Pregestational maternal diabetes was associated with an increased risk of a major congenital anomaly, but obesity itself was not, a cross-sectional study found.

In a multivariable logistic model, the major contributor to a rising rate of congenital anomalies was maternal pregestational diabetes (OR 3.8, 95% CI 2.1 to 6.6), according to Joseph R. Biggio, Jr., MD, and colleagues from the University of Alabama at Birmingham.

“Because hyperglycemia is a major contributor to developmental malformations, interventions to address obesity and identify women at risk for diabetes and hyperglycemia should be considered in efforts to reduce the occurrence of congenital anomalies,” they wrote in the February issue of Obstetrics & Gynecology.

Maternal obesity has been linked with numerous problems, including preeclampsia, gestational diabetes, fetal and neonatal death, and birth trauma, but scientists have disagreed over whether it also contributes to the risk of fetal malformations, the researchers noted.

To help settle the issue, Biggio and colleagues used a perinatal database in their university health system that included all women with singletons delivered between 1991 and 2004.

They divided the cohort into three time periods — 1991 to 1994, 1995 to 1999, and 2000 to 2004, with a total of 41,902 pregnancies.

For their primary analysis, they defined maternal obesity as a first prenatal visit weight greater than 200 lb, because during the earlier epochs many women did not have body mass index (BMI) calculated. For their secondary analyses they used BMI greater than 29 kg/m2 as the criterion for obesity.

In each epoch, there were increases in mean maternal weight, mean BMI, the proportion of women weighing more than 200 lb, the proportion with a BMI greater than 29 kg/m2, and the prevalence of pregestational diabetes (P<0.001 for all).

Univariable analysis determined that the rate of major anomalies, particularly involving the cardiac and pulmonary systems, also increased during each time period.

But there was no independent association between congenital anomalies and maternal obesity using either definition, during any of the three time periods or during the study overall.

Although no direct association was seen between congenital malformations and maternal obesity, the investigators reported that the proportion of anomalies that could be attributed to obesity increased from 0% to 23% during the overall study period.

The proportion of anomalies that could be attributed to diabetes ranged from 58% to 76%.

Moreover, for obese women with diabetes the proportion of anomalies attributed to diabetes increased sharply, from 48% in the first epoch to 74% in the third epoch.

In contrast, for the obstetric population as a whole, the population-attributable risk of congenital malformation related to obesity rose from near zero in the first epoch to 6.1% in the third epoch, while that related to diabetes increased from 3.3% to 9.2%, the investigators reported.

During the course of the study there was a nearly 15-lb increase in maternal weight and a 30% increase in the proportion of women whose BMI exceeded 29 kg/m2.

There also was a nearly twofold increase in the rate of major anomalies — and a 250% increase in the prevalence of diabetes.

The authors observed that there has been much interest in the effects of maternal obesity on birth defects.

Although the pathophysiologic basis for this possible association have not been identified, hypotheses have included increased serum insulin, lower levels of folic acid, chronic hypoxia, and increased inflammatory mediators.

“Our study provides evidence that the defects may not be due solely to the maternal obesity per se but may be due to undiagnosed diabetes,” the investigators wrote.

From a public health standpoint, the study findings suggest that efforts to reduce the prevalence of congenital anomalies should be focused less on obesity and aimed more closely at correcting hyperglycemia.

“If euglycemia could be achieved before pregnancy, or at least embryogenesis and organogenesis, the majority of these anomalies could potentially be avoided,” they observed.

They also suggested that even women of normal weight, but with other diabetes risk factors, could benefit from closer attention to glycemic control.

A weakness of the study was the fact that detailed data on glycemic control was not available in the perinatal database, “and therefore we cannot comment on the association between glycemic control and anomaly rates,” the investigators wrote.

The study was supported in part by the National Institute of Child Health and Human Development.

The authors did not report any potential conflicts of interest.

