruits, and vegetables, which contain high levels of these nutrients.
Pharmacologic Intervention
Drug therapy with insulin sensitizers, including metformin and thiazolidinediones (TZDs), has shown positive effects. A recent systemic review showed that individually tailored lifestyle interventions, when combined with metformin, demonstrated a reduction in fasting insulin and BMI in children and adolescents with insulin resistance.[21] TZDs are useful insulin sensitizers that enhance glucose uptake via their activation of peroxisome proliferator-activated receptor gamma.[13] The primary effect of TZDs is on the adipose tissue, where they favorably alter the production of inflammatory molecules that contribute to the many components of metabolic syndrome.[4]
In addition to the above, some patients may require drug therapy for hypertension and/or hypercholesterolemia, since at present each component of the syndrome is treated separately.[4]
Conclusion
Since a large percentage of youths with metabolic syndrome probably will develop type 2 diabetes and cardiovascular disorders later in life, it is important that health care providers develop and test primary prevention strategies to manage childhood metabolic syndrome.[3] By building close relationships with their patients and opening up communication, pharmacists can help identify candidates for diagnosis, provide support for patients and their families in making lifestyle changes, and advise patients on the correct use of their medications.
Kirandeep Panesar, BPharmS(Hons), MRPharmS, RPh, CPh
Introduction
There has been a renewed interest in metabolic syndrome in children in recent years in association with increasing childhood obesity, and the origins of metabolic syndrome have been traced back to childhood.[1] This article attempts to collate the information available so far and to describe the challenges currently faced in diagnosing and treating metabolic syndrome in children.
Description
Metabolic syndrome is a group of risk factors that increase a patient's chance of developing heart disease and diabetes, including abdominal obesity, dyslipidemia, glucose intolerance, and hypertension.[2] However, health care providers do not commonly recognize that these components may coexist in children and may lead to future atherosclerotic cardiovascular disease in young adults.[3]
Various attempts have been made to define metabolic syndrome in adults. Ford and Li describe metabolic syndrome as "a cluster of anthropometric, physiological, and biochemical abnormalities tied together by incompletely understood underlying mechanisms that predisposes those affected to development of diabetes and cardiovascular disease."[3] Washington defines metabolic syndrome as "a cluster of a variable number of risk factors that exceed criterion values. These risk factors include an increased waist circumference (central adiposity), systemic hypertension, elevated fasting plasma triglyceride, and an elevated fasting glucose or insulin resistance."[3] Metabolic syndrome is described by Zimmet et al as a "cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus, which include abdominal obesity, dyslipidaemia, glucose intolerance, and hypertension."[4] According to the Third Report of the National Cholesterol Education Program Adult Treatment Panel (ATP III), metabolic (or insulin resistance) syndrome is "the presence in an individual of at least three of the following five risk factors: central or abdominal obesity, hypertriglyceridemia, hypertension, low HDL cholesterol, and high fasting glucose levels."[5]
There is currently no uniform definition for metabolic syndrome in children. This poses a challenge for measuring prevalence, setting up screening measures, and establishing treatment protocols.[6,7] Furthermore, it is not possible to accurately compare the results of different studies measuring prevalence in children since the studies' threshold values vary. What is known so far is that the prevalence of metabolic syndrome in children is much lower than in adults.[8]
Management
In addition to helping patients and caregivers identify metabolic syndrome and understand the complex matrix of underlying issues, pharmacists can provide support and training for appropriate management. A number of approaches have been used to manage metabolic syndrome in children and reduce risks later in life; however, the primary focus is on lifestyle intervention. Specifically, lifestyle changes involving diet and physical activity are recommended by several expert authors as first-line therapy for overweight, hypertension, insulin resistance, and dyslipidemia.[5] One paper proposes that focusing treatment strategies on improving insulin sensitivity may be more beneficial than focusing on obesity reduction for preventing or delaying the onset of cardiovascular disease and type 2 diabetes in high-risk youths.[8] TABLE 2 lists American Academy of Pediatrics (AAP)–recommended target BMIs for determining which children need to reduce weight to be healthy.[5]
Since there is increasing evidence to support insulin resistance as the underlying cause of metabolic syndrome, treatment strategies are being developed to improve insulin sensitivity.[4] The cornerstones of treatment are diet and exercise intervention, nutritional intervention, and pharmacologic intervention.
