Laird Harrison

LAS VEGAS – It can kill crops and destroy buildings. It’s used as an industrial coolant and is present in all cancer cells. Yet, it’s ending up in our food. What is it?

If you guessed "water," you’re ahead of scores of people who have signed petitions to ban "dihydrogen monoxide," a tongue-in-cheek name for H2O. Many such hoaxes, urban legends, and fallacies are circulating via Web sites, e-mail, television news reports, and ordinary conversation, said Dr. Cyrus Rangan, director of the Bureau of Toxicology and Environmental Assessment at the Los Angeles Department of Public Health.

He dispelled the following common myths in a presentation at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

• Vaccination autism. In some cases, the origins of a myth are difficult to trace, while in others, key events are known. In this case, a 1998 study published in Lancet linked autism to vaccinations. Many studies since have refuted the link, and the journal retracted the article in February 2010. "I think it’s going to take an entire generation or more before the scarring from this incident heals," Dr. Rangan said.

• Poisonous poinsettia. In 1919, a 2-year-old child died after eating a poinsettia leaf, leading to years of unfounded concern, Dr. Rangan said. In 1975, the U.S. Consumer Product Safety Commission petitioned to include warning labels with the sale of the plant. Yet no reports of deaths attributed to a poinsettia have been recorded on Medline. In a 1980 investigation, 46 rats remained healthy on a 1-week diet of poinsettia (Clin. Toxicol. 1980;16:167-73).

• Blinding sunscreen. What should you do if some sunscreen gets into your child’s eyes? "I called the poison control center. They told me to RUSH Zack to the ER NOW!!" read one hyperbolic 1998 chain e-mail that Dr. Rangan quoted. "MANY kids each year lose their sight to waterproof sunscreen," it continued. But again, Medline has no record of any cases of blindness caused by sunscreen, either waterproof or regular.

• Microwaved plastic. A high school science experiment, apparently combined with speculation by a chemist interviewed on Hawaiian television, resulted in a 2002 chain e-mail warning against the possibility of dioxins leaching from plastic wrap into food when microwaved. "I would never say every urban legend is completely without merit," Dr. Rangan said. In fact, the plastic can release trace amounts of diethylhexyl adipate (DEHA) in excess of U.S. Food and Drug Administration standards, but it is unlikely to do this in typical microwave heating. And no human health effects have been shown. "FDA standards are not toxicity standards," Dr. Rangan said.

• Noodle wax. Another 2000 chain e-mail warned of toxic wax in foam containers for instant noodles, and even mentioned the death of an unfortunate noodle eater. But polystyrene noodle containers are not lined with wax, and no waxes have been linked to hepatotoxicity or deaths in the literature on Medline, Dr. Rangan said.

• Lipstick lead. A 2003 e-mail listed brand-name cosmetics containing lead. "Do NOT kiss your children, while wearing lipstick!!!!" it said. But the FDA tightly regulates lead in cosmetics and there are no published studies on lead in excess of FDA standards in any cosmetics, nor any cases of human exposure to lead from lipstick cited in the literature on Medline.

• Mercury fillings. "Some 80% of the population will experience only a slight change of their immune system which will result in three colds per winter instead of only two," said a 1985 report that sounded particularly convincing in its specificity about the dangers of amalgam restorations. In fact, Dr. Rangan said, there are no cases documented on Medline of immune or respiratory illnesses linked to dental amalgam.

• Lead glassware. In February 2005, a television program carried a report of high lead content in painted designs on glasses and dinner plates. "The lead you find can actually be quite alarming," Dr. Rangan said. "But we don’t scrape stuff off a glass, then drink it." The correct test for lead should have been to dunk the glassware in acetic acid to see how much lead leached off. The television program had performed that test and found that the level was safe, but chose to report the more dramatic, less relevant information about the contents of lead in scraped-off paint, Dr. Rangan said.

• Urine Luck. Not so much a myth as a scam, this Internet-marketed product contains pyridinium chlorochromate, which by dissociation yields chromium VI. Chromium VI can mask tetrahydrocannabinol (THC), the active ingredient of marijuana, in urine samples, Dr. Rangan said. However, employers now know to check for pyridinium chlorochromate in urine.

• Toxic aspartame. The rumor is that methanol, "a deadly cumulative poison," is released from aspartame artificial sweetener. In fact, methanol can be liberated from aspartame, but only in trace amounts and only when aspartame is heated to 120 degrees. Orange juice and other foods contain higher levels of methanol than you’re likely to find in a soft drink, Dr. Rangan said.

• Urine antidote. The poison control hotline gets many calls from victims of jellyfish stings wanting to know if they should urinate on themselves. The short answer? No. It’s not clear where this myth got started, Dr. Rangan said. While the acetic acid in urine might help, the urea is likely to have the opposite effect. It would be much better to use saline solution as a rinse, he said.

LAS VEGAS – It can kill crops and destroy buildings. It’s used as an industrial coolant and is present in all cancer cells. Yet, it’s ending up in our food. What is it?