PHILADELPHIA, March 17 — Children with clinical peanut allergies became at least modestly tolerant after a program of oral immunotherapy, a researcher said here.Of 20 children, 18 were eventually able to eat the equivalent of 13 peanuts with few or no allergy symptoms, reported Scott Nash, M.D., of Duke University, at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.The children, ages one to 16, did not have histories of severe anaphylactic reactions, but they had previously had moderate allergic symptoms after eating peanut protein, with positive skin prick tests and peanut-specific IgE levels of at least 15,000 units/L, consistent with significant peanut allergy.At baseline, they all had allergic reactions after eating the equivalent of less than a single peanut.

Standard treatment for such patients is avoidance of foods containing peanut products and keeping an epinephrine injector close by to deal with severe reactions, Dr. Nash said.

The study protocol began with multiple doses the first day, starting with 0.1 mg of peanut protein in the form of flour and working up to 50 mg by day’s end. All children had symptoms at this level on the first day.

The children then took peanut protein every day at home, starting at 50 mg/day and increasing by 25 mg every two weeks. The escalation stopped at 300 mg/day — the equivalent of one peanut — which was chosen as the maintenance dose.

After four to 11 months on this dose, the children were challenged with larger amounts of peanut.

Among 20 children completing the planned protocol, 19 were able to eat 3.9 g of peanut protein, 10 with no reaction at all.

One of the 19 developed hives and stridor about 90 minutes after ingesting the full amount, necessitating an emergency dose of epinephrine.

The remaining eight had mild, transient symptoms — developing early in the challenge in two cases, later on in the other six.

The twentieth child developed hives and sneezing after eating 2.1 g of peanut, at which point a concerned parent stopped the test, Dr. Nash said.

Patients were maintained on therapy for up to 42 months, with the treatment still ongoing.

Mean levels of IgE and other immunologic markers of peanut allergy increased initially and then gradually declined over time. Dr. Nash said this was consistent with results with other allergy immunotherapies.

Mean wheal sizes in skin prick tests decreased from about 8.5 mm at baseline to approximately 5 mm after six months. With continuation of therapy, wheal sizes declined to as little as 3.5 mm.

Dr. Nash noted that IgG4 levels increased during the trial. He said the role of this immunoglobulin species is not clear. It may be a blocking antibody, but that would not fully explain the effects on symptom resolution, he indicated.

He said follow-up clinical studies are aimed at increasing the immunotherapy doses further in an effort to induce greater tolerance.

“We are showing that some of those patients’ IgEs are declining, and declining to a level where their food allergy may be actually going away. Some people have been able to come off of oral immunotherapy and still tolerate a peanut challenge,” Dr. Nash said.

Also underway is a double-blind, placebo-controlled study using a similar protocol.

Funding information was not disclosed. No potential conflicts of interest were disclosed.

Primary source: AAAAI Meeting

Source reference:
Nash SD, et al “Immunotherapy for children with peanut allergy” AAAAI Meeting 2008; Abstract 529.

BOSTON, Oct. 13 — Several cups of coffee a day do not seem to pose an overall breast cancer risk, researchers here found in a large cohort study, confirming other research.

Breast cancer risk was not significantly elevated overall by drinking four or more cups of coffee a day (relative risk 1.08, 95% confidence interval 0.89 to 1.30), reported Shumin M. Zhang, M.D., of Brigham and Women’s Hospital and Harvard, and colleagues in the Oct. 13 issue of the Archives of Internal Medicine.

Nor did women with even the highest level of caffeine consumption appear to be at elevated risk (RR 1.02, 95% CI 0.84 to 1.22) in the analysis of the prospective Women’s Health Study.

But as in some previous studies, high caffeine consumption appeared to increase risk for women with a history of benign breast disease. Risk was also elevated for developing hormone receptor-negative or larger tumors.

The researchers cautioned though, that these subgroup findings may be due to chance.

The overall lack of association between caffeine and caffeinated drinks was generally consistent with results from prior prospective cohort studies in Western countries, such as the Nurses’ Health Study, they noted.

