Erik L. Goldman

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbinafine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a whole new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” said Dr. Rosen, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” Dr. Rosen said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in a very early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said.

The good news for physicians is that albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can clear refractory esophageal candidiasis very quickly.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, though it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbinafine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a whole new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” said Dr. Rosen, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” Dr. Rosen said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in a very early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said.

The good news for physicians is that albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can clear refractory esophageal candidiasis very quickly.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, though it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbinafine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a whole new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” said Dr. Rosen, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” Dr. Rosen said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in a very early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said.

The good news for physicians is that albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can clear refractory esophageal candidiasis very quickly.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, though it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbina-fine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. (See story below.) Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” Dr. Rosen said, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” he said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in an early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said. Albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can quickly clear refractory esophageal candidiasis.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, but it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbina-fine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. (See story below.) Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” Dr. Rosen said, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” he said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in an early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said. Albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can quickly clear refractory esophageal candidiasis.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, but it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — The incidence of cutaneous fungal infections is on the rise in the United States, and the old standby antifungal drugs aren't working as well as they used to, Dr. Ted Rosen said at the American Academy of Dermatology's Academy 2006 conference.

Fortunately, new antifungals are emerging that could stem the mycologic mayhem, at least for a while.

The rise in fungal infections can be partly attributed to an increase in the number of immunosuppressed people living ever-longer lives. HIV-positive people on highly active antiretroviral therapy (HAART), survivors of cancer chemotherapy, and organ transplant recipients on immunosuppressive drugs are all highly susceptible to systemic mycoses, said Dr. Rosen of the department of dermatology at Baylor College of Medicine, Houston.

Another key factor is the unprecedented mobility of the population. More people travel more often and farther than at any other time in history. Immigrants come to the United States from regions that are endemic for fungi seldom seen here in the past.

Tertiary care centers like Baylor are reporting increases in fungi such as Cryptococcus, Histoplasma capsulatum, Sporothrix, Fusarium, Rhizopus, and Fonsecaea, which often go unrecognized or misdiagnosed for a long time. Given the high numbers of military and oil-industry personnel in Texas, Baylor clinicians are seeing a rise in strange fungal infections in troops and oil workers returning from Iraq, the Persian Gulf, and South America.

Moreover, mainstay drugs like fluconazole, itraconazole, ketoconazole, terbina-fine, and griseofulvin are more widely used than ever, applying plenty of selective pressure on the fungi to develop resistance.

Which is just what is happening.

Dr. Rosen cited a recent report of terbinafine-resistant Trichophyton rubrum in a patient with onychomycosis who had never before been treated with an antifungal. “We're seeing innate resistance in a garden-variety form of T. rubrum. This old 'friend' is suddenly nonresponsive to a very powerful antifungal drug. This is problematic,” he said.

Fortunately, he noted, a passel of new antifungals is making its way into clinical practice, including a new class of cell wall-smashing echinocandins.

All of the azoles, including new ones like voriconazole (Vfend) and posaconazole (Noxafil)—as well as ravuconazole, which is not yet approved—attack fungal cell membranes.

Voriconazole has a broad spectrum and is highly effective against all species of Candida. It also works against Aspergillus and Fusarium, which generally won't yield to fluconazole. In vitro, voriconazole bests griseofulvin and ketoconazole, and it equals terbinafine in killing dermatophytes. It is also extremely bioavailable in oral dosing forms, Dr. Rosen said.

This new drug does have its downside, mainly its strong potential for adverse effects. It is metabolized via two cytochrome P450 enzymes, so it is capable of interacting with other drugs, at least in theory. It induces liver enzyme elevations, which are reversible, and it can also trigger morbilliform eruptions.

The most common adverse effect of voriconazole, though, is visual disturbances. Dr. Rosen said that a number of patients experience photophobia or a very specific visual disturbance characterized by bluish purple halos around objects.

Purple haze aside, Dr. Rosen said he's used this drug a lot, and in his experience, it is reasonably problem free. “I've used it off-label to treat patients who've failed everything else.”

Posaconazole was approved in September under the brand name Noxafil for the treatment of aspergillosis. (See story below.) Metabolism of posaconazole involves only one CYP 450 enzyme, so this drug is less likely to cause interactions. Side effects are “pretty reasonable,” Dr. Rosen said, the most common being headache and nausea.