If you guessed "water," you’re ahead of scores of people who have signed petitions to ban "dihydrogen monoxide," a tongue-in-cheek name for H2O. Many such hoaxes, urban legends, and fallacies are circulating via Web sites, e-mail, television news reports, and ordinary conversation, said Dr. Cyrus Rangan, director of the Bureau of Toxicology and Environmental Assessment at the Los Angeles Department of Public Health.

He dispelled the following common myths in a presentation at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

• Vaccination autism. In some cases, the origins of a myth are difficult to trace, while in others, key events are known. In this case, a 1998 study published in Lancet linked autism to vaccinations. Many studies since have refuted the link, and the journal retracted the article in February 2010. "I think it’s going to take an entire generation or more before the scarring from this incident heals," Dr. Rangan said.

• Poisonous poinsettia. In 1919, a 2-year-old child died after eating a poinsettia leaf, leading to years of unfounded concern, Dr. Rangan said. In 1975, the U.S. Consumer Product Safety Commission petitioned to include warning labels with the sale of the plant. Yet no reports of deaths attributed to a poinsettia have been recorded on Medline. In a 1980 investigation, 46 rats remained healthy on a 1-week diet of poinsettia (Clin. Toxicol. 1980;16:167-73).

• Blinding sunscreen. What should you do if some sunscreen gets into your child’s eyes? "I called the poison control center. They told me to RUSH Zack to the ER NOW!!" read one hyperbolic 1998 chain e-mail that Dr. Rangan quoted. "MANY kids each year lose their sight to waterproof sunscreen," it continued. But again, Medline has no record of any cases of blindness caused by sunscreen, either waterproof or regular.

• Microwaved plastic. A high school science experiment, apparently combined with speculation by a chemist interviewed on Hawaiian television, resulted in a 2002 chain e-mail warning against the possibility of dioxins leaching from plastic wrap into food when microwaved. "I would never say every urban legend is completely without merit," Dr. Rangan said. In fact, the plastic can release trace amounts of diethylhexyl adipate (DEHA) in excess of U.S. Food and Drug Administration standards, but it is unlikely to do this in typical microwave heating. And no human health effects have been shown. "FDA standards are not toxicity standards," Dr. Rangan said.

• Noodle wax. Another 2000 chain e-mail warned of toxic wax in foam containers for instant noodles, and even mentioned the death of an unfortunate noodle eater. But polystyrene noodle containers are not lined with wax, and no waxes have been linked to hepatotoxicity or deaths in the literature on Medline, Dr. Rangan said.

• Lipstick lead. A 2003 e-mail listed brand-name cosmetics containing lead. "Do NOT kiss your children, while wearing lipstick!!!!" it said. But the FDA tightly regulates lead in cosmetics and there are no published studies on lead in excess of FDA standards in any cosmetics, nor any cases of human exposure to lead from lipstick cited in the literature on Medline.

• Mercury fillings. "Some 80% of the population will experience only a slight change of their immune system which will result in three colds per winter instead of only two," said a 1985 report that sounded particularly convincing in its specificity about the dangers of amalgam restorations. In fact, Dr. Rangan said, there are no cases documented on Medline of immune or respiratory illnesses linked to dental amalgam.

• Lead glassware. In February 2005, a television program carried a report of high lead content in painted designs on glasses and dinner plates. "The lead you find can actually be quite alarming," Dr. Rangan said. "But we don’t scrape stuff off a glass, then drink it." The correct test for lead should have been to dunk the glassware in acetic acid to see how much lead leached off. The television program had performed that test and found that the level was safe, but chose to report the more dramatic, less relevant information about the contents of lead in scraped-off paint, Dr. Rangan said.

• Urine Luck. Not so much a myth as a scam, this Internet-marketed product contains pyridinium chlorochromate, which by dissociation yields chromium VI. Chromium VI can mask tetrahydrocannabinol (THC), the active ingredient of marijuana, in urine samples, Dr. Rangan said. However, employers now know to check for pyridinium chlorochromate in urine.

• Toxic aspartame. The rumor is that methanol, "a deadly cumulative poison," is released from aspartame artificial sweetener. In fact, methanol can be liberated from aspartame, but only in trace amounts and only when aspartame is heated to 120 degrees. Orange juice and other foods contain higher levels of methanol than you’re likely to find in a soft drink, Dr. Rangan said.

• Urine antidote. The poison control hotline gets many calls from victims of jellyfish stings wanting to know if they should urinate on themselves. The short answer? No. It’s not clear where this myth got started, Dr. Rangan said. While the acetic acid in urine might help, the urea is likely to have the opposite effect. It would be much better to use saline solution as a rinse, he said.

LAS VEGAS – It can kill crops and destroy buildings. It’s used as an industrial coolant and is present in all cancer cells. Yet, it’s ending up in our food. What is it?

If you guessed "water," you’re ahead of scores of people who have signed petitions to ban "dihydrogen monoxide," a tongue-in-cheek name for H2O. Many such hoaxes, urban legends, and fallacies are circulating via Web sites, e-mail, television news reports, and ordinary conversation, said Dr. Cyrus Rangan, director of the Bureau of Toxicology and Environmental Assessment at the Los Angeles Department of Public Health.