Dr. Zhang’s group analyzed caffeine intake from food frequency questionnaires completed by 39,310 female health professionals participating in the Women’s Health Study.

The primary prevention trial randomized women ages 45 and older without cancer or cardiovascular disease to low-dose aspirin and vitamin E.

Participants primarily drank coffee (81.3%), although tea (10%), diet cola (5.6%), regular cola (1.2%), and chocolate (0.3%) also contributed to their daily caffeine consumption.

Most women reported either never drinking coffee (24.1%) or two to three cups a day (32.8%). About 15% were in the highest intake category with at least four cups a day.

Overall caffeine intake was not linked to breast cancer risk for the women nor was any individual caffeinated beverage or food. The relative risks in the multivariate analysis controlling for age, randomized prevention treatment, and breast cancer risk factors were:

1.02 for women in the highest caffeine consumption quintile compared with the lowest (95% CI 0.84 to 1.22).
1.08 for four or more cups of coffee daily compared with almost never (95% CI 0.89 to 1.30).
1.03 for at least two cups of tea per day compared with tea on the rare occasion (95% CI 0.85 to 1.25).
1.17 for at least one caffeinated cola per day compared with almost never (95% CI 0.87 to 1.57).
0.88 for two or more diet cola drinks per day compared with almost never (95% CI 0.68 to 1.13).
0.97 for at least one serving of chocolate a week compared with almost never (95% CI 0.78 to 1.20).

However, for women with a history of benign breast disease, there was a borderline significant elevation in breast cancer risk with the highest caffeine intake (RR 1.32, 95% CI 0.99 to 1.76) and with at least four cups of coffee per day (RR 1.35, 95% CI 1.01 to 1.80).

Caffeine was also associated with increased risk in women with poor breast cancer prognosis. The highest intake levels were associated with significant risk of estrogen- and progesterone-receptor breast cancer (RR 1.68, 95% CI 1.01 to 2.81, P=0.02 for trend) and tumors larger than 2 cm (RR 1.79, 95% CI 1.18 to 2.72, P=0.02 for trend).

Other breast cancer characteristics, body mass index, menopausal status, and hormone therapy use did not appear to impact the associations overall.

Although these findings would suggest caffeine affects breast cancer progression independent of the estrogen pathway, the researchers noted that the results were not in line with those of the Iowa Women’s Health Study and the Nurses’ Health Study, which also looked at caffeine’s impact by hormone receptor status.

Dr. Zhang and colleagues cautioned that they could not exclude the possibility that these were chance findings because of the large number of subgroups evaluated. Further study is warranted, they said.

Another limitation of the study was data on caffeine intake only at baseline, which did not account for changes over time and would have tended to weaken any true associations, they noted.

The study was supported by research grants from the National Institutes of Health. The researchers reported no conflicts of interest.

Primary source: Archives of Internal Medicine

Source reference:

Ishitani K, et al “Caffeine Consumption and the Risk of Breast Cancer in a Large Prospective Cohort of Women” Arch Intern Med 2008; 168: 2022-2031.

The majority of patients 70 and older who have acute myeloid leukemia (AML) may not benefit from intensive chemotherapy, a single-center study showed.

Nearly three-quarters (72%) of patients undergoing intensive therapy had at least one factor predictive of eight-week mortality — including age older than 80, poor performance status, at least three karyotypic abnormalities, or elevated creatinine, according to Hagop Kantarjian, MD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues.

These patients had an eight-week mortality rate of 31% to 71%, median survival ranging from 0.5 to 5.3 months, and a three-year survival rate of less than 8%.

Patients with none of those factors, on the other hand, had an eight-week mortality rate of 16%, median survival of 11.3 months, and a three-year survival rate of 22%, the researchers reported online in Blood.

The findings clearly show that at least some older patients can undergo intensive chemotherapy, which raises the question of whether they should, Kantarjian and his colleagues noted in their paper.

“The answer is not clear cut and depends on what the treating oncologist and the patient consider a reasonable risk for a reasonable benefit with intensive chemotherapy,” they wrote.

