Damian McNamara

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

ORLANDO – Alterations in brain circuitry and chemistry mediated through the dorsolateral prefrontal cortex can cause executive dysfunction in multiple disorders, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“Executive dysfunction is there. It hits you in the face if you are dealing with schizophrenia,” said Dr. Thomas L. Schwartz. “But in depression you may have to look for it. I was always looking for that in the background–insomnia, fatigue, and executive dysfunction–the key residual symptoms of depression treatment.”

Decreased metabolism in the dorsal and medial prefrontal cortex and the anterior cingulate are neurobiologic factors that might contribute to executive dysfunction in depression, Dr. Schwartz said. A decrease in N-acetyl aspartate, a marker or neuronal function, also may play a role. “It's another way to look at the brain, and in depressed folks you can show the brain is not doing what it is supposed to,” said Dr. Schwartz, director of the depression and anxiety disorders research program at the State University of New York, Syracuse.

Executive dysfunction is associated with noradrenergic, dopaminergic, and histaminergic projections to the dorsolateral prefrontal cortex. One tactic to get more norepinephrine to flow in that circuitry is to manipulate the serotonin levels, Dr. Schwartz said.

“Too much serotonin can be a bad thing in the frontal lobes. If you inhibit the inhibitor you can get more norepinephrine up there and help return executive functioning,” he added.

Pharmacologic agents that might increase norepinephrine, dopamine, and/or histamine and help improve executive function include drugs such as bupropion, atomoxetine (Straterra), and modafinil (Provigil), and drug classes such as stimulants and atypical antipsychotics, Dr. Schwartz said.

“Use of atomoxetine for executive dysfunction in depression makes biological sense and circuitry sense,” he said. “But there are no controlled studies [of atomoxetine] in executive dysfunction in depression.”

Executive dysfunction also is associated with sleep disorders. “Your brain wants you to have a homeostatic amount of sleep. If you get sleep deprived, no matter what the cause, you function poorly and make errors in omission and commission,” Dr. Schwartz said. Again, “there is poor metabolism in the prefrontal cortex.”

Addition of a sleep aid can have positive effects on next-day functioning. Stimulants, modafinil, or armodafinil can improve attention and concentration during the day, Dr. Schwartz said. “If you can keep people more awake during the day, and they avoid napping, they may not need a sleeping pill at night.”

Insomnia is comorbid with depression in around 85% of people (J. Clin. Psychiatry 2004;65:27–32). “That is a lot of people,” Dr. Schwartz said. Some antidepressant medications can have a direct effect on sleep, he added. For example, bupropion increases REM sleep and sleep latency, but reduces sleep continuity. Trazodone decreases REM sleep time and may cause daytime sedation. In contrast, nefazodone increases REM sleep time and is associated with minimal daytime sedation.

Sleep aids are a treatment option. Examples include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). “I don't think one is better than the other, so choose based on half-life,” Dr. Schwartz suggested. Sonata has the shorter half life; Ambien is in the middle; Lunesta has the longest. “Which one can you take at 3 a.m, if you need to work at 9 in the morning? Sonata.”

Modafinil is another pharmacologic option in patients with executive dysfunction and other adverse effects of impaired sleep. “This will not save every one of your patients but you can try it,” Dr. Schwartz said. “It's the only product that raises histamine that I know of, and histamine going up to the cortex is good for executive function.”

Dr. Schwartz said, “Modafinil is a funny drug–doses above 300 mg backfire in certain populations. Lower doses may be better for treatment of executive dysfunction.”

ORLANDO – Alterations in brain circuitry and chemistry mediated through the dorsolateral prefrontal cortex can cause executive dysfunction in multiple disorders, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“Executive dysfunction is there. It hits you in the face if you are dealing with schizophrenia,” said Dr. Thomas L. Schwartz. “But in depression you may have to look for it. I was always looking for that in the background–insomnia, fatigue, and executive dysfunction–the key residual symptoms of depression treatment.”

Decreased metabolism in the dorsal and medial prefrontal cortex and the anterior cingulate are neurobiologic factors that might contribute to executive dysfunction in depression, Dr. Schwartz said. A decrease in N-acetyl aspartate, a marker or neuronal function, also may play a role. “It's another way to look at the brain, and in depressed folks you can show the brain is not doing what it is supposed to,” said Dr. Schwartz, director of the depression and anxiety disorders research program at the State University of New York, Syracuse.

Executive dysfunction is associated with noradrenergic, dopaminergic, and histaminergic projections to the dorsolateral prefrontal cortex. One tactic to get more norepinephrine to flow in that circuitry is to manipulate the serotonin levels, Dr. Schwartz said.

“Too much serotonin can be a bad thing in the frontal lobes. If you inhibit the inhibitor you can get more norepinephrine up there and help return executive functioning,” he added.

Pharmacologic agents that might increase norepinephrine, dopamine, and/or histamine and help improve executive function include drugs such as bupropion, atomoxetine (Straterra), and modafinil (Provigil), and drug classes such as stimulants and atypical antipsychotics, Dr. Schwartz said.

“Use of atomoxetine for executive dysfunction in depression makes biological sense and circuitry sense,” he said. “But there are no controlled studies [of atomoxetine] in executive dysfunction in depression.”

Executive dysfunction also is associated with sleep disorders. “Your brain wants you to have a homeostatic amount of sleep. If you get sleep deprived, no matter what the cause, you function poorly and make errors in omission and commission,” Dr. Schwartz said. Again, “there is poor metabolism in the prefrontal cortex.”

Addition of a sleep aid can have positive effects on next-day functioning. Stimulants, modafinil, or armodafinil can improve attention and concentration during the day, Dr. Schwartz said. “If you can keep people more awake during the day, and they avoid napping, they may not need a sleeping pill at night.”

Insomnia is comorbid with depression in around 85% of people (J. Clin. Psychiatry 2004;65:27–32). “That is a lot of people,” Dr. Schwartz said. Some antidepressant medications can have a direct effect on sleep, he added. For example, bupropion increases REM sleep and sleep latency, but reduces sleep continuity. Trazodone decreases REM sleep time and may cause daytime sedation. In contrast, nefazodone increases REM sleep time and is associated with minimal daytime sedation.

Sleep aids are a treatment option. Examples include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). “I don't think one is better than the other, so choose based on half-life,” Dr. Schwartz suggested. Sonata has the shorter half life; Ambien is in the middle; Lunesta has the longest. “Which one can you take at 3 a.m, if you need to work at 9 in the morning? Sonata.”

Modafinil is another pharmacologic option in patients with executive dysfunction and other adverse effects of impaired sleep. “This will not save every one of your patients but you can try it,” Dr. Schwartz said. “It's the only product that raises histamine that I know of, and histamine going up to the cortex is good for executive function.”

Dr. Schwartz said, “Modafinil is a funny drug–doses above 300 mg backfire in certain populations. Lower doses may be better for treatment of executive dysfunction.”