Diet and Exercise Intervention
It is well established that lifestyle changes, such as diet and level of physical activity, are fundamental to prevention. Regular exercise not only improves response to a 2-hour glucose tolerance test, but also improves insulin sensitivity, even without weight loss.[5] It is thought that this action occurs through the activation of cellular glucose uptake independent of insulin.[5] Additionally, exercise is associated with lower blood pressure.
A recent study examining the effect of diet and exercise intervention on metabolic syndrome in overweight children indicated that metabolic syndrome can be reversed even with short-term lifestyle intervention.[16] The 16 study participants, aged 10 to 17 years, were given a complete physical examination and then underwent underwent a 14-day diet and exercise program. In addition to attending daily cooking classes and talks about nutrition, exercise, and general wellness, the subjects consumed a healthy, balanced diet containing less than 100 mg cholesterol and less than 1,600 mg sodium per day. Caffeinated beverages were not permitted. To meet the goal of increased physical activity and energy expenditure, the subjects engaged in 2 to 2.5 hours of supervised activity, including tennis, beach games, and gym-based exercises, each day. Before the intervention, seven subjects had metabolic syndrome based on parameters of insulin level, insulin resistance, body weight, cholesterol, and triglycerides, as well as blood pressure. In all subjects, all values except body weight were reduced post-intervention.
In an earlier study, high-intensity physical training for 8 months in overweight adolescents resulted in improvements in fasting plasma triglycerides, LDL particle size, and diastolic blood pressure, despite little change in body weight.[17] Non–weight-bearing activities, in particular, have been shown to be more acceptable to overweight children and to promote long-term health. Therefore, youthful patients should be directed to concentrate on cardiovascular training activities that are more enjoyable for children and adolescents.[18]
Similarly, a 12-week program based on the Kids N Fitness lifestyle intervention program had a positive effect on reducing risk factors for metabolic syndrome and insulin resistance in overweight children.[19] Parents and caregivers attended educational sessions about the comorbidities of obesity, and the children took part in an exercise program. The exercise sessions included cardiovascular training activities such as dodgeball, volleyball, jump rope, and running.[19] This was followed by family-centered educational sessions for both children and caregivers. Statistically significant improvements in BMI, systolic blood pressure, cholesterol and triglycerides, postprandial glucose, and leptin levels were seen in all children who completed the program.[19]
The CASPIAN study discovered an association between physical activity and metabolic syndrome in children that was independent of BMI and age.[1] The researchers used questionnaires to collect data regarding the children's level of physical activity.[1] The level of physical activity was assessed and categorized, and the measurements for metabolic syndrome were based on the criteria set forth by ATP III.[1]
In addition to providing advice on healthy eating and exercise, pharmacists can assist children and adolescents who need to lose weight by discouraging them from spending long periods of time in front of the television, supporting physical-education programs in schools, and helping create safe neighborhoods that promote physical activity.
Different authorities have proposed guidelines for healthy eating habits. The U.S. Department of Health and Human Services recommends that children and adolescents consume at least five fruits and vegetables a day and that no more than 30% of total calories per day comes from dietary fat. This program encourages increased consumption of whole grains and advises the avoidance of sweets, sodas, and other empty-calorie foods.[5]
The "stoplight diet," created by Epstein and Squires, divides foods into three categories: green (foods that can be eaten at any time), yellow (foods that are eaten within limits), and red (foods that should be avoided).[5] The AAP takes a slightly different approach, guiding parents and families to make lifestyle changes by teaching them strategies to promote and maintain healthy eating habits and physical activity.[20] While the majority of patients should be referred to a dietitian when making drastic changes to their diet, pharmacists should have a basic understanding of healthy eating habits to better guide their patients.
Nutritional Intervention
Grains, fiber, and phytoestrogens are the primary nutrients that have beneficial effects on insulin sensitivity.[8] Pharmacists and dietitians should encourage patients to regularly consume foods such as soy, flaxseed, whole-grain cereals, fruits, and vegetables, which contain high levels of these nutrients.