“Most would probably agree that an eight-week mortality of less than 10% to 20% to achieve a complete response rate of more than 40% and a three-year survival of more than 10% would be an acceptable benefit:risk ratio with intensive chemotherapy.”

Kantarjian and his colleagues set out to identify a subset of older patients with AML who would benefit from intensive chemotherapy.

They looked at 446 patients 70 and older who had AML with 20% or more myeloblasts and who were treated with cytarabine-based intensive chemotherapy between 1990 and 2008.

Excluding 16 patients who had favorable karyotypes, the complete response rate in the remaining 430 was a “reasonable” 45%, according to the researchers.

However, four-week mortality was 26% and eight-week mortality was 36%. Median survival was 4.6 months and the survival rate at one, two, and three years was 28%, 16%, and 10%, respectively.

The following four factors were associated with an increased likelihood of dying within the first eight weeks of treatment in a multivariate analysis (P<0.05 for all): Poor performance status (ECOG score of 2 to 4): OR 3.25 Age 80 and older: OR 2.31 Complex karyotypes (with at least three abnormalities): OR 2.07 Creatinine greater than 1.3 mg/dL: OR 1.96

The eight-week mortality rate increased as the number of factors a patient had increased. The complete response rate dropped at the same time (from 57% in those with none of those factors to 16% in those with at least three).

The fact that the eight-week mortality rate was greater than 30% in the patients who had at least one of those predictive factors — nearly three-quarters of the patients — indicates that clinicians may want to consider lower-risk strategies, according to the researchers.

“It is reasonable that such patients … would be considered for alternative investigational therapies,” they wrote.

Patients who share characteristics with those who had complete response rates above 50%, an eight-week mortality rate less than 20%, and median survival of 11.3 months, however, “should be encouraged to undergo intensive chemotherapy in leukemia centers with expertise in intensive supportive care.”

The authors received research grants from Genzyme, Celgene, and Eisai.

Chronic kidney disease patients who responded to a survey said that their end-of-life planning fell far short of their wants and needs.

Nearly half of patients with advanced chronic disease said they would like to make advance care plans with their nephrologist, but only 10% had actually discussed it, Sara N. Davison, MD, of the University of Alberta in Edmonton, found.

They had done no better with their family doctors, Davison wrote online in the Clinical Journal of the American Society of Nephrology, reporting the results of her survey of 584 patients. Only 8% of patients reported talking about end-of-life issues with family physicians, but 39% indicated that they wanted such discussions.

Most patients also said they didn’t know much about the palliative care options or how their final weeks of life would progress. Yet they expressed strong desires for more information and involvement in decision-making.

“Communication of prognosis and discussions related to planning for future death are lacking in the routine care of chronic kidney disease patients,” Davison wrote.

“Most patients reported that they think about their future health and that they are comfortable talking about end-of-life care issues with both family and renal staff,” she added. “Even those less comfortable with having these discussions still feel they needed to occur.”

Davison administered a 35-item questionnaire to patients with stage 4 or 5 chronic kidney disease who were receiving dialysis treatment. Patients were approached when they came to a dialysis clinic, with a response rate of 86%. Those scheduled for kidney transplant were not excluded.

The questions covered five main areas: self-reported knowledge, importance of certain issues relating to advance care planning, patients’ preferences for end-of-life care, and the status of current plans.

Nearly 90% of patients indicated that they were very or somewhat uninformed about their condition and its future trajectory. Some 70% said they didn’t know what palliative care was and half were ignorant of hospice care.

Large majorities, though, said every one of 10 issues related to end-of-life care was important to them, including their current medical status and prognosis, the need for advance planning, involvement in decision-making, and communication with their providers.

Among the most telling findings was that 61% of respondents said they regretted starting dialysis. Patients indicated that the decision reflected their families’ and physicians’ wishes more than their own, she said.