ORLANDO – Alterations in brain circuitry and chemistry mediated through the dorsolateral prefrontal cortex can cause executive dysfunction in multiple disorders, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

“Executive dysfunction is there. It hits you in the face if you are dealing with schizophrenia,” said Dr. Thomas L. Schwartz. “But in depression you may have to look for it. I was always looking for that in the background–insomnia, fatigue, and executive dysfunction–the key residual symptoms of depression treatment.”

Decreased metabolism in the dorsal and medial prefrontal cortex and the anterior cingulate are neurobiologic factors that might contribute to executive dysfunction in depression, Dr. Schwartz said. A decrease in N-acetyl aspartate, a marker or neuronal function, also may play a role. “It's another way to look at the brain, and in depressed folks you can show the brain is not doing what it is supposed to,” said Dr. Schwartz, director of the depression and anxiety disorders research program at the State University of New York, Syracuse.

Executive dysfunction is associated with noradrenergic, dopaminergic, and histaminergic projections to the dorsolateral prefrontal cortex. One tactic to get more norepinephrine to flow in that circuitry is to manipulate the serotonin levels, Dr. Schwartz said.

“Too much serotonin can be a bad thing in the frontal lobes. If you inhibit the inhibitor you can get more norepinephrine up there and help return executive functioning,” he added.

Pharmacologic agents that might increase norepinephrine, dopamine, and/or histamine and help improve executive function include drugs such as bupropion, atomoxetine (Straterra), and modafinil (Provigil), and drug classes such as stimulants and atypical antipsychotics, Dr. Schwartz said.

“Use of atomoxetine for executive dysfunction in depression makes biological sense and circuitry sense,” he said. “But there are no controlled studies [of atomoxetine] in executive dysfunction in depression.”

Executive dysfunction also is associated with sleep disorders. “Your brain wants you to have a homeostatic amount of sleep. If you get sleep deprived, no matter what the cause, you function poorly and make errors in omission and commission,” Dr. Schwartz said. Again, “there is poor metabolism in the prefrontal cortex.”

Addition of a sleep aid can have positive effects on next-day functioning. Stimulants, modafinil, or armodafinil can improve attention and concentration during the day, Dr. Schwartz said. “If you can keep people more awake during the day, and they avoid napping, they may not need a sleeping pill at night.”

Insomnia is comorbid with depression in around 85% of people (J. Clin. Psychiatry 2004;65:27–32). “That is a lot of people,” Dr. Schwartz said. Some antidepressant medications can have a direct effect on sleep, he added. For example, bupropion increases REM sleep and sleep latency, but reduces sleep continuity. Trazodone decreases REM sleep time and may cause daytime sedation. In contrast, nefazodone increases REM sleep time and is associated with minimal daytime sedation.

Sleep aids are a treatment option. Examples include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). “I don't think one is better than the other, so choose based on half-life,” Dr. Schwartz suggested. Sonata has the shorter half life; Ambien is in the middle; Lunesta has the longest. “Which one can you take at 3 a.m, if you need to work at 9 in the morning? Sonata.”

Modafinil is another pharmacologic option in patients with executive dysfunction and other adverse effects of impaired sleep. “This will not save every one of your patients but you can try it,” Dr. Schwartz said. “It's the only product that raises histamine that I know of, and histamine going up to the cortex is good for executive function.”

Dr. Schwartz said, “Modafinil is a funny drug–doses above 300 mg backfire in certain populations. Lower doses may be better for treatment of executive dysfunction.”

MIAMI BEACH — Dermatologists often prevail in malpractice lawsuits when there is no breach of duty and no permanent damage, according to presentations at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"As long as you are doing what others are doing, and not doing something kooky or as an outlier, you did not breach your duty," said Dr. David J. Goldberg. "If there is no nexus between breach of duty and their alleged damages, they can take you to court—but they cannot win."

A patient receiving an aesthetic procedure who sues a dermatologist over postprocedure erythema that later resolves, for example, should not have a viable case. And then there's the patient treated periorally who, unbeknownst to the physician, has a history of herpes infection.

"This is my patient. I goofed up. We all make mistakes. I treated her mouth, and I neglected to ask her if she had a history of cold sores. But her adverse outcome cleared up, so there were no damages," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

"If you really made a mistake, you are really better off acknowledging it. You may have a hassle on your hands, but you may not get to a lawsuit," said Dr. Goldberg, who also is adjunct professor at Fordham University School of Law in New York.

Poor communication, retribution, economic gain, and negligence are the primary reasons that patients sue their physicians. Cosmetic patients also sue over hyperpigmentation and scarring. "Hyperpigmentation generally goes away, although sometimes it does not. It is less likely to go away in darker-skinned individuals," Dr. Goldberg said. "These people may be angry and upset." Often, scarring is permanent.

Dr. Goldberg said that he knew of two scarring cases—one after a deep peel and another after a cosmetic laser treatment—that resulted in malpractice claims: "One case settled; one went to court for significant damages."

In a separate presentation at the meeting, Dr. Brian Berman highlighted some dermatology medical liability cases from 1997 to 2006 that were extracted from the LexisNexis database. There were two isotretinoin lawsuits, a case in which a doctor was sued when his cosmetologist "botched" a trichloroacetic acid (TCA) peel and a case in which a doctor was sued over hyperpigmentation after laser treatment.

"We looked at the cases that went to verdict, not those settled out of court. Perhaps these are the best cases to represent scenarios where a dermatologist had a chance to be successful," said Dr. Berman of the departments of dermatology and internal medicine at the University of Miami.

In one of the isotretinoin cases, the dermatologist prescribed the drug to a 14-year-old girl with her stepmother present. Both assured the physician that the patient was neither pregnant nor sexually active. The dermatologist decided against testing her for pregnancy.

"Turns out she was pregnant and had a child with cerebral palsy and mild mental retardation," Dr. Berman said. "Interestingly, it was not the stepmom but the adoptive parents of this new baby who sued the dermatologist." The jury verdict was $2.7 million against the doctor.

The second case involved a dermatologist who prescribed tetracycline to a 17-year-old boy with acne. The patient then consulted another dermatologist, who discontinued the tetracycline and prescribed isotretinoin. "The first doctor was sued for not prescribing [the retinoid]," Dr. Berman said. "There was a defense verdict, so there was no award."

In the third case, a cosmetologist had treated the hands of a long-term patient with a 30% TCA peel. The peel was done incorrectly, and the patient experienced second- and third-degree burns, as well as permanent scarring and hypopigmentation.

The cosmetologist was a previous regular employee of the dermatologist but had established a corporation within the office of the doctor prior to treating this patient. The dermatologist testified that he had trained her not to use 30% TCA on the dorsal aspects of hands. The verdict was $500,000 against the cosmetologist and nothing against the physician, Dr. Berman said.

Informed consent was the issue in the fourth case he discussed. In this instance, a pediatric dermatologist used a laser to treat multiple port wine stains on the face, neck, and arms of an 8-year-old with Sturge-Weber syndrome. The patient experienced hyperpigmentation, including permanent hyperpigmentation on the left forearm.