Pharmacologic Intervention
Drug therapy with insulin sensitizers, including metformin and thiazolidinediones (TZDs), has shown positive effects. A recent systemic review showed that individually tailored lifestyle interventions, when combined with metformin, demonstrated a reduction in fasting insulin and BMI in children and adolescents with insulin resistance.[21] TZDs are useful insulin sensitizers that enhance glucose uptake via their activation of peroxisome proliferator-activated receptor gamma.[13] The primary effect of TZDs is on the adipose tissue, where they favorably alter the production of inflammatory molecules that contribute to the many components of metabolic syndrome.[4]
In addition to the above, some patients may require drug therapy for hypertension and/or hypercholesterolemia, since at present each component of the syndrome is treated separately.[4]
Conclusion
Since a large percentage of youths with metabolic syndrome probably will develop type 2 diabetes and cardiovascular disorders later in life, it is important that health care providers develop and test primary prevention strategies to manage childhood metabolic syndrome.[3] By building close relationships with their patients and opening up communication, pharmacists can help identify candidates for diagnosis, provide support for patients and their families in making lifestyle changes, and advise patients on the correct use of their medications.
Giving Influenza Vaccine to Egg-Allergic Patients
From Medscape Pediatrics > Viewpoints
William T. Basco, Jr., MD
Pediatrics. 2010;125:e1024-e1030
Study Summary
In this article, Chung, Huang, and Schneider review the conflicted state of affairs with respect to giving influenza vaccine to patients with egg allergy. Given that many patients with egg allergy also have asthma, which places them at high risk for morbidity from influenza illness, the patients who might benefit most from influenza vaccination have difficulty getting it.
The current approach for administration of influenza vaccine to patients with egg allergy involves 3 steps:
(1) skin prick testing with the vaccine;
(2) administration of a low dose of vaccine; and
(3) administration of the remainder of the vaccine. The sequence is completed only if the patient does not react at each successive stage.
The aim of this study was to determine the safety of skipping the first stage, skin prick testing.
The investigators reviewed the outcomes of patients with egg allergy who were immunized against influenza at 1 institution from the 2002/2003 influenza season to the 2008/2009 season.
The participants were 6 months to 18 years old; all had egg allergy as determined by a series of criteria that included skin test results, RAST test results, and history of clinical allergic reaction to egg.
During the first 5 influenza seasons studied, the institution followed the 3-step protocol of skin testing, followed by administration of 10% of the vaccine dose (followed by 30 minutes of observation), followed by administration of the remaining 90% of the vaccine dose.
During the last 3 seasons evaluated, the investigators eliminated the skin-testing step and gave the influenza vaccine in the graded fashion. The clinical notes included data about both local and systemic reactions (urticaria, wheezing, or exacerbation of eczema). They skin-tested 146 participants before influenza vaccination during the first 5 influenza seasons. Ninety-one (62.3%) had a positive skin-prick test, and 55 had negative skin tests (53 of whom received influenza vaccine). Three subjects with a positive skin-prick test still received the influenza vaccine. Therefore, 56 participants received influenza vaccine under the 3-step protocol compared with 115 who received the vaccine later under the 2-step protocol.
A large majority of participants in both the 3-step group and the 2-step group had allergies to more than 1 food (91% and 84%, respectively) and had atopic dermatitis (71% and 64%, respectively). The groups were slightly different in other ways; specifically, the 3-step group had a higher mean age (6.2 years vs 3.9 years), a higher frequency of asthma (76.8% vs 49.6%), and higher rates of allergic rhinitis. Many of the differences were a result of a change in influenza vaccine recommendations during the study period such that the later period included more patients without asthma and younger children who had egg allergy. The study authors attempted to adjust for these between-group differences by using propensity scores in their regression analyses. No differences were seen in the percentages of participants who tolerated influenza vaccine without any reaction (78.6% in the 3-step group and 79.1% in the 2-step group). The frequency of tolerating vaccine without a systemic reaction was 94.6% and 96.5%, respectively, in the 3-step and 2-step groups. Seven subjects (3 in the 3-step group and 4 in the 2-step group) had systemic adverse reactions, and another 29 experienced localized adverse reactions. None of the participants experienced anaphylaxis. The investigators concluded that the influenza vaccine can be administered safely to patients with egg allergy in a graded approach, without first conducting skin prick testing.