“This highlights the need to reevaluate decision-making around the initiation of dialysis and involving patients in discussions about prognosis and goals of care,” she wrote.

Patients had different ideas of the appropriate time to begin discussing end-of-life issues. About 39% said they would wait until they became seriously ill or when their treatment team thought it was necessary. Another 24% wanted to initiate such discussions themselves, whereas 14% would undertake them before starting dialysis and 10% would begin planning after dialysis but before becoming ill.

About 70% of patients said they were comfortable with discussing end-of-life matters in the dialysis clinic.

Not surprisingly, most patients said they would prefer to die at home or in a hospice, as opposed to a hospital or nursing home.

Davison pointed out that, currently, most patients with chronic kidney disease die in acute care facilities without receiving palliative treatment. She suggested that lack of knowledge of palliative options and hospice may be a reason for this reality.

“End-of-life care policies and resources should be directed toward ensuring that patients die in their location of choice, which includes not only home but within-institutional settings, such as inpatient hospice,” she recommended.

In an accompanying editorial, Daniel Cukor, PhD, of Downstate Medical Center in Brooklyn, N.Y., and Paul L. Kimmel, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Md., said the findings were “a clarion call to the broader nephrology community to be more sensitive to the end-of-life preferences of patients with chronic kidney disease and end-stage renal disease.”

They said the study showed that professionals as well as patients lack knowledge of end-of-life issues.

“It is not sufficient for the treatment team to be working only toward preserving life, but as patients become more ill, it is appropriate to help support patients’ contemplation and facilitation of their end-of-life wishes,” Cukor and Kimmel wrote.

Davison acknowledged several limitations of the study. Patients may have misunderstood some of the questions or answers in the multiple-choice format, and participants were predominantly white, middle-class English speakers.

No external funding for the study was reported.

No potential conflicts of interest were reported by Davison or the editorialists.

ORLANDO, Dec. 12 — Antibody-directed therapy added to induction chemotherapy for acute myeloid leukemia (AML) improved disease-free survival without major added toxicity, international researchers reported here.

Preliminary results from a study of 1,113 patients younger than 60 who were randomized to standard induction chemotherapy regimens with our without the addition of Mylotarg (gemtuzumab ozogamicin) showed that patients who received the antibody had significantly better disease-free survival, said Alan K. Burnett, M.D., of Cardiff University in Wales, at the of the American Society of Hematology meeting here.

“This is the first example of antibody-directed therapy in cancer,” Dr. Burnett said. “It’s the first randomized trial of Mylotarg, and it does indeed seem to have an advantage in reducing the relapse risk without increasing toxicity.”

Mylotarg is an immunoconjugate consisting of a monoclonal antibody directed against the CD33 receptor on leukemia cells and an antitumor antibiotic.

Dr. Burnett and Danish colleagues enrolled the 1,113 patients in a randomized controlled trial in which patients were assigned to conventional chemotherapy with either danorubicin plus Ara-C (cytarabine), the same two drugs plus etoposide, or FLAG-IDA, a combination fludarabine, Ara-C, granulocyte colony stimulating factor and idarubicin.

In addition, half the patients were randomized to receive Mylotarg at 3 mg/m2 on day one of each course of therapy.

The median patient age was 49 (range 0-71 years). The gender breakdown was 592 male and 521 female. Most of the patients (1,025) had de novo disease and 88 had secondary diseases.

In all, 95% of patients had WHO performances scores less than 2.

The investigators found that the overall remission rates were similar between the Mylotarg and no-Mylotarg groups, at 84% and 86%, respectively, and no differences in complete remission (85% in each group) induction deaths, or resistant disease.

There was a modest increase in mucositis in the Mylotarg group during the first course of chemotherapy only (P=0.04) and increased liver enzymes (P=0.002 for AST, and P=0.03 for ALT), but no difference in bilirubin grades, and grade 3-4 liver toxicities were similar.