"The plaintiff contended there was a lack of consent" to treat the arm, he said, but "the dermatologist testified that she followed her customary practice and provided full informed consent." The doctor was not liable.

After reviewing a decade of dermatology cases, Dr. Berman concluded that "anyone can sue for any reason, and there will always be a dermatologist willing to be an expert witness for the plaintiff." He also noted that "there was a paucity of cases on the use of systemic medications that dermatologists worry about, such as interferon, methotrexate, and all the biologics—nothing in the last 10 years."

MIAMI BEACH — Dermatologists often prevail in malpractice lawsuits when there is no breach of duty and no permanent damage, according to presentations at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"As long as you are doing what others are doing, and not doing something kooky or as an outlier, you did not breach your duty," said Dr. David J. Goldberg. "If there is no nexus between breach of duty and their alleged damages, they can take you to court—but they cannot win."

A patient receiving an aesthetic procedure who sues a dermatologist over postprocedure erythema that later resolves, for example, should not have a viable case. And then there's the patient treated periorally who, unbeknownst to the physician, has a history of herpes infection.

"This is my patient. I goofed up. We all make mistakes. I treated her mouth, and I neglected to ask her if she had a history of cold sores. But her adverse outcome cleared up, so there were no damages," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

"If you really made a mistake, you are really better off acknowledging it. You may have a hassle on your hands, but you may not get to a lawsuit," said Dr. Goldberg, who also is adjunct professor at Fordham University School of Law in New York.

Poor communication, retribution, economic gain, and negligence are the primary reasons that patients sue their physicians. Cosmetic patients also sue over hyperpigmentation and scarring. "Hyperpigmentation generally goes away, although sometimes it does not. It is less likely to go away in darker-skinned individuals," Dr. Goldberg said. "These people may be angry and upset." Often, scarring is permanent.

Dr. Goldberg said that he knew of two scarring cases—one after a deep peel and another after a cosmetic laser treatment—that resulted in malpractice claims: "One case settled; one went to court for significant damages."

In a separate presentation at the meeting, Dr. Brian Berman highlighted some dermatology medical liability cases from 1997 to 2006 that were extracted from the LexisNexis database. There were two isotretinoin lawsuits, a case in which a doctor was sued when his cosmetologist "botched" a trichloroacetic acid (TCA) peel and a case in which a doctor was sued over hyperpigmentation after laser treatment.

"We looked at the cases that went to verdict, not those settled out of court. Perhaps these are the best cases to represent scenarios where a dermatologist had a chance to be successful," said Dr. Berman of the departments of dermatology and internal medicine at the University of Miami.

In one of the isotretinoin cases, the dermatologist prescribed the drug to a 14-year-old girl with her stepmother present. Both assured the physician that the patient was neither pregnant nor sexually active. The dermatologist decided against testing her for pregnancy.

"Turns out she was pregnant and had a child with cerebral palsy and mild mental retardation," Dr. Berman said. "Interestingly, it was not the stepmom but the adoptive parents of this new baby who sued the dermatologist." The jury verdict was $2.7 million against the doctor.

The second case involved a dermatologist who prescribed tetracycline to a 17-year-old boy with acne. The patient then consulted another dermatologist, who discontinued the tetracycline and prescribed isotretinoin. "The first doctor was sued for not prescribing [the retinoid]," Dr. Berman said. "There was a defense verdict, so there was no award."

In the third case, a cosmetologist had treated the hands of a long-term patient with a 30% TCA peel. The peel was done incorrectly, and the patient experienced second- and third-degree burns, as well as permanent scarring and hypopigmentation.

The cosmetologist was a previous regular employee of the dermatologist but had established a corporation within the office of the doctor prior to treating this patient. The dermatologist testified that he had trained her not to use 30% TCA on the dorsal aspects of hands. The verdict was $500,000 against the cosmetologist and nothing against the physician, Dr. Berman said.

Informed consent was the issue in the fourth case he discussed. In this instance, a pediatric dermatologist used a laser to treat multiple port wine stains on the face, neck, and arms of an 8-year-old with Sturge-Weber syndrome. The patient experienced hyperpigmentation, including permanent hyperpigmentation on the left forearm.

"The plaintiff contended there was a lack of consent" to treat the arm, he said, but "the dermatologist testified that she followed her customary practice and provided full informed consent." The doctor was not liable.

After reviewing a decade of dermatology cases, Dr. Berman concluded that "anyone can sue for any reason, and there will always be a dermatologist willing to be an expert witness for the plaintiff." He also noted that "there was a paucity of cases on the use of systemic medications that dermatologists worry about, such as interferon, methotrexate, and all the biologics—nothing in the last 10 years."

MIAMI BEACH — Dermatologists often prevail in malpractice lawsuits when there is no breach of duty and no permanent damage, according to presentations at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"As long as you are doing what others are doing, and not doing something kooky or as an outlier, you did not breach your duty," said Dr. David J. Goldberg. "If there is no nexus between breach of duty and their alleged damages, they can take you to court—but they cannot win."

A patient receiving an aesthetic procedure who sues a dermatologist over postprocedure erythema that later resolves, for example, should not have a viable case. And then there's the patient treated periorally who, unbeknownst to the physician, has a history of herpes infection.

"This is my patient. I goofed up. We all make mistakes. I treated her mouth, and I neglected to ask her if she had a history of cold sores. But her adverse outcome cleared up, so there were no damages," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

"If you really made a mistake, you are really better off acknowledging it. You may have a hassle on your hands, but you may not get to a lawsuit," said Dr. Goldberg, who also is adjunct professor at Fordham University School of Law in New York.

Poor communication, retribution, economic gain, and negligence are the primary reasons that patients sue their physicians. Cosmetic patients also sue over hyperpigmentation and scarring. "Hyperpigmentation generally goes away, although sometimes it does not. It is less likely to go away in darker-skinned individuals," Dr. Goldberg said. "These people may be angry and upset." Often, scarring is permanent.

Dr. Goldberg said that he knew of two scarring cases—one after a deep peel and another after a cosmetic laser treatment—that resulted in malpractice claims: "One case settled; one went to court for significant damages."

In a separate presentation at the meeting, Dr. Brian Berman highlighted some dermatology medical liability cases from 1997 to 2006 that were extracted from the LexisNexis database. There were two isotretinoin lawsuits, a case in which a doctor was sued when his cosmetologist "botched" a trichloroacetic acid (TCA) peel and a case in which a doctor was sued over hyperpigmentation after laser treatment.

"We looked at the cases that went to verdict, not those settled out of court. Perhaps these are the best cases to represent scenarios where a dermatologist had a chance to be successful," said Dr. Berman of the departments of dermatology and internal medicine at the University of Miami.

In one of the isotretinoin cases, the dermatologist prescribed the drug to a 14-year-old girl with her stepmother present. Both assured the physician that the patient was neither pregnant nor sexually active. The dermatologist decided against testing her for pregnancy.