Viewpoint
Although propensity scores can eliminate bias, they do not eliminate all bias. It is difficult to know how much the differences between groups might have affected the outcomes, but the raw percentages for adverse reactions are similar despite the differences in the patient populations. The investigators reviewed several advantages of skipping the skin-testing step, including the time required to administer and observe the test, the fact that patients must discontinue antihistamines prior to skin testing, and the fact that false-positive skin-testing results can occur from local irritation reactions. It is also important to remember that none of these subjects had a history of anaphylactic reaction to eggs, so these results should not be extended to that high-risk group.
Abstract
William T. Basco, Jr., MD
Pediatrics. 2010;125:e1024-e1030
Study Summary
In this article, Chung, Huang, and Schneider review the conflicted state of affairs with respect to giving influenza vaccine to patients with egg allergy. Given that many patients with egg allergy also have asthma, which places them at high risk for morbidity from influenza illness, the patients who might benefit most from influenza vaccination have difficulty getting it.
The current approach for administration of influenza vaccine to patients with egg allergy involves 3 steps:
(1) skin prick testing with the vaccine;
(2) administration of a low dose of vaccine; and
(3) administration of the remainder of the vaccine. The sequence is completed only if the patient does not react at each successive stage.
The aim of this study was to determine the safety of skipping the first stage, skin prick testing.
The investigators reviewed the outcomes of patients with egg allergy who were immunized against influenza at 1 institution from the 2002/2003 influenza season to the 2008/2009 season.
The participants were 6 months to 18 years old; all had egg allergy as determined by a series of criteria that included skin test results, RAST test results, and history of clinical allergic reaction to egg.
During the first 5 influenza seasons studied, the institution followed the 3-step protocol of skin testing, followed by administration of 10% of the vaccine dose (followed by 30 minutes of observation), followed by administration of the remaining 90% of the vaccine dose.
During the last 3 seasons evaluated, the investigators eliminated the skin-testing step and gave the influenza vaccine in the graded fashion. The clinical notes included data about both local and systemic reactions (urticaria, wheezing, or exacerbation of eczema). They skin-tested 146 participants before influenza vaccination during the first 5 influenza seasons. Ninety-one (62.3%) had a positive skin-prick test, and 55 had negative skin tests (53 of whom received influenza vaccine). Three subjects with a positive skin-prick test still received the influenza vaccine. Therefore, 56 participants received influenza vaccine under the 3-step protocol compared with 115 who received the vaccine later under the 2-step protocol.
A large majority of participants in both the 3-step group and the 2-step group had allergies to more than 1 food (91% and 84%, respectively) and had atopic dermatitis (71% and 64%, respectively). The groups were slightly different in other ways; specifically, the 3-step group had a higher mean age (6.2 years vs 3.9 years), a higher frequency of asthma (76.8% vs 49.6%), and higher rates of allergic rhinitis. Many of the differences were a result of a change in influenza vaccine recommendations during the study period such that the later period included more patients without asthma and younger children who had egg allergy. The study authors attempted to adjust for these between-group differences by using propensity scores in their regression analyses. No differences were seen in the percentages of participants who tolerated influenza vaccine without any reaction (78.6% in the 3-step group and 79.1% in the 2-step group). The frequency of tolerating vaccine without a systemic reaction was 94.6% and 96.5%, respectively, in the 3-step and 2-step groups. Seven subjects (3 in the 3-step group and 4 in the 2-step group) had systemic adverse reactions, and another 29 experienced localized adverse reactions. None of the participants experienced anaphylaxis. The investigators concluded that the influenza vaccine can be administered safely to patients with egg allergy in a graded approach, without first conducting skin prick testing.
Viewpoint
Although propensity scores can eliminate bias, they do not eliminate all bias. It is difficult to know how much the differences between groups might have affected the outcomes, but the raw percentages for adverse reactions are similar despite the differences in the patient populations. The investigators reviewed several advantages of skipping the skin-testing step, including the time required to administer and observe the test, the fact that patients must discontinue antihistamines prior to skin testing, and the fact that false-positive skin-testing results can occur from local irritation reactions. It is also important to remember that none of these subjects had a history of anaphylactic reaction to eggs, so these results should not be extended to that high-risk group.