Patients in the Mylotarg arm also used more platelets (19 units versus 14, P

WASHINGTON, Oct. 17 — An investigational embolic protection system for carotid stenting that combines a filter with aspiration was associated with a 30-day event rate of 3%, the safety threshold recommended by the American Heart Association.

A month after stenting, the mortality rate was 0.4%, the stroke rate 2.1%, and the myocardial infarction rate 0.9%, said Subbarao Myla, M.D., of Hoag Memorial Hospital in Newport Beach, Calif.

Dr. Myla reported results of the 237-patient EPIC trial (Evaluating the Use of the FiberNet Embolic Protection System In Carotid Artery Stenting) at the Transcatheter Cardiovascular Therapeutics meeting.

The stroke rate, he said, was particularly low compared with other trials of carotid stenting.

For example, the stroke rate in the SAPPHIRE trial, which compared carotid stenting with endarterectomy, was 4.9% — results that were hailed as “landmark” when reported at the AHA meeting in 2002.

With the FiberNet system, a filter wire expands to a form a plug distal to the carotid lesion. This plug allows blood to flow but embolic debris cannot pass.

After the stent is deployed, an aspiration catheter sucks out all downstream debris as well as “hanging chads, the disrupted plaque that may be hanging in the stent,” Dr. Myla said at a press briefing.

He said that the aspiration needs to be carefully and completely performed — about 60 cc are usually aspirated — in order to be sure that all embolic debris are removed. The filter wire is then compressed and withdrawn.

In the EPIC trial, which was conducted at 26 sites in the U.S., the technical success rate was 97.5%, the FiberNet device success rate was 94.1%, and “90.9% of the filters capture visible debris,” Dr. Myla said.

He said the device could capture particles as small as 40 ?µm.

Carotid stenting is approved for patients who are at high risk of complications with carotid endarterectomy, and that was the population studied in EPIC — the mean age was 74, 21.1% were octogenarians, 62.4% were men, 39.7% had diabetes, 22% were current smokers, and 20% were symptomatic, Dr. Myla said.

Patients with total occlusion or stenosis that was unsuitable for stenting and those with lesions that required more than one stent were excluded from the trial.

Also excluded were patients who had had a stroke within the previous 48 hours, those who had had a myocardial infarction within 14 days, and patients who were scheduled for carotid endarterectomy in the contralateral carotid within 30 days.

Lumen Biomedical of Plymouth, Minn., maker of the FiberNet device, funded the study.

Dr. Myla disclosed research funding from Johnson & Johnson, Abbott, Guidant, Boston Scientific, eV3, and Bard. He said he was a consultant or advisory board member at Johnson & Johnson, Boston Scientific, eV3, and Lumen Biomedical and owned stock in Boston Scientific and Lumen Biomedical.

Primary source: Transcatheter Cardiovascular Therapeutics Meeting

Source reference:
Myla S, et al “Evaluating the Use of the FiberNet Embolic Protection System In Carotid Artery Stenting” TCT 2008.

TURKU, Finland, Nov. 7 — Most children with acute otitis media have infections caused by both bacteria and viruses, suggesting that antibiotics may not be enough to control the infections, researchers here have found.

When the investigators drew middle ear fluid through tympanostomy tubes in children with new-onset acute otitis media with effusion, they found that 96% of the samples contained at least one respiratory pathogen, and two-thirds contained both bacteria and viruses, reported Aino Ruohola, M.D., Ph.D., of Turku University Hospital, and colleagues.

“The clinical impact of coinfections of the middle ear is based on observations that bacterial eradication and clinical outcomes are poorer in coinfections than in solely bacterial infections,” the investigators wrote in the Dec. 1 issue of Clinical Infectious Diseases.

Viral coinfections may exacerbate the inflammation that is a hallmark of acute otitis media, and may also interfere with the efficacy of antimicrobial therapies, the authors suggested.

The findings suggest that the strategy of observation alone for mild and select stubborn cases of acute otitis media, endorsed by the American Academy of Pediatrics, may be appropriate in children with bacterial and viral infections, noted an otitis media researcher who was not involved in the study.