"Turns out she was pregnant and had a child with cerebral palsy and mild mental retardation," Dr. Berman said. "Interestingly, it was not the stepmom but the adoptive parents of this new baby who sued the dermatologist." The jury verdict was $2.7 million against the doctor.

The second case involved a dermatologist who prescribed tetracycline to a 17-year-old boy with acne. The patient then consulted another dermatologist, who discontinued the tetracycline and prescribed isotretinoin. "The first doctor was sued for not prescribing [the retinoid]," Dr. Berman said. "There was a defense verdict, so there was no award."

In the third case, a cosmetologist had treated the hands of a long-term patient with a 30% TCA peel. The peel was done incorrectly, and the patient experienced second- and third-degree burns, as well as permanent scarring and hypopigmentation.

The cosmetologist was a previous regular employee of the dermatologist but had established a corporation within the office of the doctor prior to treating this patient. The dermatologist testified that he had trained her not to use 30% TCA on the dorsal aspects of hands. The verdict was $500,000 against the cosmetologist and nothing against the physician, Dr. Berman said.

Informed consent was the issue in the fourth case he discussed. In this instance, a pediatric dermatologist used a laser to treat multiple port wine stains on the face, neck, and arms of an 8-year-old with Sturge-Weber syndrome. The patient experienced hyperpigmentation, including permanent hyperpigmentation on the left forearm.

"The plaintiff contended there was a lack of consent" to treat the arm, he said, but "the dermatologist testified that she followed her customary practice and provided full informed consent." The doctor was not liable.

After reviewing a decade of dermatology cases, Dr. Berman concluded that "anyone can sue for any reason, and there will always be a dermatologist willing to be an expert witness for the plaintiff." He also noted that "there was a paucity of cases on the use of systemic medications that dermatologists worry about, such as interferon, methotrexate, and all the biologics—nothing in the last 10 years."

MIAMI BEACH — A unipolar radiofrequency device that is not yet approved in the United States shows promise for the treatment of cellulite, Dr. David J. Goldberg said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

The unipolar handpiece on the Accent device (Alma Lasers Inc.) heats deeper, compared with current devices that have only a bipolar radiofrequency (RF) option, said Dr. Goldberg, who is on the speakers' bureau for Alma Lasers.

In a study by a group of Mexican investigators, the deeper unipolar RF energy penetration—an estimated 2–6 mm deep—noninvasively heated subcutaneous adipose tissue and caused collagen fibers to contract (J. Drugs Dermatol. 2006;5:714–22). In the study, 68% of 26 women demonstrated at least 20% volumetric contraction on ultrasound.

This is a "hot device right now and very popular outside the United States," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Cellulite is more common among whites, its severity increases with age, and it can be hereditary. "Eighty-five percent of women have cellulite, and the other 15% think they do, so it's a big market," he said, adding that "cellulite is going to become the hot topic in aesthetic medicine in the next 5 years."

In another study of 30 women treated with the Accent unipolar RF handpiece, 27 showed improvements in thigh circumference. The mean decrease was 2.45 cm, a finding that is "better than in other studies or with other technologies," Dr. Goldberg said. Participants underwent six treatment sessions over a 12-week period. The study was funded in part by a research grant from Alma Lasers.

Bipolar RF is superficial, but unipolar is more like ultrasound or magnetic resonance imaging. The unipolar device provides a "very high MHz frequency, almost like MRI," he said.

Investigators rated improvement of cellulite on a 1–4 scale. The mean improvement in the study was 2.9.

Treatment is simple and fairly painless, and patients typically get some erythema. The device's cooling tip avoids blistering of the skin. "Patients should feel some warmth—nothing more," he added.

"The typical result is tightening of the skin from deep, diffuse radiofrequency," Dr. Goldberg said. Not everyone, however, is a candidate. "They cannot be fat or have a lot of muscle rippling, but you can get a nice result for loose skin," he said.

There were no significant changes in blood lipids or patient weight during the study. Similarly, MRI scans of the treated areas showed no changes. Histology showed upper dermal fibrosis and tightened collagen formation.

"This Accent device is highly effective for skin tightening," Dr. Goldberg said. "When [it is] FDA approved, it will be a potent device in the treatment of cellulite."

A patient with cellulite is shown before treatment with the Accent device.

Mean improvement among 30 patients was rated at 2.9 on a scale of 1–4. Photos courtesy Dr. David Goldberg

MIAMI BEACH — A unipolar radiofrequency device that is not yet approved in the United States shows promise for the treatment of cellulite, Dr. David J. Goldberg said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

The unipolar handpiece on the Accent device (Alma Lasers Inc.) heats deeper, compared with current devices that have only a bipolar radiofrequency (RF) option, said Dr. Goldberg, who is on the speakers' bureau for Alma Lasers.

In a study by a group of Mexican investigators, the deeper unipolar RF energy penetration—an estimated 2–6 mm deep—noninvasively heated subcutaneous adipose tissue and caused collagen fibers to contract (J. Drugs Dermatol. 2006;5:714–22). In the study, 68% of 26 women demonstrated at least 20% volumetric contraction on ultrasound.

This is a "hot device right now and very popular outside the United States," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Cellulite is more common among whites, its severity increases with age, and it can be hereditary. "Eighty-five percent of women have cellulite, and the other 15% think they do, so it's a big market," he said, adding that "cellulite is going to become the hot topic in aesthetic medicine in the next 5 years."

In another study of 30 women treated with the Accent unipolar RF handpiece, 27 showed improvements in thigh circumference. The mean decrease was 2.45 cm, a finding that is "better than in other studies or with other technologies," Dr. Goldberg said. Participants underwent six treatment sessions over a 12-week period. The study was funded in part by a research grant from Alma Lasers.

Bipolar RF is superficial, but unipolar is more like ultrasound or magnetic resonance imaging. The unipolar device provides a "very high MHz frequency, almost like MRI," he said.

Investigators rated improvement of cellulite on a 1–4 scale. The mean improvement in the study was 2.9.

Treatment is simple and fairly painless, and patients typically get some erythema. The device's cooling tip avoids blistering of the skin. "Patients should feel some warmth—nothing more," he added.

"The typical result is tightening of the skin from deep, diffuse radiofrequency," Dr. Goldberg said. Not everyone, however, is a candidate. "They cannot be fat or have a lot of muscle rippling, but you can get a nice result for loose skin," he said.

There were no significant changes in blood lipids or patient weight during the study. Similarly, MRI scans of the treated areas showed no changes. Histology showed upper dermal fibrosis and tightened collagen formation.

"This Accent device is highly effective for skin tightening," Dr. Goldberg said. "When [it is] FDA approved, it will be a potent device in the treatment of cellulite."

A patient with cellulite is shown before treatment with the Accent device.

Mean improvement among 30 patients was rated at 2.9 on a scale of 1–4. Photos courtesy Dr. David Goldberg

MIAMI BEACH — A unipolar radiofrequency device that is not yet approved in the United States shows promise for the treatment of cellulite, Dr. David J. Goldberg said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

The unipolar handpiece on the Accent device (Alma Lasers Inc.) heats deeper, compared with current devices that have only a bipolar radiofrequency (RF) option, said Dr. Goldberg, who is on the speakers' bureau for Alma Lasers.