He dispelled the following common myths in a presentation at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

• Vaccination autism. In some cases, the origins of a myth are difficult to trace, while in others, key events are known. In this case, a 1998 study published in Lancet linked autism to vaccinations. Many studies since have refuted the link, and the journal retracted the article in February 2010. "I think it’s going to take an entire generation or more before the scarring from this incident heals," Dr. Rangan said.

• Poisonous poinsettia. In 1919, a 2-year-old child died after eating a poinsettia leaf, leading to years of unfounded concern, Dr. Rangan said. In 1975, the U.S. Consumer Product Safety Commission petitioned to include warning labels with the sale of the plant. Yet no reports of deaths attributed to a poinsettia have been recorded on Medline. In a 1980 investigation, 46 rats remained healthy on a 1-week diet of poinsettia (Clin. Toxicol. 1980;16:167-73).

• Blinding sunscreen. What should you do if some sunscreen gets into your child’s eyes? "I called the poison control center. They told me to RUSH Zack to the ER NOW!!" read one hyperbolic 1998 chain e-mail that Dr. Rangan quoted. "MANY kids each year lose their sight to waterproof sunscreen," it continued. But again, Medline has no record of any cases of blindness caused by sunscreen, either waterproof or regular.

• Microwaved plastic. A high school science experiment, apparently combined with speculation by a chemist interviewed on Hawaiian television, resulted in a 2002 chain e-mail warning against the possibility of dioxins leaching from plastic wrap into food when microwaved. "I would never say every urban legend is completely without merit," Dr. Rangan said. In fact, the plastic can release trace amounts of diethylhexyl adipate (DEHA) in excess of U.S. Food and Drug Administration standards, but it is unlikely to do this in typical microwave heating. And no human health effects have been shown. "FDA standards are not toxicity standards," Dr. Rangan said.

• Noodle wax. Another 2000 chain e-mail warned of toxic wax in foam containers for instant noodles, and even mentioned the death of an unfortunate noodle eater. But polystyrene noodle containers are not lined with wax, and no waxes have been linked to hepatotoxicity or deaths in the literature on Medline, Dr. Rangan said.

• Lipstick lead. A 2003 e-mail listed brand-name cosmetics containing lead. "Do NOT kiss your children, while wearing lipstick!!!!" it said. But the FDA tightly regulates lead in cosmetics and there are no published studies on lead in excess of FDA standards in any cosmetics, nor any cases of human exposure to lead from lipstick cited in the literature on Medline.

• Mercury fillings. "Some 80% of the population will experience only a slight change of their immune system which will result in three colds per winter instead of only two," said a 1985 report that sounded particularly convincing in its specificity about the dangers of amalgam restorations. In fact, Dr. Rangan said, there are no cases documented on Medline of immune or respiratory illnesses linked to dental amalgam.

• Lead glassware. In February 2005, a television program carried a report of high lead content in painted designs on glasses and dinner plates. "The lead you find can actually be quite alarming," Dr. Rangan said. "But we don’t scrape stuff off a glass, then drink it." The correct test for lead should have been to dunk the glassware in acetic acid to see how much lead leached off. The television program had performed that test and found that the level was safe, but chose to report the more dramatic, less relevant information about the contents of lead in scraped-off paint, Dr. Rangan said.

• Urine Luck. Not so much a myth as a scam, this Internet-marketed product contains pyridinium chlorochromate, which by dissociation yields chromium VI. Chromium VI can mask tetrahydrocannabinol (THC), the active ingredient of marijuana, in urine samples, Dr. Rangan said. However, employers now know to check for pyridinium chlorochromate in urine.

• Toxic aspartame. The rumor is that methanol, "a deadly cumulative poison," is released from aspartame artificial sweetener. In fact, methanol can be liberated from aspartame, but only in trace amounts and only when aspartame is heated to 120 degrees. Orange juice and other foods contain higher levels of methanol than you’re likely to find in a soft drink, Dr. Rangan said.

• Urine antidote. The poison control hotline gets many calls from victims of jellyfish stings wanting to know if they should urinate on themselves. The short answer? No. It’s not clear where this myth got started, Dr. Rangan said. While the acetic acid in urine might help, the urea is likely to have the opposite effect. It would be much better to use saline solution as a rinse, he said.

LAS VEGAS — What's the treatment of choice for group A streptococcal tonsillopharyngitis?

In 2009, attendees at this pediatric update sponsored by the American Academy of Pediatrics California District 9 were advised that cephalexin was the best first-line treatment. But those who returned this year heard a conflicting recommendation – for amoxicillin taken in one dose per day. Both recommendations differ from the AAP Red Book.

“Amoxicillin is my favorite,” said Dr. Christopher J. Harrison, a pediatrician who is an infectious disease specialist at Children's Mercy Hospital in Kansas City, who presented this year.

While the AAP Red Book, Centers for Disease Control and Prevention, and other organizations still recommend penicillin as the first line of treatment, recent studies have shown it to be less effective than amoxicillin, said Dr. Harrison, citing an article that compared the two regimens in 152 children (Pediatrics 1999;103:47-51).