“For severe acute otitis media cases for which antibiotic is indicated, viral coinfection could lead to clinical failure even when appropriate antibiotic has sterilized the middle ear fluid,” wrote Tansee Chonmaitree, M.D., of the University of Texas Medical Branch in Galveston, in an accompanying editorial.

“When one keeps in mind the possibility of combined bacterial and viral infections in acute otitis media,” she continued, “expectations for antibiotic treatment of acute otitis media will be more realistic, and a failed course of antibiotic treatment may not be promptly blamed on antibiotic-resistant bacteria, leading to continuous changes in antibiotic regimens. Watchful waiting after a treatment course may also become an alternative.”

At least 15% of patients with acute otitis media have an infection of unknown origin, Dr. Ruohola and colleagues noted. To get a better sense of the etiology of acute otitis media, they performed microbiological studies on middle ear effusions collected from 79 young children with otitis media infections that were less than 48 hours old.

The children had a median age of 21 months (range seven to 71 months), and all had tympanostomy tubes through which the investigators could aspirate middle ear fluid following sterilization of the tubes.

The authors used culture and polymerase chain reaction to characterize bacterial isolates, and culture, antigen detection, and PCR to identify viral isolates.

They found that 76 of the 79 children (96%) had a least one respiratory tract pathogen.

Bacteria were found in samples from 73 children (92%), and included the usual suspects, such as Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis.

Viruses were found in 55 of the 79 children (70%). The list included, but was not limited to, rhinovirus, NT picornavirus, respiratory syncytial virus, and human metapneumovirus, plus parainfluenza, enterovirus, and coronavirus species.

Bacteria and viruses were found concomitantly in 52 patients (66%). Viral co-travelers were found in 77% of samples positive for S. pneumoniae, 65% of those positive for H. influenzae, and 73% of those positive M. catarrhalis, but the authors did not find associations of any bacteria with any specific virus.

The authors pointed out that “viruses strengthen the bacteria-induced inflammation in the middle ear, which is evident by the higher concentrations of inflammatory mediators in coinfections than in cases of acute otitis media due solely to bacteria. Thus, viruses do not seem to be ‘innocent bystanders’ in the middle ear.”

Concomitant viral and bacterial infections are associated with more severe symptoms and poorer treatment responses in respiratory tract infections, they noted.

“Our findings suggest that coinfection with bacteria and viruses in the middle ear may be a more common cause for a poor treatment response in acute otitis media than previously thought,” they wrote.

The finding that combined bacterial and viral infections are common in children with acute middle ear implications has important clinical implications, Dr. Chonmaitree suggested in her editorial.

“Results of antibiotic treatment of acute otitis media may not be as expected when the disease is not a pure bacterial infection, and the concept may also apply to other respiratory diseases, such as sinusitis and pneumonia, in both adults and children,” she wrote.

Primary source: Clinical Infectious Diseases

Source reference:
Ruohola A et al. “Microbiology of Acute Otitis Media in Children with Tympanostomy Tubes: Prevalences of Bacteria and Viruses.” Clinical Infectious Diseases 2006;43:1417-1422

Additional source: Clinical Infectious Diseases

Source reference:
Chonmaitree T. “Acute Otitis Media Is Not a Pure Bacterial Disease.” Clinical Infectious Diseases 2006;43:1423-1425.

ORLANDO, Oct. 8 — Patients with ulcerative colitis appeared to maintain remission better with a once-a-day granulated mesalamine than with placebo, researchers said here.

Among patients taking the investigative formulation, 78% remained in remission over six months compared with just 59% of patients assigned to placebo (P

Gymnasts, wrestlers and boxers often feel pressure to lose weight to boost performance, but the drastic methods they sometimes use — including strictly limiting calories and intentional dehydration — can be dangerous to their health, experts warn.

To offer guidance to athletes, coaches and parents, the National Athletic Trainers’ Association has issued a new set of guidelines for safe weight loss by athletes.