Abstract
Headache in Teens Related to Lack of Exercise, Weight Gain, Smoking
From Medscape Medical News
Allison Gandey
August 19, 2010 — Teenagers who get little exercise, are overweight, or who smoke are more likely to have frequent headaches or migraines, report researchers.
"There was a significant trend for stronger associations between the number of negative lifestyle factors that were present and the different headache diagnoses and headache frequency," point out the investigators led by John-Anker Zwart, MD, from Oslo University in Norway. "We believe that the associations observed and the additive effect of these negative lifestyle factors on the prevalence of recurrent headache strongly indicates that these lifestyle factors are possible targets for headache preventive measures."
The new study appears in the August 18 issue of Neurology. As part of the cross-sectional study, researchers interviewed more than 5500 students about headache complaints. The adolescents also completed a questionnaire and underwent a clinical examination with height and weight measurements.
Investigators classified adolescents who were very physically fit and who were not current smokers as having a good lifestyle. Negative lifestyle factors were surprisingly common with low physical activity in 31%, smoking in 19%, and overweight in 16% of these teens.
In adjusted multivariate analyses, recurrent headache was associated with overweight (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2 – 1.6; P < .0001), low physical activity (OR, 1.2; 95% CI, 1.1 – 1.4; P = .002), and smoking (OR, 1.5; 95% CI, 1.3 – 1.7; P < .0001). The presence of more than 1 negative lifestyle factor heightened the risk of headache.
This study shows overweight, low physical activity, and smoking are independently and in combination associated with recurrent headache among adolescents, report the study authors.
In an accompanying editorial, Dr. Andrew Hershey and Dr. Richard Lipton say that "this study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders."
Dr. Hershey is at the University of Cincinnati in Ohio and Dr. Lipton is at the Albert Einstein College of Medicine in the Bronx, New York. They point out the effects of each negative lifestyle factor were similar in magnitude for each headache type. "This lack of specificity for headache type raises the possibility that these factors may be associated not just with headache but with all-cause pain."
These results mirror those of another study published in June in the journal Headache. Investigators led by Rudiger von Kries, MD, from Ludwig-Maximilians-University in Munich, Germany, found that being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent headaches in adolescents.
The study included 1260 students, and after controlling for socioeconomic variables, the prevalence of any headache was increased in teens who reported regularly drinking cocktails (OR, 2.0; 95% CI, 1.3 – 3.0), who drank at least 1 cup of coffee per day (OR, 2.0; 95% CI, 1.2 – 3.5), and who were physically less active (OR, 2.0; 95% CI, 1.3 – 3.1). Smoking daily had an OR of 1.8.
These findings, say editorialists, suggest that a better understanding of modifiable risk factors and trigger factors may lead to novel intervention strategies.
Neurology. 2010;75:712-717.
Allison Gandey
August 19, 2010 — Teenagers who get little exercise, are overweight, or who smoke are more likely to have frequent headaches or migraines, report researchers.
"There was a significant trend for stronger associations between the number of negative lifestyle factors that were present and the different headache diagnoses and headache frequency," point out the investigators led by John-Anker Zwart, MD, from Oslo University in Norway. "We believe that the associations observed and the additive effect of these negative lifestyle factors on the prevalence of recurrent headache strongly indicates that these lifestyle factors are possible targets for headache preventive measures."
The new study appears in the August 18 issue of Neurology. As part of the cross-sectional study, researchers interviewed more than 5500 students about headache complaints. The adolescents also completed a questionnaire and underwent a clinical examination with height and weight measurements.
Investigators classified adolescents who were very physically fit and who were not current smokers as having a good lifestyle. Negative lifestyle factors were surprisingly common with low physical activity in 31%, smoking in 19%, and overweight in 16% of these teens.
In adjusted multivariate analyses, recurrent headache was associated with overweight (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2 – 1.6; P < .0001), low physical activity (OR, 1.2; 95% CI, 1.1 – 1.4; P = .002), and smoking (OR, 1.5; 95% CI, 1.3 – 1.7; P < .0001). The presence of more than 1 negative lifestyle factor heightened the risk of headache.