One problem with penicillin is that the generic versions taste bad, he said, so patients are less likely to take the full course. “The taste has always been an issue,” said Dr. Harrison. Amoxicillin tastes better. So he recommends amoxicillin 50 mg/kg up to 1 g, taken once per day – an approach shown to be effective in one study (Arch. Dis. Child. 2008;93:474-8).

The standard recommendation for amoxicillin is 750 mg four times a day, but administering a drug three to four times a day is hard for families, he said. “That's not something that our parents are going to get done.”

So Dr. Harrison prescribes the amoxicillin all in one dose per day. “The single big dose – or twice a day – is actually pharmacokinetically better than what we used to do,” he said. Fewer, larger doses result in a longer period of time in which the serum level of the drug is at a high concentration. The longer time at a higher concentration is helpful in eradicating bacteria that can protect themselves in biofilm, he said.

He also cited studies showing that cephalosporins, such as cephalexin, are more effective than penicillin.

But he agreed with the Red Book recommendation that these drugs should be used as second-line treatments because of the risk that the bacteria might develop resistance to them. He also pointed out that the cephalosporins, while more successful in eradicating the bacteria, have never been shown to directly prevent rheumatic fever.

Asked to comment, Dr. Michael E. Pichichero, a pediatrician who is an infectious disease specialist at the University of Rochester (N.Y.) Medical Center, stuck to the position he articulated at last year's meeting: that cephalexin is the best first-line treatment. He uses two 15-mg doses per kilogram per day.

He cited his own research, including a study to which he contributed published in Clinical Pediatrics (2008;47:549-54), which found that children treated with first-generation cephalosporins are much less likely to experience symptomatic relapses than children treated with amoxicillin, which in turn works better than penicillin.

“Cephalexin tastes good,” he said. “It can be used twice a day. It doesn't kill the normal flora. And it's no more expensive.” The possibility that the use of cephalexin as a first-line treatment might lead to more resistant strains of streptococcus “has never been shown,” he said. “It's hypothetical.”

Dr. Pichichero pointed out that there are reasons to eradicate the bacteria besides preventing rheumatic fever. “We know that treating results in a reduction in contagion,” he said. “And it prevents sequelae like abscesses of the lymph nodes.”

The question of which antibiotic to use was not the only group A strep controversy Dr. Harrison discussed. He also spoke highly of new rapid tests for strep, citing a recent study in Clinical Pediatrics (2010;49:1050-2) that found that several of the new tests had sensitivity and specificity above 95%.

Based on this research, he doesn't think everyone needs to order a throat culture in the case of a negative result with a rapid test. “It's not really a necessary thing, in my personal opinion, for everyone, although it's recommended.”

The exception? In an area with rheumatic fever or some other special cause for concern, the throat culture is still advisable.

Dr. Harrison disclosed that he has had a financial relationship with GlaxoSmithKline Vaccine Group. Dr. Pichichero said that he had no relevant financial disclosures.

Cephalosporins should be used as second-line treatments because of the risk of bacterial resistance.

Source DR. HARRISON

LAS VEGAS — What's the treatment of choice for group A streptococcal tonsillopharyngitis?

In 2009, attendees at this pediatric update sponsored by the American Academy of Pediatrics California District 9 were advised that cephalexin was the best first-line treatment. But those who returned this year heard a conflicting recommendation – for amoxicillin taken in one dose per day. Both recommendations differ from the AAP Red Book.

“Amoxicillin is my favorite,” said Dr. Christopher J. Harrison, a pediatrician who is an infectious disease specialist at Children's Mercy Hospital in Kansas City, who presented this year.

While the AAP Red Book, Centers for Disease Control and Prevention, and other organizations still recommend penicillin as the first line of treatment, recent studies have shown it to be less effective than amoxicillin, said Dr. Harrison, citing an article that compared the two regimens in 152 children (Pediatrics 1999;103:47-51).

One problem with penicillin is that the generic versions taste bad, he said, so patients are less likely to take the full course. “The taste has always been an issue,” said Dr. Harrison. Amoxicillin tastes better. So he recommends amoxicillin 50 mg/kg up to 1 g, taken once per day – an approach shown to be effective in one study (Arch. Dis. Child. 2008;93:474-8).

The standard recommendation for amoxicillin is 750 mg four times a day, but administering a drug three to four times a day is hard for families, he said. “That's not something that our parents are going to get done.”

So Dr. Harrison prescribes the amoxicillin all in one dose per day. “The single big dose – or twice a day – is actually pharmacokinetically better than what we used to do,” he said. Fewer, larger doses result in a longer period of time in which the serum level of the drug is at a high concentration. The longer time at a higher concentration is helpful in eradicating bacteria that can protect themselves in biofilm, he said.

He also cited studies showing that cephalosporins, such as cephalexin, are more effective than penicillin.

But he agreed with the Red Book recommendation that these drugs should be used as second-line treatments because of the risk that the bacteria might develop resistance to them. He also pointed out that the cephalosporins, while more successful in eradicating the bacteria, have never been shown to directly prevent rheumatic fever.