“What really makes this drug stand out, aside from its ability to deal with weird fungi, is that it really works for zygomycetes—those deep fungi that really penetrate the nasopharynx in diabetes patients and transplant recipients. It's also great for everything refractory, and it does this orally,” he said.

Ravuconazole initially looked quite promising, with excellent in vitro efficacy against dermatophytes, but further development seems to have stalled for reasons that are not clear, he said.

Albaconazole, the newest triazole, is still in an early developmental stage, but “it is better than itraconazole, fluconazole, or voriconazole for almost all of the common dermatophytes and saprophytes, and at least as good as or better than all the existing triazoles,” Dr. Rosen said. Albaconazole will be initially formulated as a nail lacquer along with oral and intravenous forms.

The echinocandins bring a new therapeutic mechanism into the antifungal picture: They break down the fungal cell walls by attacking the glucan building blocks and inhibiting the enzyme complexes involved in synthesizing glucans.

According to Dr. Rosen, the candins are strong medicine for “seriously sick patients with really bad bugs.” Basically, the candins make it impossible for the fungi to build their cell walls, and the current trend among fungal infection specialists is to combine an echinocandin with one of the new triazoles.

He noted that he has worked with caspofungin (Cancidas) quite a bit and has found that it greatly extends Candida coverage. In HIV-positive patients, it can quickly clear refractory esophageal candidiasis.

Micafungin (Mycamine) is the other hot candin these days. It is excellent for Candida and Aspergillus, but it does not work as well against Zygomycetes or Fusarium.

The main drawback to the candins as a class is that they are available only in intravenous forms. “All these drugs are cyclic hexapeptides, and all are destroyed by acids. Therefore, oral formulations are not possible,” Dr. Rosen said.

There are a few other antifungals in the offing. PLD-118, also known as icofungipen, is neither an azole nor a candin. It is a tiny molecule that binds to fungal isoleucyl transfer RNA, thus affecting a wide range of Candida species. PLD-118 is being developed as topical as well as systemic therapy.

Milbemycin, derived from Streptomyces, trips up the fungal gene that enables resistant fungi to “spit out” other antifungals, he said. When it eventually comes to market, it will probably find its place as an adjunct for many of the more conventional antifungals, potentiating their effects against resistant pathogens.

Finally, there's the yet-to-be properly named P-113, the world's first “swish and spit” antifungal. This drug, which is being developed as a therapeutic mouthwash, is a 12-amino acid fragment of histatin 5, a compound produced by the body that has fungistatic effects, especially against Candida. Histatin 5 is “basically what prevents most of us from getting thrush. So this drug is essentially a duplication of the natural mechanism for controlling yeasts,” Dr. Rosen said.

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. "Unfortunately, the doctors seldom know this," said Dr. Anderson, a dermatologist in private practice in Tyler, Tex. He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. "In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years," Dr. Anderson explained.

"During this time our services will be needed more and more, and it will be harder for us to get and keep good employees." The bottom line, said Dr. Anderson, is that dermatologists and all other physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, dermatologists and other physicians are now facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41–50 years old, and 29% are 51–60 years old. "More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s," Dr. Anderson noted.

Although the attitudinal differences between the Baby Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. "Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way." They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the "question authority" attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things. "With this generation, rules don't count unless they have input and understand the rationale," Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

In Dr. Anderson's experience, Gen-Xers are pretty practical. "They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion." He has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies.

These generational inclinations are rough guidelines, Dr. Anderson stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. "Find out what each employee wants, and reward them accordingly," he said.

Tips for Keeping Gen-X Staffers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. "Unfortunately, the doctors seldom know this," said Dr. Anderson, a dermatologist in private practice in Tyler, Tex. He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. "In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years," Dr. Anderson explained.

"During this time our services will be needed more and more, and it will be harder for us to get and keep good employees." The bottom line, said Dr. Anderson, is that dermatologists and all other physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, dermatologists and other physicians are now facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41–50 years old, and 29% are 51–60 years old. "More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s," Dr. Anderson noted.

Although the attitudinal differences between the Baby Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. "Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way." They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the "question authority" attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things. "With this generation, rules don't count unless they have input and understand the rationale," Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

In Dr. Anderson's experience, Gen-Xers are pretty practical. "They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion." He has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies.