In a study by a group of Mexican investigators, the deeper unipolar RF energy penetration—an estimated 2–6 mm deep—noninvasively heated subcutaneous adipose tissue and caused collagen fibers to contract (J. Drugs Dermatol. 2006;5:714–22). In the study, 68% of 26 women demonstrated at least 20% volumetric contraction on ultrasound.

This is a "hot device right now and very popular outside the United States," said Dr. Goldberg of the department of dermatology at Mount Sinai School of Medicine, New York.

Cellulite is more common among whites, its severity increases with age, and it can be hereditary. "Eighty-five percent of women have cellulite, and the other 15% think they do, so it's a big market," he said, adding that "cellulite is going to become the hot topic in aesthetic medicine in the next 5 years."

In another study of 30 women treated with the Accent unipolar RF handpiece, 27 showed improvements in thigh circumference. The mean decrease was 2.45 cm, a finding that is "better than in other studies or with other technologies," Dr. Goldberg said. Participants underwent six treatment sessions over a 12-week period. The study was funded in part by a research grant from Alma Lasers.

Bipolar RF is superficial, but unipolar is more like ultrasound or magnetic resonance imaging. The unipolar device provides a "very high MHz frequency, almost like MRI," he said.

Investigators rated improvement of cellulite on a 1–4 scale. The mean improvement in the study was 2.9.

Treatment is simple and fairly painless, and patients typically get some erythema. The device's cooling tip avoids blistering of the skin. "Patients should feel some warmth—nothing more," he added.

"The typical result is tightening of the skin from deep, diffuse radiofrequency," Dr. Goldberg said. Not everyone, however, is a candidate. "They cannot be fat or have a lot of muscle rippling, but you can get a nice result for loose skin," he said.

There were no significant changes in blood lipids or patient weight during the study. Similarly, MRI scans of the treated areas showed no changes. Histology showed upper dermal fibrosis and tightened collagen formation.

"This Accent device is highly effective for skin tightening," Dr. Goldberg said. "When [it is] FDA approved, it will be a potent device in the treatment of cellulite."

A patient with cellulite is shown before treatment with the Accent device.

Mean improvement among 30 patients was rated at 2.9 on a scale of 1–4. Photos courtesy Dr. David Goldberg

MIAMI BEACH — With expertise and the right technique, aesthetic surgery patients can get long-lasting results from the first permanent facial filler approved by the Food and Drug Administration, Dr. Marta I. Rendon said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"You can correct things that need to be corrected long term, such as birth defects," Dr. Rendon said, "but stay away from thin-skin areas, for example, around eyes and lips."

ArteFill (Artes Medical Inc.) became the first nonresorbable injectable filler implant approved for aesthetic use in October 2006. The official FDA indication is for correction of nasolabial folds. Dr. Rendon is a member of Artes Medical's advisory board.

Inject the product deeply using a 26G needle. "You never want to see the gray of the needle when you are injecting," she said. Employ a linear retrograde tunneling technique. Stop the injection before you withdraw the needle to avoid superficial placement.

The filler is thicker than most other aesthetic products. ArteFill is, for example, about three times thicker than Zyplast, said Dr. Rendon of the University of Miami.

ArteFill consists of polymethylmethacrylate microspheres suspended in a gel carrier of rapidly-dissolving bovine collagen. The microspheres are 30–50 mcm and stimulate the patient's own collagen to form a permanent support structure beneath the skin. The manufacturer had to demonstrate the uniformity of these microspheres prior to approval.

Dr. Rendon said that any microsphere smaller than 20 mcm would be absorbed by macrophages.

A closed herd of cattle to provide the collagen and a manufacturing facility in the United States were additional requirements.

These conditions stem from concerns that the FDA had following studies of an earlier formulation, ArteColl. In a clinical trial of ArteColl in 251 patients, for example, there were 10 reports of lumpiness, including 1 case that was severe.

Granuloma formation is a concern with all injectable fillers. "Most are late onset and the majority are in the perioral area," she said. This is one reason she advises against use of ArteFill in thin-skin areas.

There were no granuloma reports at a 1-year follow-up in the ArteFill clinical trial, but there were two granulomas at a 5-year follow-up. One was excised from a patient's lip and the other was treated with steroid injections into a nasolabial fold.

A total of 142 participants were assessed at a mean of 5.4 years, and 90% reported satisfaction. "Patient cosmetic appearance continued to improve. You can still see an upward slope in improvement over 5 years," Dr. Rendon said.

"These patients look younger at 5 years than before treatment," Dr. Rendon said. "We are almost halting the aging process in these patients." Keep in mind, though, that all fillers are foreign bodies, and they may interact with drugs, trauma, and surgery years after implantation.

MIAMI BEACH — With expertise and the right technique, aesthetic surgery patients can get long-lasting results from the first permanent facial filler approved by the Food and Drug Administration, Dr. Marta I. Rendon said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"You can correct things that need to be corrected long term, such as birth defects," Dr. Rendon said, "but stay away from thin-skin areas, for example, around eyes and lips."

ArteFill (Artes Medical Inc.) became the first nonresorbable injectable filler implant approved for aesthetic use in October 2006. The official FDA indication is for correction of nasolabial folds. Dr. Rendon is a member of Artes Medical's advisory board.

Inject the product deeply using a 26G needle. "You never want to see the gray of the needle when you are injecting," she said. Employ a linear retrograde tunneling technique. Stop the injection before you withdraw the needle to avoid superficial placement.

The filler is thicker than most other aesthetic products. ArteFill is, for example, about three times thicker than Zyplast, said Dr. Rendon of the University of Miami.

ArteFill consists of polymethylmethacrylate microspheres suspended in a gel carrier of rapidly-dissolving bovine collagen. The microspheres are 30–50 mcm and stimulate the patient's own collagen to form a permanent support structure beneath the skin. The manufacturer had to demonstrate the uniformity of these microspheres prior to approval.

Dr. Rendon said that any microsphere smaller than 20 mcm would be absorbed by macrophages.

A closed herd of cattle to provide the collagen and a manufacturing facility in the United States were additional requirements.

These conditions stem from concerns that the FDA had following studies of an earlier formulation, ArteColl. In a clinical trial of ArteColl in 251 patients, for example, there were 10 reports of lumpiness, including 1 case that was severe.

Granuloma formation is a concern with all injectable fillers. "Most are late onset and the majority are in the perioral area," she said. This is one reason she advises against use of ArteFill in thin-skin areas.

There were no granuloma reports at a 1-year follow-up in the ArteFill clinical trial, but there were two granulomas at a 5-year follow-up. One was excised from a patient's lip and the other was treated with steroid injections into a nasolabial fold.

A total of 142 participants were assessed at a mean of 5.4 years, and 90% reported satisfaction. "Patient cosmetic appearance continued to improve. You can still see an upward slope in improvement over 5 years," Dr. Rendon said.