Asked to comment, Dr. Michael E. Pichichero, a pediatrician who is an infectious disease specialist at the University of Rochester (N.Y.) Medical Center, stuck to the position he articulated at last year's meeting: that cephalexin is the best first-line treatment. He uses two 15-mg doses per kilogram per day.

He cited his own research, including a study to which he contributed published in Clinical Pediatrics (2008;47:549-54), which found that children treated with first-generation cephalosporins are much less likely to experience symptomatic relapses than children treated with amoxicillin, which in turn works better than penicillin.

“Cephalexin tastes good,” he said. “It can be used twice a day. It doesn't kill the normal flora. And it's no more expensive.” The possibility that the use of cephalexin as a first-line treatment might lead to more resistant strains of streptococcus “has never been shown,” he said. “It's hypothetical.”

Dr. Pichichero pointed out that there are reasons to eradicate the bacteria besides preventing rheumatic fever. “We know that treating results in a reduction in contagion,” he said. “And it prevents sequelae like abscesses of the lymph nodes.”

The question of which antibiotic to use was not the only group A strep controversy Dr. Harrison discussed. He also spoke highly of new rapid tests for strep, citing a recent study in Clinical Pediatrics (2010;49:1050-2) that found that several of the new tests had sensitivity and specificity above 95%.

Based on this research, he doesn't think everyone needs to order a throat culture in the case of a negative result with a rapid test. “It's not really a necessary thing, in my personal opinion, for everyone, although it's recommended.”

The exception? In an area with rheumatic fever or some other special cause for concern, the throat culture is still advisable.

Dr. Harrison disclosed that he has had a financial relationship with GlaxoSmithKline Vaccine Group. Dr. Pichichero said that he had no relevant financial disclosures.

Cephalosporins should be used as second-line treatments because of the risk of bacterial resistance.

Source DR. HARRISON

LAS VEGAS — What's the treatment of choice for group A streptococcal tonsillopharyngitis?

In 2009, attendees at this pediatric update sponsored by the American Academy of Pediatrics California District 9 were advised that cephalexin was the best first-line treatment. But those who returned this year heard a conflicting recommendation – for amoxicillin taken in one dose per day. Both recommendations differ from the AAP Red Book.

“Amoxicillin is my favorite,” said Dr. Christopher J. Harrison, a pediatrician who is an infectious disease specialist at Children's Mercy Hospital in Kansas City, who presented this year.

While the AAP Red Book, Centers for Disease Control and Prevention, and other organizations still recommend penicillin as the first line of treatment, recent studies have shown it to be less effective than amoxicillin, said Dr. Harrison, citing an article that compared the two regimens in 152 children (Pediatrics 1999;103:47-51).

One problem with penicillin is that the generic versions taste bad, he said, so patients are less likely to take the full course. “The taste has always been an issue,” said Dr. Harrison. Amoxicillin tastes better. So he recommends amoxicillin 50 mg/kg up to 1 g, taken once per day – an approach shown to be effective in one study (Arch. Dis. Child. 2008;93:474-8).

The standard recommendation for amoxicillin is 750 mg four times a day, but administering a drug three to four times a day is hard for families, he said. “That's not something that our parents are going to get done.”

So Dr. Harrison prescribes the amoxicillin all in one dose per day. “The single big dose – or twice a day – is actually pharmacokinetically better than what we used to do,” he said. Fewer, larger doses result in a longer period of time in which the serum level of the drug is at a high concentration. The longer time at a higher concentration is helpful in eradicating bacteria that can protect themselves in biofilm, he said.

He also cited studies showing that cephalosporins, such as cephalexin, are more effective than penicillin.

But he agreed with the Red Book recommendation that these drugs should be used as second-line treatments because of the risk that the bacteria might develop resistance to them. He also pointed out that the cephalosporins, while more successful in eradicating the bacteria, have never been shown to directly prevent rheumatic fever.

Asked to comment, Dr. Michael E. Pichichero, a pediatrician who is an infectious disease specialist at the University of Rochester (N.Y.) Medical Center, stuck to the position he articulated at last year's meeting: that cephalexin is the best first-line treatment. He uses two 15-mg doses per kilogram per day.

He cited his own research, including a study to which he contributed published in Clinical Pediatrics (2008;47:549-54), which found that children treated with first-generation cephalosporins are much less likely to experience symptomatic relapses than children treated with amoxicillin, which in turn works better than penicillin.

“Cephalexin tastes good,” he said. “It can be used twice a day. It doesn't kill the normal flora. And it's no more expensive.” The possibility that the use of cephalexin as a first-line treatment might lead to more resistant strains of streptococcus “has never been shown,” he said. “It's hypothetical.”

Dr. Pichichero pointed out that there are reasons to eradicate the bacteria besides preventing rheumatic fever. “We know that treating results in a reduction in contagion,” he said. “And it prevents sequelae like abscesses of the lymph nodes.”

The question of which antibiotic to use was not the only group A strep controversy Dr. Harrison discussed. He also spoke highly of new rapid tests for strep, citing a recent study in Clinical Pediatrics (2010;49:1050-2) that found that several of the new tests had sensitivity and specificity above 95%.

Based on this research, he doesn't think everyone needs to order a throat culture in the case of a negative result with a rapid test. “It's not really a necessary thing, in my personal opinion, for everyone, although it's recommended.”