These generational inclinations are rough guidelines, Dr. Anderson stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. "Find out what each employee wants, and reward them accordingly," he said.

Tips for Keeping Gen-X Staffers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. "Unfortunately, the doctors seldom know this," said Dr. Anderson, a dermatologist in private practice in Tyler, Tex. He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. "In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years," Dr. Anderson explained.

"During this time our services will be needed more and more, and it will be harder for us to get and keep good employees." The bottom line, said Dr. Anderson, is that dermatologists and all other physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, dermatologists and other physicians are now facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41–50 years old, and 29% are 51–60 years old. "More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s," Dr. Anderson noted.

Although the attitudinal differences between the Baby Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. "Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way." They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the "question authority" attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things. "With this generation, rules don't count unless they have input and understand the rationale," Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

In Dr. Anderson's experience, Gen-Xers are pretty practical. "They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion." He has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies.

These generational inclinations are rough guidelines, Dr. Anderson stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. "Find out what each employee wants, and reward them accordingly," he said.

Tips for Keeping Gen-X Staffers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — The rise in incidence of unusual fungi, especially in immunocompromised individuals, is complicating the diagnosis of cutaneous mycoses, said Dr. Ted Rosen at the American Academy of Dermatology's Academy 2006 conference.

“Fungal illnesses can mimic lots of different things, especially in immunocompromised patients. For example, Cryptococcus infection can look like Kaposi's sarcoma, bacterial cellulitis, molluscum, or even herpes,” said Dr. Rosen of the department of dermatology, Baylor College of Medicine, Houston. “In HIV-positive patients, all morphologic bets are off.”

As a result, many patients with strange fungal infections go undiagnosed or misdiagnosed for long periods. If one is in doubt about any cutaneous symptoms, taking a biopsy and getting fungal cultures is worthwhile, he said.

Dr. Rosen mentioned a case in which a 41-year-old HIV-positive white man presented with brown-purple papules and plaques, some of which were ulcerated. The referring physicians thought it was Kaposi's sarcoma (KS) with a secondary bacterial infection. Like many HIV-positive patients, the man had a complicated history peppered with opportunistic infections, including Pneumocystis carinii pneumonia, herpes zoster, and cytomegalovirus. He'd also had oral KS, so it was reasonable for the referring physician to think about cutaneous KS.

“I saw the lesions and understood right away why they thought it was KS. But the diffuse, brownish ulceration was strange, so I took a biopsy of all the brownish areas, and they came back showing Cryptococcus neoformans,” Dr. Rosen said. The patient's blood and bone marrow were also positive for Cryptococcus.

Unfortunately, the patient committed suicide before Dr. Rosen was able to treat the fungal infection with amphotericin B. He recommends 1 mg/kg for 2 weeks of the standard form of amphotericin B, rather than the lipid-based form. In some cases, it makes sense to add flucytosine, 100 mg/kg per day, and then fluconazole, 400 mg per day for 10 weeks. Some HIV-positive patients should remain on fluconazole maintenance, at a dose in the 200- to 400-mg range, for life.

Dr. Rosen said between 5% and 10% of all HIV-positive individuals get Cryptococcus, and nearly 90% of all Cryptococcus cases are in HIV-positive people, though it can also affect organ transplant patients and pregnant women.

Fungal infections need not be life threatening to cause major problems for patients. Dr. Rosen described another case involving a 24-year-old, otherwise healthy woman who'd had a chronic eczemalike rash on her cheeks for 13 years. She had been applying steroid creams for years, to no avail.

Biopsy showed pseudoepitheliomatous hyperplasia, granulomata, and small, short budding yeast forms. The culture grew out a thick fungal plaque that turned out to be Phoma complex, an aggregate of soil fungi that normally affect celery, beets, tomatoes, potatoes, and peppers.

“We reread the original biopsy specimen from 13 years ago, and we were able to grow out the Phoma. For 13 years, this patient was smearing steroids on a plant pathogen.” The patient had spent a lot of time as a child on a pig farm, which is where she likely picked up the plant fungus.

“I asked for in vitro testing, to see what [the fungi were] sensitive to. You really need help from a good microbiologist in cases like this.” They proved sensitive to ketoconazole and itraconazole, but not to fluconazole or griseofulvin. Dr. Rosen went with ketoconazole, 200 mg, twice daily, which resulted in a clinical and histologic cure within 18 months.