"These patients look younger at 5 years than before treatment," Dr. Rendon said. "We are almost halting the aging process in these patients." Keep in mind, though, that all fillers are foreign bodies, and they may interact with drugs, trauma, and surgery years after implantation.

MIAMI BEACH — With expertise and the right technique, aesthetic surgery patients can get long-lasting results from the first permanent facial filler approved by the Food and Drug Administration, Dr. Marta I. Rendon said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"You can correct things that need to be corrected long term, such as birth defects," Dr. Rendon said, "but stay away from thin-skin areas, for example, around eyes and lips."

ArteFill (Artes Medical Inc.) became the first nonresorbable injectable filler implant approved for aesthetic use in October 2006. The official FDA indication is for correction of nasolabial folds. Dr. Rendon is a member of Artes Medical's advisory board.

Inject the product deeply using a 26G needle. "You never want to see the gray of the needle when you are injecting," she said. Employ a linear retrograde tunneling technique. Stop the injection before you withdraw the needle to avoid superficial placement.

The filler is thicker than most other aesthetic products. ArteFill is, for example, about three times thicker than Zyplast, said Dr. Rendon of the University of Miami.

ArteFill consists of polymethylmethacrylate microspheres suspended in a gel carrier of rapidly-dissolving bovine collagen. The microspheres are 30–50 mcm and stimulate the patient's own collagen to form a permanent support structure beneath the skin. The manufacturer had to demonstrate the uniformity of these microspheres prior to approval.

Dr. Rendon said that any microsphere smaller than 20 mcm would be absorbed by macrophages.

A closed herd of cattle to provide the collagen and a manufacturing facility in the United States were additional requirements.

These conditions stem from concerns that the FDA had following studies of an earlier formulation, ArteColl. In a clinical trial of ArteColl in 251 patients, for example, there were 10 reports of lumpiness, including 1 case that was severe.

Granuloma formation is a concern with all injectable fillers. "Most are late onset and the majority are in the perioral area," she said. This is one reason she advises against use of ArteFill in thin-skin areas.

There were no granuloma reports at a 1-year follow-up in the ArteFill clinical trial, but there were two granulomas at a 5-year follow-up. One was excised from a patient's lip and the other was treated with steroid injections into a nasolabial fold.

A total of 142 participants were assessed at a mean of 5.4 years, and 90% reported satisfaction. "Patient cosmetic appearance continued to improve. You can still see an upward slope in improvement over 5 years," Dr. Rendon said.

"These patients look younger at 5 years than before treatment," Dr. Rendon said. "We are almost halting the aging process in these patients." Keep in mind, though, that all fillers are foreign bodies, and they may interact with drugs, trauma, and surgery years after implantation.

DENVER — Radical resection with initial curative intent provides the best chance of long-term, disease-free survival for pediatric patients with a craniopharyngioma, according to a follow-up study presented at a meeting on pediatric neurologic surgery.

Researchers retrospectively evaluated 80 consecutive pediatric patients who had a radical resection of a craniopharyngioma at New York University Medical Center. Gross total resection was achieved in 70 (87%) of the patients and a subtotal resection achieved in 10 (13%). All 55 of the children with a primary tumor had a gross total resection, compared with 15 (60%) of the 25 recurrent cancer group patients.

When an audience member commented: “I have a problem with starting with surgery in all children with a craniopharyngioma”, Dr. Kevin Hsieh replied: “We just analyzed all the postoperative patients during the last 21 years. As far as the decision-making process, this was not part of the study.”

Craniopharyngiomas are the most common nonglial tumor in pediatric patients, Dr. Hsieh said. An estimated 0.5–2 million such tumors occur each year. Surgical management of craniopharyngiomas continues to be controversial, specifically whether long-term outcomes are better with total resection versus partial resection and radiation therapy, according to Dr. Hsieh, of the department of neurosurgery at NYU Medical Center.

Not surprisingly, quality of life was better among those with a primary versus recurrent tumor. Also, “quality of life is reasonable and generally better among those with primary tumors that were successfully resected,” said Dr. Hsieh.

In addition, the primary craniopharyngioma group experienced lower mortality and recurrence rates, compared with the recurrent cancer group. There was no statistical difference in tumor size between the two groups.

Twelve patients died. There were two perioperative and two delayed deaths in the primary cancer group, compared with one perioperative and seven delayed deaths in the recurrent cancer group.

Among the children with primary tumors, 8 of 55 had a cancer recurrence. Among the 25 children initially treated for recurrence, 14 experienced a subsequent recurrence. There were few adverse events from the surgery if the child survived the first 2.5 years, judging from events during a mean follow-up of 7 years.

There was a total of 93 surgeries in the series. The average age at surgery was 10 years. An overwhelming majority of the patients, 77 of 80, required some endocrine replacement therapy after surgery. “The goal of treatment was radical resection of tumor through a transcranial approach,” Dr. Hsieh said at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

The researchers assessed survival using Kaplan-Meier curves. The 2.5-year actuarial survival rate was 0.86.

Radical resection for surgical cure has an excellent progression-free survival and overall survival, according to the investigators. They added that morbidity and quality of life are at least comparable to partial resection with radiation therapy. “Our philosophy is the best chance for long-term disease-free survival is to treat with curative intent up front,” Dr. Hsieh said.

DENVER — Radical resection with initial curative intent provides the best chance of long-term, disease-free survival for pediatric patients with a craniopharyngioma, according to a follow-up study presented at a meeting on pediatric neurologic surgery.

Researchers retrospectively evaluated 80 consecutive pediatric patients who had a radical resection of a craniopharyngioma at New York University Medical Center. Gross total resection was achieved in 70 (87%) of the patients and a subtotal resection achieved in 10 (13%). All 55 of the children with a primary tumor had a gross total resection, compared with 15 (60%) of the 25 recurrent cancer group patients.

When an audience member commented: “I have a problem with starting with surgery in all children with a craniopharyngioma”, Dr. Kevin Hsieh replied: “We just analyzed all the postoperative patients during the last 21 years. As far as the decision-making process, this was not part of the study.”

Craniopharyngiomas are the most common nonglial tumor in pediatric patients, Dr. Hsieh said. An estimated 0.5–2 million such tumors occur each year. Surgical management of craniopharyngiomas continues to be controversial, specifically whether long-term outcomes are better with total resection versus partial resection and radiation therapy, according to Dr. Hsieh, of the department of neurosurgery at NYU Medical Center.

Not surprisingly, quality of life was better among those with a primary versus recurrent tumor. Also, “quality of life is reasonable and generally better among those with primary tumors that were successfully resected,” said Dr. Hsieh.

In addition, the primary craniopharyngioma group experienced lower mortality and recurrence rates, compared with the recurrent cancer group. There was no statistical difference in tumor size between the two groups.

Twelve patients died. There were two perioperative and two delayed deaths in the primary cancer group, compared with one perioperative and seven delayed deaths in the recurrent cancer group.