This study shows overweight, low physical activity, and smoking are independently and in combination associated with recurrent headache among adolescents, report the study authors.
In an accompanying editorial, Dr. Andrew Hershey and Dr. Richard Lipton say that "this study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders."
Dr. Hershey is at the University of Cincinnati in Ohio and Dr. Lipton is at the Albert Einstein College of Medicine in the Bronx, New York. They point out the effects of each negative lifestyle factor were similar in magnitude for each headache type. "This lack of specificity for headache type raises the possibility that these factors may be associated not just with headache but with all-cause pain."
These results mirror those of another study published in June in the journal Headache. Investigators led by Rudiger von Kries, MD, from Ludwig-Maximilians-University in Munich, Germany, found that being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent headaches in adolescents.
The study included 1260 students, and after controlling for socioeconomic variables, the prevalence of any headache was increased in teens who reported regularly drinking cocktails (OR, 2.0; 95% CI, 1.3 – 3.0), who drank at least 1 cup of coffee per day (OR, 2.0; 95% CI, 1.2 – 3.5), and who were physically less active (OR, 2.0; 95% CI, 1.3 – 3.1). Smoking daily had an OR of 1.8.
These findings, say editorialists, suggest that a better understanding of modifiable risk factors and trigger factors may lead to novel intervention strategies.
Neurology. 2010;75:712-717.
allergies - simple to severe slide show
http://www.medscape.com/features/slideshow/allergic-reactions?src=mp&spon=17&uac=23823SG
Saturday, August 28, 2010
New 13-Valent Pneumococcal Vaccine Expands Protection in Young Children
From Reuters Health Information
NEW YORK (Reuters Health) Aug 23 - The 13-valent pneumococcal conjugate vaccine (PCV13) is as effective as the seven-valent vaccine against the original seven pneumococcal serotypes and should provide further protection against the six additional serotypes, a multicenter team reports.
PCV13, also known by the brand name Prevnar 13 (Wyeth), was approved by the US Food and Drug Administration in February 2010 for preventing invasive pneumococcal disease in children aged 6 weeks to 71 months.
One of the pivotal studies of the immunogenicity and safety of PCV13 in infants and toddlers appeared online today in Pediatrics.
Lead author Dr. Sylvia H. Yeh, at the UCLA-Kaiser Vaccine Research Center in Torrance, California, and colleagues explain that the 7-valent pneumococcal conjugate vaccine (PCV7) covers the serotypes that caused up to 90% of invasive disease in the U.S. before its introduction.
"The widespread use of PCV7 in the U.S. has dramatically reduced the burden of this disease in children, with herd immunity benefiting adults as well," she said in an e-mail. "However, pneumococcal disease still occurs in the U.S. due to replacement serotypes."
The six additional serotypes in PCV13 account for up to 92% of invasive cases worldwide in children under five. "Whereas the potential impact of PCV7 was limited in certain countries such as Africa and Asia, PCV13 potentially expands the impact of disease prevention through vaccine use in these countries," Dr. Yeh said.
The current study compared PCV13 with PCV7 in terms of immunogenicity and safety in toddlers and infants. Ultimately, the authors report, "The evaluable immunogenicity populations consisted of 504 infants (PCV13: 252; PCV7: 252) and 462 toddlers (PCV13: 239; PCV7: 223)."
The immunoglobulin G titers elicited by PCV13 for the original seven serotypes were noninferior but somewhat lower than those elicited by PCV7. The PCV13 toddler dose produced higher immune responses than the infant-series doses, according to the authors.
Local and systemic reactions were mild for the most part and much the same in both vaccine groups. "For specific reactions, the only statistical difference was in the incidence of moderate fever after dose 1 (2.8% vs 0.0% for PCV13 and PCV7, respectively; p=0.026)," the report states.
"Data from this study support that PCV13 will be as effective as PCV7 in preventing disease caused by serotypes common to both vaccines," the authors conclude. "In addition, PCV13 should mediate protection against the 6 additional serotypes, all of which are important worldwide causes of severe pneumococcal disease."