With worldwide travel and immigration come new and unusual fungal infections that mimic other common skin diseases. A case in point is a 47-year-old male construction worker who Dr. Rosen saw for a scaly, horseshoe-shaped plaquelike lesion on his forearm. The presenting lesion was actually a recurrence of the original lesion, which had been excised by a physician who thought it was a skin cancer.

The surface of the lesion was coated with a blackish powdery substance. Dr. Rosen cultured it and grew out Fonsecaea pedrosoi, a soil fungus that is rare in the United States and usually seen in Central American agricultural workers. It is also common in Madagascar and parts of South America. The lesions can be dead ringers for skin cancers.

For relatively mild cases of Fonsecaea infection, itraconazole is a good choice, said Dr. Rosen. Roughly 60% of U.S. isolates are sensitive to this drug at a dose in the 200- to 400-mg range. For more severe cases, posaconazole is the most promising choice. Cryotherapy or thermotherapy can also help, in conjunction with drug treatment. But large lesions can be hard to clear and often take a year or more of continuous treatment before showing a complete resolution, he warned.

Whenever one sees something that looks a bit unusual, especially in patients who are immunocompromised or taking any medication that might impair the immune system, one should think “fungi,” said Dr. Rosen.

Novel “biologics” and anti-TNF drugs can leave patients susceptible to opportunistic fungi such as Sporothrix. Clinical conditions such as alcoholism, diabetes, and some forms of cancer can also leave patients vulnerable to odd fungi, he said.

SAN DIEGO — The rise in incidence of unusual fungi, especially in immunocompromised individuals, is complicating the diagnosis of cutaneous mycoses, said Dr. Ted Rosen at the American Academy of Dermatology's Academy 2006 conference.

“Fungal illnesses can mimic lots of different things, especially in immunocompromised patients. For example, Cryptococcus infection can look like Kaposi's sarcoma, bacterial cellulitis, molluscum, or even herpes,” said Dr. Rosen of the department of dermatology, Baylor College of Medicine, Houston. “In HIV-positive patients, all morphologic bets are off.”

As a result, many patients with strange fungal infections go undiagnosed or misdiagnosed for long periods. If one is in doubt about any cutaneous symptoms, taking a biopsy and getting fungal cultures is worthwhile, he said.

Dr. Rosen mentioned a case in which a 41-year-old HIV-positive white man presented with brown-purple papules and plaques, some of which were ulcerated. The referring physicians thought it was Kaposi's sarcoma (KS) with a secondary bacterial infection. Like many HIV-positive patients, the man had a complicated history peppered with opportunistic infections, including Pneumocystis carinii pneumonia, herpes zoster, and cytomegalovirus. He'd also had oral KS, so it was reasonable for the referring physician to think about cutaneous KS.

“I saw the lesions and understood right away why they thought it was KS. But the diffuse, brownish ulceration was strange, so I took a biopsy of all the brownish areas, and they came back showing Cryptococcus neoformans,” Dr. Rosen said. The patient's blood and bone marrow were also positive for Cryptococcus.

Unfortunately, the patient committed suicide before Dr. Rosen was able to treat the fungal infection with amphotericin B. He recommends 1 mg/kg for 2 weeks of the standard form of amphotericin B, rather than the lipid-based form. In some cases, it makes sense to add flucytosine, 100 mg/kg per day, and then fluconazole, 400 mg per day for 10 weeks. Some HIV-positive patients should remain on fluconazole maintenance, at a dose in the 200- to 400-mg range, for life.

Dr. Rosen said between 5% and 10% of all HIV-positive individuals get Cryptococcus, and nearly 90% of all Cryptococcus cases are in HIV-positive people, though it can also affect organ transplant patients and pregnant women.

Fungal infections need not be life threatening to cause major problems for patients. Dr. Rosen described another case involving a 24-year-old, otherwise healthy woman who'd had a chronic eczemalike rash on her cheeks for 13 years. She had been applying steroid creams for years, to no avail.

Biopsy showed pseudoepitheliomatous hyperplasia, granulomata, and small, short budding yeast forms. The culture grew out a thick fungal plaque that turned out to be Phoma complex, an aggregate of soil fungi that normally affect celery, beets, tomatoes, potatoes, and peppers.