Among the children with primary tumors, 8 of 55 had a cancer recurrence. Among the 25 children initially treated for recurrence, 14 experienced a subsequent recurrence. There were few adverse events from the surgery if the child survived the first 2.5 years, judging from events during a mean follow-up of 7 years.

There was a total of 93 surgeries in the series. The average age at surgery was 10 years. An overwhelming majority of the patients, 77 of 80, required some endocrine replacement therapy after surgery. “The goal of treatment was radical resection of tumor through a transcranial approach,” Dr. Hsieh said at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

The researchers assessed survival using Kaplan-Meier curves. The 2.5-year actuarial survival rate was 0.86.

Radical resection for surgical cure has an excellent progression-free survival and overall survival, according to the investigators. They added that morbidity and quality of life are at least comparable to partial resection with radiation therapy. “Our philosophy is the best chance for long-term disease-free survival is to treat with curative intent up front,” Dr. Hsieh said.

DENVER — Radical resection with initial curative intent provides the best chance of long-term, disease-free survival for pediatric patients with a craniopharyngioma, according to a follow-up study presented at a meeting on pediatric neurologic surgery.

Researchers retrospectively evaluated 80 consecutive pediatric patients who had a radical resection of a craniopharyngioma at New York University Medical Center. Gross total resection was achieved in 70 (87%) of the patients and a subtotal resection achieved in 10 (13%). All 55 of the children with a primary tumor had a gross total resection, compared with 15 (60%) of the 25 recurrent cancer group patients.

When an audience member commented: “I have a problem with starting with surgery in all children with a craniopharyngioma”, Dr. Kevin Hsieh replied: “We just analyzed all the postoperative patients during the last 21 years. As far as the decision-making process, this was not part of the study.”

Craniopharyngiomas are the most common nonglial tumor in pediatric patients, Dr. Hsieh said. An estimated 0.5–2 million such tumors occur each year. Surgical management of craniopharyngiomas continues to be controversial, specifically whether long-term outcomes are better with total resection versus partial resection and radiation therapy, according to Dr. Hsieh, of the department of neurosurgery at NYU Medical Center.

Not surprisingly, quality of life was better among those with a primary versus recurrent tumor. Also, “quality of life is reasonable and generally better among those with primary tumors that were successfully resected,” said Dr. Hsieh.

In addition, the primary craniopharyngioma group experienced lower mortality and recurrence rates, compared with the recurrent cancer group. There was no statistical difference in tumor size between the two groups.

Twelve patients died. There were two perioperative and two delayed deaths in the primary cancer group, compared with one perioperative and seven delayed deaths in the recurrent cancer group.

Among the children with primary tumors, 8 of 55 had a cancer recurrence. Among the 25 children initially treated for recurrence, 14 experienced a subsequent recurrence. There were few adverse events from the surgery if the child survived the first 2.5 years, judging from events during a mean follow-up of 7 years.

There was a total of 93 surgeries in the series. The average age at surgery was 10 years. An overwhelming majority of the patients, 77 of 80, required some endocrine replacement therapy after surgery. “The goal of treatment was radical resection of tumor through a transcranial approach,” Dr. Hsieh said at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

The researchers assessed survival using Kaplan-Meier curves. The 2.5-year actuarial survival rate was 0.86.

Radical resection for surgical cure has an excellent progression-free survival and overall survival, according to the investigators. They added that morbidity and quality of life are at least comparable to partial resection with radiation therapy. “Our philosophy is the best chance for long-term disease-free survival is to treat with curative intent up front,” Dr. Hsieh said.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said.

An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.”

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients from influenza, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, Md.

One goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until the reservoir is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006:369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, a researcher at the University of Michigan School of Public Health in Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.”

The CDC initiative will address the utility of many of these nonpharmacologic means for control of a future influenza pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said.

An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.”

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients from influenza, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, Md.

One goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until the reservoir is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006:369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, a researcher at the University of Michigan School of Public Health in Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.”

The CDC initiative will address the utility of many of these nonpharmacologic means for control of a future influenza pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said.

An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.”

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients from influenza, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Bethesda, Md.

One goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until the reservoir is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006:369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, a researcher at the University of Michigan School of Public Health in Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.”

The CDC initiative will address the utility of many of these nonpharmacologic means for control of a future influenza pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006-2007 influenza season,” Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“This applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “The current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Md. One goal is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time. “We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicious use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, 270 confirmed human H5N1 cases and 164 human deaths had been reported. Most affected humans had been in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until that is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic like 1918's pandemic occurred today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211-8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to rate pandemic outbreaks on a scale of 1 to 5, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, of the University of Michigan School of Public Health, Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.” The CDC initiative will address the utility of such nonpharmacologic means for controlling a future pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006-2007 influenza season,” Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“This applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “The current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Md. One goal is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time. “We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicious use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, 270 confirmed human H5N1 cases and 164 human deaths had been reported. Most affected humans had been in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until that is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic like 1918's pandemic occurred today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211-8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to rate pandemic outbreaks on a scale of 1 to 5, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, of the University of Michigan School of Public Health, Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.” The CDC initiative will address the utility of such nonpharmacologic means for controlling a future pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic similar to the one in 1918 that killed more than 50 million people worldwide, according to an expert panel that held a Feb. 1 teleconference during the Seasonal & Pandemic Influenza 2007 meeting.

Primary care physicians on the front line of diagnosis and initial response need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for members and the patients they treat, Dr. Whitley said. “This message has been ignored for many years.

“We need to immunize more children,” as they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised. There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006-2007 influenza season,” Dr. Whitley said. “So we've well exceeded acceptable levels of morbidity and mortality.”

“This applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “The current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.” Clinicians have a duty to protect themselves and their patients, he said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

“We've made some substantial advances but we have a long way to go,” said Dr. Anthony Fauci, director, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, Md. One goal is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic. One promising finding is that there appears to be a “good degree of cross protection” from the vaccination of animals and/or humans, although clinical trial results are still needed to confirm this effect.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time. “We need to get point-of-care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicious use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, 270 confirmed human H5N1 cases and 164 human deaths had been reported. Most affected humans had been in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

The current resurgence following aggressive eradication efforts raises the question of what is the ultimate reservoir, Dr. Webster said. Until that is identified, “we cannot control it [H5N1]. … These viruses are diversifying at an amazing rate.”

If a pandemic like 1918's pandemic occurred today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211-8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak—whether it is widespread as in 1918 or more mild, as in 1968, experts said. The Centers for Disease Control and Prevention is releasing a strategy to rate pandemic outbreaks on a scale of 1 to 5, similar to what is used to rate hurricane intensity.

“The distinction between a category 4 or 5 and a smaller pandemic is key,” said Dr. Arnold Monto, of the University of Michigan School of Public Health, Ann Arbor. “What we can take away from the 1918 pandemic in terms of school closings and social distancing—which occasionally occur if there is a big seasonal outbreak—is that they usually occur late after the outbreak has taken off. It could be catastrophic if these measures are not taken in advance.” The CDC initiative will address the utility of such nonpharmacologic means for controlling a future pandemic.

