CHICAGO—Individuals who use gastric acid-suppressive medications may be at an elevated risk of developing community-acquired pneumonia, according to an article in the October 27 issue of JAMA.

According to background information in the article, 20 to 40 percent of the general population experiences at least one episode of indigestion or gastroesophageal reflux disease (GERD, a backflow of acid from the stomach into the swallowing tube or esophagus) and five percent consult a general practitioner for their ailment. In primary care, a common way to treat these symptoms is to reduce gastric (stomach) acid secretions with the use of acid-suppressive drugs. However, these medications can increase vulnerability to infections, as stomach acidity is a major defense mechanism against ingested pathogens.

Robert J.F. Laheij, Ph.D., from the University Medical Center St. Radboud, Nijmegen, Netherlands, and colleagues studied pneumonia rates of both patients who did and did not use acid-suppressing medication. Patients were identified from the Integrated Primary Care Information (IPCI) database between January 1995 and December 2002. The study population included 364,683 individuals from the Netherlands who developed 5,551 cases of pneumonia for the first time.

The researchers found that current use of all acid-suppressive drugs was associated with a 27 percent increase in the risk of pneumonia, with higher risks for specific classes of acid-suppressive drugs (such as proton pump inhibitors or H2-receptor antagonist drugs).

CHICAGO—Treating children and adolescents with obsessive-compulsive disorder (OCD) with a combination of cognitive-behavior therapy (CBT) and the medication sertraline is more effective than CBT or sertraline alone, according to a study in the October 27 issue of JAMA.

Epidemiologic data suggest that approximately 1 in 200 young people suffers from OCD, which in many cases severely disrupts academic, social, and vocational functioning, according to background information in the article. Among adults with OCD, one-third to one-half develop the disorder during childhood or adolescence, which suggests that early intervention in childhood may prevent long-term illness in adulthood. Previous research has shown the effectiveness of short-term CBT or medical management with a selective serotonin reuptake inhibitor (such as sertraline, an antidepressant). However, little is known about their relative and combined efficacy. CBT is a form of psychotherapy that helps patients change their thought patterns and behaviors related to obsessive thoughts and compulsions.

OCD is characterized by recurrent obsessions and/or compulsions that are intense enough to cause severe discomfort. Obsessions are recurrent and persistent thoughts, impulses, or images that are unwanted and cause marked anxiety or distress. Compulsions are repetitive behaviors or rituals (such as hand washing, hoarding, checking something over and over) or mental acts (such as counting, repeating words silently).

John S. March, M.D., M.P.H., of the Duke University Medical Center, Durham, N.C., and members of the Pediatric OCD Treatment Study (POTS) team, evaluated the efficacy of CBT alone, medication management with the SSRI sertraline alone, or combined treatment consisting of CBT and sertraline as initial treatment for children and adolescents with OCD. POTS, a randomized controlled trial, was conducted at three academic centers in the U.S. and included 112 patients aged 7 through 17 years with a diagnosis of OCD. Patients were recruited between September 1997 and December 2002. Participants were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks.

Ninety-seven of 112 patients (87 percent) completed the full 12 weeks of treatment. The researchers found that "patients treated with CBT either alone or in combination with medication showed a substantially higher probability of improvement, with the edge going to combination treatment over CBT alone in one site but not in the other. Sertraline alone proved statistically superior to placebo, confirming the efficacy of medication used to treat OCD in youth; however, the effect size of CBT alone was larger than that for sertraline alone, and more patients receiving CBT alone entered remission than did those receiving sertraline alone (39.3 percent vs. 21.4 percent, respectively), though these differences did not reach statistical significance. Thus, we conclude that children and adolescents with OCD should begin treatment with CBT alone or with CBT plus an SSRI."

The three active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others.

CHICAGO—Asian children and black children experience higher rates of ruptured appendixes than white children, as do uninsured or Medicaid-insured children, compared to children covered by private insurance, according to a study in the October 27 issue of JAMA. The rate of "negative appendectomy" (appendix removal without appendicitis) declines at hospitals that perform more appendectomies.

According to background information in the article, the primary adverse outcome of appendicitis is appendiceal (appendix) rupture. Patients with a ruptured appendix at the time of surgical exploration have as high as a 39 percent chance of having a postsurgical complication, such as intra-abdominal abscess or wound infection, compared with an approximately 8 percent chance if the appendix is not perforated. It has been assumed that the natural history of appendix rupture is within the control of the hospital or physician and that a high rate of rupture reflects a failure of medical care.

Given the difficulty of diagnosing appendicitis in both children and adults, the traditional approach by hospitals to decrease the rupture rate has been to encourage early surgical exploration. In fact, high rates of negative exploration for appendicitis have been tolerated to lessen the likelihood of ruptured appendicitis and its complications. In essence, one complication (a negative exploration) is encouraged to decrease the incidence of another complication (appendiceal rupture). Rates for both of these in children remain high despite efforts to reduce them. Little is known about the factors that influence these rates.

Todd A. Ponsky, M.D., of Children's National Medical Center and George Washington University Medical Center, Washington, D.C., and colleagues examined the patterns of diagnosis and care of children aged 5 to 17 years with appendicitis at 36 major children's hospitals to assess the contributions of race, health insurance status, age, sex, and hospital volume on the ruptured appendicitis rate. They also evaluated the correlation between rupture rate and negative appendectomy rate (surgical removal of a nondiseased appendix). The researchers reviewed a database containing information on 24,411 appendectomies performed on children in the United States between 1997 and 2002.

The researchers found that the average negative appendectomy rate was 3 percent and the average appendix rupture rate was 35 percent. The rupture rate was 66 percent higher in Asian children and 13 percent higher in black children compared with white children. Children without health insurance had a 36 percent increased likelihood for an appendix rupture and children with Medicaid insurance had a 48 percent increased likelihood compared with children who had private health insurance. No correlation existed between negative appendectomy rate and race, health insurance status, or hospital appendiceal rupture rate. The negative appendectomy rate improved as the hospital appendectomy volume increased.

PSYCHOTHERAPY PLUS ANTI-DEPRESSANT BEST TREATMENT FOR KIDS WITH OBSESSIVE-COMPLUSIVE DISORDER