Pediatrics. Posted online August 23, 2010. Abstract
NEW YORK (Reuters Health) Aug 23 - The 13-valent pneumococcal conjugate vaccine (PCV13) is as effective as the seven-valent vaccine against the original seven pneumococcal serotypes and should provide further protection against the six additional serotypes, a multicenter team reports.
PCV13, also known by the brand name Prevnar 13 (Wyeth), was approved by the US Food and Drug Administration in February 2010 for preventing invasive pneumococcal disease in children aged 6 weeks to 71 months.
One of the pivotal studies of the immunogenicity and safety of PCV13 in infants and toddlers appeared online today in Pediatrics.
Lead author Dr. Sylvia H. Yeh, at the UCLA-Kaiser Vaccine Research Center in Torrance, California, and colleagues explain that the 7-valent pneumococcal conjugate vaccine (PCV7) covers the serotypes that caused up to 90% of invasive disease in the U.S. before its introduction.
"The widespread use of PCV7 in the U.S. has dramatically reduced the burden of this disease in children, with herd immunity benefiting adults as well," she said in an e-mail. "However, pneumococcal disease still occurs in the U.S. due to replacement serotypes."
The six additional serotypes in PCV13 account for up to 92% of invasive cases worldwide in children under five. "Whereas the potential impact of PCV7 was limited in certain countries such as Africa and Asia, PCV13 potentially expands the impact of disease prevention through vaccine use in these countries," Dr. Yeh said.
The current study compared PCV13 with PCV7 in terms of immunogenicity and safety in toddlers and infants. Ultimately, the authors report, "The evaluable immunogenicity populations consisted of 504 infants (PCV13: 252; PCV7: 252) and 462 toddlers (PCV13: 239; PCV7: 223)."
The immunoglobulin G titers elicited by PCV13 for the original seven serotypes were noninferior but somewhat lower than those elicited by PCV7. The PCV13 toddler dose produced higher immune responses than the infant-series doses, according to the authors.
Local and systemic reactions were mild for the most part and much the same in both vaccine groups. "For specific reactions, the only statistical difference was in the incidence of moderate fever after dose 1 (2.8% vs 0.0% for PCV13 and PCV7, respectively; p=0.026)," the report states.
"Data from this study support that PCV13 will be as effective as PCV7 in preventing disease caused by serotypes common to both vaccines," the authors conclude. "In addition, PCV13 should mediate protection against the 6 additional serotypes, all of which are important worldwide causes of severe pneumococcal disease."
Pediatrics. Posted online August 23, 2010. Abstract
Prepubertal Overweight Children With Prediabetes May Have Lower Bone Mass
From Medscape Medical News
Laurie Barclay, MD
August 24, 2010 — Prepubertal overweight children with prediabetes may have lower bone mass and an increased risk for poor skeletal development, according to the results of a study reported online July 16 in the Journal of Bone and Mineral Research.
"Childhood studies of the fat-bone relationship are conflicting, possibly reflecting the influence of metabolic abnormalities in some but not all obese children," write Norman K. Pollock, from Medical College of Georgia's Prevention Institute in Augusta, and colleagues.
The investigators compared bone mass in 41 prepubertal overweight children with prediabetes with that in 99 prepubertal overweight children without prediabetes. The study authors also evaluated associations of bone mass with measures of total and central adiposity, glucose intolerance, insulin sensitivity, lipid profile, markers of systemic inflammation, and osteocalcin. Age range of the children was 7 to 11 years.
Prediabetes was identified from an oral glucose tolerance test, which also allowed measurement of glucose, 2-hour glucose, glucose area under the curve (AUC), insulin, 2-hour insulin, and insulin AUC. Blood levels of lipids, C-reactive protein, and osteocalcin were also measured. Using dual-energy x-ray absorptiometry, the investigators measured total body bone mineral content (BMC), fat-free soft tissue mass (FFST), and fat mass (FM), whereas visceral adipose tissue (VAT) and subcutaneous abdominal adipose tissue (SAAT) were evaluated with magnetic resonance imaging scans.
After adjustment for sex, race, height, and weight, overweight children with prediabetes had a total body BMC 4% lower than those without prediabetes (P = .03). FM correlated directly with BMC in the total sample (β = .16; P = .01), after adjustment for sex, race, height, and FFST.