The exception? In an area with rheumatic fever or some other special cause for concern, the throat culture is still advisable.

Dr. Harrison disclosed that he has had a financial relationship with GlaxoSmithKline Vaccine Group. Dr. Pichichero said that he had no relevant financial disclosures.

Cephalosporins should be used as second-line treatments because of the risk of bacterial resistance.

Source DR. HARRISON

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases. “So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. “Terbinafine is so cost effective,” he said. “You can get it for $4-$7 per month. It used to be $1,200 for a full course.”

His recommended dosages to treat onychomycosis are the following:

▸ For children weighing less than 20 kg: 62.5 mg/day.

▸ For children weighing 20-40 kg: 125 mg/day.

▸ For children weighing more than 40 kg: 250 mg/day.

“It's recommended that you get baseline lab work,” he said. “Many of us will repeat [it] 1 month into the therapy.”

Dr. Eichenfield reported having no relevant conflicts of interest.

Topical medications alone seldom cure tinea capitis, but they can be used in combination with systemic drugs.

Source DR. EICHENFIELD

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases. “So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. “Terbinafine is so cost effective,” he said. “You can get it for $4-$7 per month. It used to be $1,200 for a full course.”

His recommended dosages to treat onychomycosis are the following:

▸ For children weighing less than 20 kg: 62.5 mg/day.

▸ For children weighing 20-40 kg: 125 mg/day.

▸ For children weighing more than 40 kg: 250 mg/day.

“It's recommended that you get baseline lab work,” he said. “Many of us will repeat [it] 1 month into the therapy.”

Dr. Eichenfield reported having no relevant conflicts of interest.

Topical medications alone seldom cure tinea capitis, but they can be used in combination with systemic drugs.

Source DR. EICHENFIELD

LAS VEGAS – Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases. “So it's worth doing a routine culture,” said Dr. Eichenfield, adding that it's fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. “Terbinafine is so cost effective,” he said. “You can get it for $4-$7 per month. It used to be $1,200 for a full course.”

His recommended dosages to treat onychomycosis are the following:

▸ For children weighing less than 20 kg: 62.5 mg/day.

▸ For children weighing 20-40 kg: 125 mg/day.

▸ For children weighing more than 40 kg: 250 mg/day.

“It's recommended that you get baseline lab work,” he said. “Many of us will repeat [it] 1 month into the therapy.”

Dr. Eichenfield reported having no relevant conflicts of interest.

Topical medications alone seldom cure tinea capitis, but they can be used in combination with systemic drugs.

Source DR. EICHENFIELD

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – Pediatricians should not condemn all performance-enhancing drugs, according to Dr. Gregory L. Landry, a pediatrician who specializes in sports medicine at the University of Wisconsin, Madison.

Because the use of creatine has been associated with little risk, physicians should take a more neutral attitude toward it than toward more dangerous substances such as anabolic steroids, he said. He acknowledged that this position contradicts the American Academy of Pediatrics position (Pediatrics 2005;115:1103-6), which states that the "use of performance-enhancing substances for athletic or other purposes should be strongly discouraged."

"I disagree with the academy," Dr. Landry said at a pediatric update sponsored by the American Academy of Pediatrics California Chapter 9. "Compared to other risk-taking behaviors, creatine is low risk. We have more important battles [to fight], like seat belts, binge drinking, and unprotected sex."

Doctors should be honest with their patients about potential benefits as well as risks to various performance-enhancing substances, he said. Although there is evidence that creatine, caffeine, carbohydrate-electrolyte beverages, and sodium bicarbonate may work, amino acids, beta-hydroxy-beta-methylbutyrate, and chromium are not helpful, and anabolic steroids should be avoided because of their side effects, he said.

The use of creatine appears to be increasing. "Where I work, this is the most popular supplement that kids are asking about," he said. In one survey of 4,011 Wisconsin high school athletes, more than a quarter of the boys had used creatine supplements.

Exogenous creatine occurs naturally in foods such as red meat and fish, and human beings can synthesize it as well, so there is no daily requirement. But exogenous creatine is absorbed 100% unchanged.

In muscles, it is converted to phosphocreatine, which in turn produces adenosine triphosphate, a molecule that provides energy. With maximum exertion, levels of this molecule fall. Creatine may also buffer lactate. "Many athletes feel they can work harder and longer by using creatine," said Dr. Landry.

Several studies have investigated the effects on athletic performance, he said. In general, they suggest that creatine supplementation can increase peak power, but that it may be detrimental in endurance sports. "The best benefit is in repeated short bursts of power, such as in U.S. football and sprinting," said Dr. Landry.

Common short-term side effects include nausea, abdominal pain, diarrhea, water weight gain, and possible muscle strains. Dr. Landry said he encourages athletes to drink more water when they are taking creatine. But a meta-analysis found no evidence that the supplements increase heat illness (J. Athl. Train. 2009;44:215-23). One case of renal failure in an athlete taking creatine was reversed when the athlete stopped taking the supplements.

The supplements are readily available for sale. Uptake in muscles is enhanced by ingesting them with 90 g of glucose, said Dr. Landry.