They include: using body composition assessments to measure lean body mass versus fat; gradually shedding no more than 1.5 percent of body weight a week; eating a balanced diet that includes all food groups; and losing weight under the supervision of nutrition, health and weight management experts.

“In the performance sports — gymnastics, dance, ballet — they have this huge responsibility to not only do a performance but to look good while they are doing it. It’s a unwritten rule that they have to be a certain weight, and they get a lot of pressure, not just from dance masters but from the public’s expectations and themselves,” said Paula Sammarone Turocy, lead author of the guidelines and chair of the department of athletic training at Duquesne University in Pittsburgh. “We also see it in traditional sports — jockeys, wrestlers, boxers. They all have weight requirements. If they don’t make the weight, they don’t compete.”

And the pressure to shed weight cuts across all sports, she added. Many cyclists, swimmers, runners, soccer players and even football players believe that losing weight will mean they can run, swim and jump faster.

Getting down to an ideal body weight to improve performance isn’t a problem in and of itself, she said. It’s when athletes go to extremes that their drive can backfire. “When it’s done improperly or done to extremes it does interfere with performance,” she explained.

The new guidelines were to be presented Monday at the annual meeting of the National Athletic Trainers’ Association in New Orleans and are published in the June issue of the Journal of Athletic Training.

Ashleigh Clare-Kearney has been there. As a high school student, she was a standout gymnast, in more ways than one. She was powerful and graceful, although she was 5-foot-4 and weighed 155 pounds.

“I didn’t fit the stereotypical frame, which is 4 feet, 10 inches, 110 pounds,” Clare-Kearney said. “I was told, ‘You need to lose weight. You will be viewed as a risk. You are not going to be able to compete in elite international competitions.’ People said I wouldn’t make it because of my size.”

She defied their predictions. As a gymnast at Louisiana State University (LSU), she became the NCAA national champion in vault and floor, captain of the team and a NCAA Woman of the Year finalist.

Yet she couldn’t deny it — slimming down would help her performance. She’d put on weight when she got to college, and she knew that carrying less heft might allow her to vault even higher.

Working with the athletic trainers and the coaches at LSU, she got down to about 145 pounds by focusing on nutrition. “I was never going to be 110 pounds. That’s not the way I’m built,” she said. “What really resonated with me was the way the athletic training staff understood that. They said, ‘Let’s be realistic.’”

For Clare-Kearney, that included keeping a food diary, making sure to always eat breakfast, drinking water instead of sweetened beverages and eating more fruits and vegetables and less processed foods.

But not every athlete manages to handle the pressure to lose weight so well.

Before competitions, some wrestlers, jockeys and boxers intentionally dehydrate themselves by exercising in heavy clothing and restricting certain foods and fluids to lose weight quickly.

There are even anecdotal reports that elite, international athletes have their blood removed by IV prior to weigh-in. The blood is then re-infused before competition.

Among wrestlers at least, intentional dehydration may be less popular than it used to be due to changes in the rules from the high school level on up that call for urine tests to detect hydration status at weigh-in. In 2006, for example, the National Federation of State High School Associations not only adopted the hydration status rules, but also minimum body fat requirements (greater than 7 percent in boys and 12 percent in girls) in order to compete.

Not only can rapid weight loss hurt performance over the short term because athletes simply don’t have the energy to perform at their best, but experts add that restricting calories can also have long-term consequences.

Over time, dietary restrictions can impact the endocrine system, hindering the growth and functioning of muscles and bones. A poor diet can also impair thyroid function, lower metabolism and hormone production and suppress the immune system.

Clare-Kearney, now a law student at Southern University Law Center of Baton Rouge and a volunteer coach for her alma mater, urges young athletes to consider the consequences of their diets.

“Food really does fuel your body. Your body can only handle so much without the proper fuel and nutrition,” she said. “And there is life beyond gymnastics. We also have to keep our body healthy for life after gymnastics.”

More information

The U.S. National Institute of Mental Health has more on eating disorders.