The Seasonal & Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, NIAID, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic, according to an expert panel that held a Feb. 1 teleconference during the Seasonal and Pandemic Influenza 2007 meeting.

Primary care physicians need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for their physician members and the patients they treat, Dr. Whitley said.

“We need to immunize more children, because they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised,” he said.

“There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley added.

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.”

Clinicians have a duty to protect themselves and their patients from influenza, Dr. Bartlett said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

Another goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point of care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale.

The Seasonal and Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, National Institute of Allergy and Infectious Diseases, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic, according to an expert panel that held a Feb. 1 teleconference during the Seasonal and Pandemic Influenza 2007 meeting.

Primary care physicians need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for their physician members and the patients they treat, Dr. Whitley said.

“We need to immunize more children, because they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised,” he said.

“There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley added.

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.”

Clinicians have a duty to protect themselves and their patients from influenza, Dr. Bartlett said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

Another goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point of care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale.

The Seasonal and Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, National Institute of Allergy and Infectious Diseases, and the Society for Healthcare Epidemiology of America.

Despite promising advances, clinicians, hospitals, and public health officials remain largely unprepared for a global influenza pandemic, according to an expert panel that held a Feb. 1 teleconference during the Seasonal and Pandemic Influenza 2007 meeting.

Primary care physicians need a better appreciation of the current morbidity and mortality caused by seasonal influenza outbreaks in the United States, Dr. Richard Whitley said. An influenza pandemic may incite more fear among physicians and the public, but seasonal influenza causes an estimated 36,000 deaths and more than 200,000 hospitalizations each year, said Dr. Whitley, professor of pediatrics at the University of Alabama, Birmingham.

The American Academy of Pediatrics and the American Academy of Family Physicians need to stress the importance of influenza vaccinations for their physician members and the patients they treat, Dr. Whitley said.

“We need to immunize more children, because they are a main source of infection for other family members, including high-risk groups such as the elderly and the immunocompromised,” he said.

“There have already been 100 children admitted to Children's Hospital in Birmingham and nine deaths so far in the United States during the 2006–2007 influenza season, Dr. Whitley added.

“I would add that this applies to physicians who take care of adults as well,” said Dr. John Bartlett, professor of medicine at Johns Hopkins University, Baltimore. “Data indicate the current vaccination [rate] is good in elderly, less so in the immunocompromised patients, and poor in health care workers, about 40%.”

Clinicians have a duty to protect themselves and their patients from influenza, Dr. Bartlett said.

One proposal for boosting vaccination rates among hospital-based health care providers is to make mandatory the reporting of such rates to the Joint Commission on Accreditation of Healthcare Organizations. In addition, the Infectious Diseases Society of America (IDSA) is reportedly going to push for immunization of all health care workers.

Another goal on the horizon is to reduce the prohibitively high doses of influenza vaccine that would be required during a pandemic.

A quick point-of-care test for pandemic strains of influenza is in development, according to panel members. A similar test for seasonal influenza strains is limited by its long turnaround time.

“We need to get point of care diagnostics down to a time frame that is clinically useful. Now it takes several hours to do,” Dr. Bartlett said. Having more rapid diagnostic assays would allow for more judicial use of antibiotics, particularly in children.

Panel members focused on the prevention of a bird flu pandemic caused by the H5N1 lethal strain of influenza virus subtype that mainly infects birds. As of Jan. 30, there were 270 confirmed human H5N1 cases and 164 human deaths had been reported. The vast majority of affected humans were in close contact with infected poultry.

“The greatest concern … is the resurgence of these viruses in countries such as Japan and Korea. … It suggests migratory birds have probably brought these viruses back in,” said Robert Webster, Ph.D., professor of virology at St. Jude Children's Hospital in Memphis, Tenn., and director of the World Health Organization's Center on Studies on the Ecology of Influenza in Animals and Birds.

If a pandemic similar to the 1918 pandemic were to occur today, it would cause an estimated 62 million deaths worldwide (Lancet 2006;369:2211–8). Health care resources in the United States would be quickly overwhelmed, according to data from the Center for Biosecurity at the University of Pittsburgh. Researchers estimated an influenza pandemic similar to 1918 would take 191% of the beds in the United States.

Response to an influenza pandemic should be tailored to the extent of the outbreak, experts said. The Centers for Disease Control and Prevention is releasing a strategy to categorize pandemic outbreaks on a 1 to 5 severity scale.

The Seasonal and Pandemic Influenza 2007 meeting was endorsed by the AAP, IDSA, CDC, National Institute of Allergy and Infectious Diseases, and the Society for Healthcare Epidemiology of America.

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home.

The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida.

“I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs. Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff.

The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home.

The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida.

“I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs. Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff.

The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”

DENVER — Lessons learned by clinicians at a multidisciplinary program regarding the transition of pediatric patients with spina bifida to an adult medical home can help others meeting the same challenges, according to a presentation at a meeting on pediatric neurologic surgery.

“As patients with spina bifida reach adulthood, there is an ongoing challenge,” Dr. Hector E. James said. “Most of us know the difficulty of finding an adult medical home for patients we've seen for years in a multidisciplinary setting. There is a lack of knowledge amongst adult heath care providers as to the needs of the young adult with spina bifida.”

Some answers may come from the Jacksonville Health and Adult Transitional Services (JaxHATS) program. Dr. James reported that JaxHATS has successfully transitioned patients from the spinal defects clinic at Wolfson Children's Hospital in Jacksonville, Fla., to an adult medical home.

The program, launched in 2005, includes a pediatrician, internist, nurse-coordinator, unit manager, and medical social worker.

It can be a challenge to find neurosurgeons who are willing to become primary care providers for young adults with spina bifida.

“I am obviously generalizing, but it's not an uncommon problem,” he added at the meeting, which was jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A meeting attendee asked how the JaxHATS clinicians get “buy-in” from adult providers. “We were fortunate in finding a pediatrician and internist who were willing to do this,” Dr. James replied.

These doctors assess the teenager and then educate the adult subspecialist about their special needs. Also, “incorporating an educational component for residents at our academic institution helped gain acceptance from administrators,” said Dr. James, a pediatric neurosurgeon at the Lucy Gooding Pediatric Neurosurgery Center at Wolfson Children's Hospital.

The adolescent and family are prepared for the transition process into adulthood during visits to the spinal defects clinic. Then intake information is taken by the JaxHATS staff.

The clinic coordinator and nurse-coordinator prepare a “transition medical summary” for the pediatrician and internist. Insurance reimbursement must be established in advance, Dr. James said. “It is extremely important to have insurance paperwork done correctly for the first appointment. The social worker and manager assist families with this and follow-up appointments.”

An initial 16 patients have successfully completed the transition. Although the JaxHATS program “is still a work in progress,” Dr. James said, “it is a very rewarding experience. It may not be a model for everyone, but it worked for us.”