Creatine is not banned by any sports-governing body, nor are any testing for it. However, Dr. Landry cautioned that commercially available supplements are often tainted, so he advised purchasing them from a scientific source.

Moving quickly through a list of other supplements Dr. Landry said there is evidence that caffeine, which increases the utilization of fat, may have benefits in endurance sports like cycling and rowing. Side effects include anxiety, diuresis, diarrhea, and palpitations. The National Collegiate Athletic Association has set a limit on the amount of caffeine allowed in athletes’ urine, but other sports-governing bodies have not.

Sodium bicarbonate may help in medium-duration sports, such as a 1,500-m race. However, it can cause bloating and diarrhea.

Numerous studies show that athletes drinking carbohydrate-electrolyte beverages performed better in endurance events, although not in short events. Dr. Landry recommended a carbohydrate concentration of 5%-7%.

Pharmacologic androgens do build muscle and enhance performance, but are associated with many side effects. Androgenic supplements are less effective and may have more side effects. Androgen precursors are of dubious benefit, he said.

Beta-hydroxy-beta-methylbutyrate might increase muscle mass, but has not been shown to have a benefit in athletic performance. No short-term side effects have been shown.

Amino acids probably don’t help American athletes because most athletes are already getting more than enough in their diets.

Chromium could theoretically increase muscle mass, but benefits for athletic performance have not been shown, and cases of liver failure and renal dysfunction have been reported.

As for what advice Dr. Landry gives his own patients, "I usually talk about diet," he said. "What we do with our college athletes is we’re teaching them to cook and we’re teaching them to shop. We tell them that’s going to have a bigger effect on their performance than any supplement."

Dr. Landry said he had no relevant financial disclosures.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

Photo credit: (c) Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

Photo credit: (c) Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

Photo credit: (c) Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS – In the movies, a savvy hero saves the victim of a rattler by quickly ripping up a shirt to use as a tourniquet, then sucking the venom from the wound. In real life, forget it.

"A cell phone – that's your snakebite kit," said Dr. Cyrus Rangan, director of toxics epidemiology at the Los Angeles County Department of Health Services in his talk on envenomations at the meeting sponsored by the American Academy of Pediatrics California District 9.

© Tim Goodwin/FOTOLIA

Few people suffer from severely toxic bites in the United States, but getting the treatment right is essential in these cases. "When it does happen, it's important to know what your next move is going to be," said Dr. Rangan, who focused on bites by rattlesnakes and spiders.

Snakes bite about 3-4 out of every 100,000 people each year in the United States. A quarter of these are "dry bites" in which no venom is released. Half result in severe morbidity. Deaths are rare.

The most common poisonous snake in the United States is the rattlesnake (Crotalus atrox and Crotalus viridis helleri). The bites usually penetrate only a few millimeters and, as a result, the damage is localized. In the rare case when the venom enters a vein, the consequences can be serious. The teeth usually leave simple puncture wounds, but sometimes they drag along the skin far enough to cause lacerations.

In women, such bites are mostly on the foot, the result of accidentally stepping on or near the snake. "Ninety percent of the time men get bitten on the hand because they're doing something dumb," said Dr. Rangan. He told the story of a man who kissed a rattler on the mouth – and got bitten – in two separate incidents.

Presentation includes stinging, burning pain, distal-to-proximal swelling, blebs and ecchymoses (caused by someone trying to suck out the venom), and occasional oozing from the bite site. Don't worry about the oozing or try to treat with platelets, Dr. Rangan advised.

Patients may also experience nausea, a metallic taste, diaphoresis, paresthesia, and rarely hypotension, arrhythmias, or rhabdomyolysis. Fasciculations (muscle twitching) may occur anywhere in the body – the result of neurotoxins in the venom, said Dr. Rangan.

The venom contains enzymes that promote thrombin-like activity and fibrinolysis. Tourniquets are a mistake because it's better to let the venom circulate rather than be concentrated in one place where it can cause necrosis. Other folk remedies that do more harm than good include extreme icing, attempting to cut away the affected tissue, burning, and even electrotherapy.

What should be done instead? Besides calling a pharmacy to make sure it has the appropriate antivenom in stock, Dr. Rangan said, appropriate first aid includes immobilizing the patient and elevating the bitten extremity above the heart.

At the hospital, he advised doctors to remove all constricting bands, continue to elevate the extremity, monitor the progression of swelling, administer tetanus prophylaxis, and take platelet and fibrinogen labs. Other labs might include CBC, CPK (creatine phosphokinase), Type+Screen in preparation for a possible blood transfusion, and PT (prothrombin time).

The appropriate antivenom is Crotalidae polyvalent immune Fab (CroFab), which is made by injecting sheep with the venom, then isolating the antibodies. CroFab contains intact IgG antibodies digested with papain to yield Fab fragments.

Dr. Rangan advised administering six vials in increments until the cessation of swelling and the stabilization of coagulation abnormalities. Empiric antibiotics and blood products can be considered. Anticipate and treat serum sickness. "Don't forget pain control," he said.