"This finding provides the first clue linking childhood obesity to skeletal fractures," Dr. Pollock said in a news release. "While overweight children may have more bone mass than normal-weight kids, it may not be big or strong enough to compensate for their larger size."
After controlling for sex, race, height, FFST, FM, and SAAT or VAT, however, VAT (β = -.13; P = .03) and SAAT (β = -0.34; P = .02) were inversely associated with BMC. BMC was not significantly associated with any of the biochemical measurements.
"Taken together, it seems that excessive abdominal fat may play a key role linking pre-diabetes to lower bone mass," Dr. Pollock said. "Our greatest window of opportunity to enhance bone strength and ultimately reduce the risk of osteoporosis is during childhood, before the capacity to build bone diminishes. One of the best things you can do for bone development and general health is exercise."
Limitations of this study include bone measurements derived only from dual-energy x-ray absorptiometry of the total body; and small sample size, precluding separate analysis of data by boys and girls or by white and black race.
"Children have a lot of potential and a whole lot of time to make positive changes," said coauthor Catherine Davis, also from the Prevention Institute. "If you could patent exercise as a drug, somebody would be really, really rich."
J Bone Mineral Res. Published online July 16, 2010. Abstract
Laurie Barclay, MD
August 24, 2010 — Prepubertal overweight children with prediabetes may have lower bone mass and an increased risk for poor skeletal development, according to the results of a study reported online July 16 in the Journal of Bone and Mineral Research.
"Childhood studies of the fat-bone relationship are conflicting, possibly reflecting the influence of metabolic abnormalities in some but not all obese children," write Norman K. Pollock, from Medical College of Georgia's Prevention Institute in Augusta, and colleagues.
The investigators compared bone mass in 41 prepubertal overweight children with prediabetes with that in 99 prepubertal overweight children without prediabetes. The study authors also evaluated associations of bone mass with measures of total and central adiposity, glucose intolerance, insulin sensitivity, lipid profile, markers of systemic inflammation, and osteocalcin. Age range of the children was 7 to 11 years.
Prediabetes was identified from an oral glucose tolerance test, which also allowed measurement of glucose, 2-hour glucose, glucose area under the curve (AUC), insulin, 2-hour insulin, and insulin AUC. Blood levels of lipids, C-reactive protein, and osteocalcin were also measured. Using dual-energy x-ray absorptiometry, the investigators measured total body bone mineral content (BMC), fat-free soft tissue mass (FFST), and fat mass (FM), whereas visceral adipose tissue (VAT) and subcutaneous abdominal adipose tissue (SAAT) were evaluated with magnetic resonance imaging scans.
After adjustment for sex, race, height, and weight, overweight children with prediabetes had a total body BMC 4% lower than those without prediabetes (P = .03). FM correlated directly with BMC in the total sample (β = .16; P = .01), after adjustment for sex, race, height, and FFST.
"This finding provides the first clue linking childhood obesity to skeletal fractures," Dr. Pollock said in a news release. "While overweight children may have more bone mass than normal-weight kids, it may not be big or strong enough to compensate for their larger size."
After controlling for sex, race, height, FFST, FM, and SAAT or VAT, however, VAT (β = -.13; P = .03) and SAAT (β = -0.34; P = .02) were inversely associated with BMC. BMC was not significantly associated with any of the biochemical measurements.
"Taken together, it seems that excessive abdominal fat may play a key role linking pre-diabetes to lower bone mass," Dr. Pollock said. "Our greatest window of opportunity to enhance bone strength and ultimately reduce the risk of osteoporosis is during childhood, before the capacity to build bone diminishes. One of the best things you can do for bone development and general health is exercise."
Limitations of this study include bone measurements derived only from dual-energy x-ray absorptiometry of the total body; and small sample size, precluding separate analysis of data by boys and girls or by white and black race.
"Children have a lot of potential and a whole lot of time to make positive changes," said coauthor Catherine Davis, also from the Prevention Institute. "If you could patent exercise as a drug, somebody would be really, really rich."
J Bone Mineral Res. Published online July 16, 2010. Abstract
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