Surgical intervention is rarely needed. Some necrotic tissue debridement might be called for, but fasciotomy is rarely indicated and is the largest contributor to comorbidity, he added.

Dangerous Spiders

Dr. Rangan emphasized that the brown recluse spider (Loxosceles reclusa) is confined almost entirely to the central Southern states, and even there bites are extremely rare. Likewise, he said, tarantula (Theraphosidae) bites are mostly more painful than damaging. These spiders also can eject barbed hairs, which are generally only serious if they get into a patient's eyes.

Black widows (Latrodectus), on the other hand, can cause major havoc. "If there is one spider you have to worry about, this is the one," said Dr. Rangan. These bites can be fatal in small children or the frail elderly.

The bites are single needle-like puncture wounds. A quarter is dry bites that cause little harm, but 60% present with an erythematous macule, 30% with a "target" lesion, 5% with an erythema marginatum, and 5% with tiny distinct dual fang marks. "If you see a patch of sweat and a little red dot, it's virtually pathognomonic," said Dr. Rangan.

Symptoms begin 20 minutes to a few hours after the bite. Cramping moves quickly to the abdominal wall where it can resemble a wide range of other syndromes. Pain can be severe and may be accompanied by headache, diarrhea, diaphoresis, photophobia, dyspnea, nausea, vomiting, and agitation.

It's important to administer the antivenom quickly. In this case, it is equine-derived, so it can cause anaphylaxis in allergic patients. A skin test is available.

Antivenom may relieve symptoms quickly, but in the meantime, you can control pain with diazepam or morphine. Calcium gluconate and methocarbamol have been used in the past for black widow bites, but Dr. Rangan advised against them.

When it doubt, he urged, call Poison Control at 800-222-1222, a national hotline.

Dr. Rangan said he had nothing to disclose.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.

LAS VEGAS - Competition among large retailers is bringing down the cost of terbinafine, but griseofulvin is still better for many fungal infections, according to Dr. Lawrence F. Eichenfield.

The ideal prescription depends on the type of fungus and the site of the infection, said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego, at the pediatric update sponsored by the American Academy of Pediatrics California Chapter 9.

Topical medications alone can seldom cure tinea capitis because the fungus finds protection inside hair follicles, but he advised using them in combination with systemic drugs.

The signs of tinea capitis include scaling, pustules, kerion, black dots, alopecia, adenopathy, and autoeczematization (also known as id reaction). The condition can resemble seborrheic dermatitis, psoriasis, folliculitis, and other diseases.

"So it's worth doing a routine culture," said Dr. Eichenfield, adding that it’s fairly easy to obtain a specimen with a toothbrush, cotton swabs, or bacterial culturettes.

The most common culprit is Trichophyton tonsurans, which is spread by human contact. The second most common cause is Microsporum canis, which is spread by cats.

Family coinfection can contribute to treatment failure, so inquire about tinea capitis and tinea corporis in other affected family members and pets, said Dr. Eichenfield. The standard therapy for tinea capitis is microsized griseofulvin (20 mg/kg) for 6-8 weeks, he advised.

The only other approved drug is terbinafine granules, and these are hard to obtain, he said, but itraconazole and fluconazole might also work.

Particularly if griseofulvin fails, Dr. Eichenfield recommended terbinafine 4-8 mg/kg per day for 4 weeks. But one recent study found that griseofulvin was much better than terbinafine for M. canis (J. Am. Acad. Dermatol. 2008;59:41-54).

The same organisms, along with T. rubrum and T. mentagrophytes, can cause tinea corporis. Patients present with red scaling plaque, often with an active border. Central clearing may give the lesions a ring shape.

They can be treated with a wide variety of topical drugs, among them clotrimazole, econazole, oxiconazole, ciclopirox, terbinafine, and ketoconazole. Systemic treatment should be reserved for extensive disease or special circumstances, such as for wrestlers. The best systemic treatment is griseofulvin, 15-20 mg/kg (5-10 mg/kg ultramicrosize), said Dr. Eichenfield.

Although fewer than 1% of children suffer from onychomycosis, the proportion increases with age; more than a third of adults older than 70 years have the disease. In children who are not severely affected, the disease can go untreated.

There is no approved treatment for onychomycosis in children, but Dr. Eichenfield said that he is comfortable recommending terbinafine as long as parents are informed that this is an off-label use of the drug. "Terbinafine is so cost effective," he said. "You can get it for $4-$7 per month. It used to be $1,200 for a full course."

His recommended dosages to treat onychomycosis are the following:

• For children weighing less than 20 kg: 62.5 mg/day.

• For children weighing 20-40 kg: 125 mg/day.

• For children weighing more than 40 kg: 250 mg/day.

"It's recommended that you get baseline lab work," he said. "Many of us will repeat [it] 1 month into the therapy."

In a study presented at the American Academy of Dermatology annual meeting in 2007, 39% of children treated with ciclopirox lacquer achieved a complete cure, compared with 22% of children who were treated with a placebo, suggesting that the disease can spontaneously resolve.

And what about lasers? "Whether lasers are any better than any other debridement has not been addressed," he said.

Dr. Eichenfield reported having no relevant financial disclosures.