“We reread the original biopsy specimen from 13 years ago, and we were able to grow out the Phoma. For 13 years, this patient was smearing steroids on a plant pathogen.” The patient had spent a lot of time as a child on a pig farm, which is where she likely picked up the plant fungus.

“I asked for in vitro testing, to see what [the fungi were] sensitive to. You really need help from a good microbiologist in cases like this.” They proved sensitive to ketoconazole and itraconazole, but not to fluconazole or griseofulvin. Dr. Rosen went with ketoconazole, 200 mg, twice daily, which resulted in a clinical and histologic cure within 18 months.

With worldwide travel and immigration come new and unusual fungal infections that mimic other common skin diseases. A case in point is a 47-year-old male construction worker who Dr. Rosen saw for a scaly, horseshoe-shaped plaquelike lesion on his forearm. The presenting lesion was actually a recurrence of the original lesion, which had been excised by a physician who thought it was a skin cancer.

The surface of the lesion was coated with a blackish powdery substance. Dr. Rosen cultured it and grew out Fonsecaea pedrosoi, a soil fungus that is rare in the United States and usually seen in Central American agricultural workers. It is also common in Madagascar and parts of South America. The lesions can be dead ringers for skin cancers.

For relatively mild cases of Fonsecaea infection, itraconazole is a good choice, said Dr. Rosen. Roughly 60% of U.S. isolates are sensitive to this drug at a dose in the 200- to 400-mg range. For more severe cases, posaconazole is the most promising choice. Cryotherapy or thermotherapy can also help, in conjunction with drug treatment. But large lesions can be hard to clear and often take a year or more of continuous treatment before showing a complete resolution, he warned.

Whenever one sees something that looks a bit unusual, especially in patients who are immunocompromised or taking any medication that might impair the immune system, one should think “fungi,” said Dr. Rosen.

Novel “biologics” and anti-TNF drugs can leave patients susceptible to opportunistic fungi such as Sporothrix. Clinical conditions such as alcoholism, diabetes, and some forms of cancer can also leave patients vulnerable to odd fungi, he said.

SAN DIEGO — The rise in incidence of unusual fungi, especially in immunocompromised individuals, is complicating the diagnosis of cutaneous mycoses, said Dr. Ted Rosen at the American Academy of Dermatology's Academy 2006 conference.

“Fungal illnesses can mimic lots of different things, especially in immunocompromised patients. For example, Cryptococcus infection can look like Kaposi's sarcoma, bacterial cellulitis, molluscum, or even herpes,” said Dr. Rosen of the department of dermatology, Baylor College of Medicine, Houston. “In HIV-positive patients, all morphologic bets are off.”

As a result, many patients with strange fungal infections go undiagnosed or misdiagnosed for long periods. If one is in doubt about any cutaneous symptoms, taking a biopsy and getting fungal cultures is worthwhile, he said.

Dr. Rosen mentioned a case in which a 41-year-old HIV-positive white man presented with brown-purple papules and plaques, some of which were ulcerated. The referring physicians thought it was Kaposi's sarcoma (KS) with a secondary bacterial infection. Like many HIV-positive patients, the man had a complicated history peppered with opportunistic infections, including Pneumocystis carinii pneumonia, herpes zoster, and cytomegalovirus. He'd also had oral KS, so it was reasonable for the referring physician to think about cutaneous KS.

“I saw the lesions and understood right away why they thought it was KS. But the diffuse, brownish ulceration was strange, so I took a biopsy of all the brownish areas, and they came back showing Cryptococcus neoformans,” Dr. Rosen said. The patient's blood and bone marrow were also positive for Cryptococcus.

Unfortunately, the patient committed suicide before Dr. Rosen was able to treat the fungal infection with amphotericin B. He recommends 1 mg/kg for 2 weeks of the standard form of amphotericin B, rather than the lipid-based form. In some cases, it makes sense to add flucytosine, 100 mg/kg per day, and then fluconazole, 400 mg per day for 10 weeks. Some HIV-positive patients should remain on fluconazole maintenance, at a dose in the 200- to 400-mg range, for life.

Dr. Rosen said between 5% and 10% of all HIV-positive individuals get Cryptococcus, and nearly 90% of all Cryptococcus cases are in HIV-positive people, though it can also affect organ transplant patients and pregnant women.

Fungal infections need not be life threatening to cause major problems for patients. Dr. Rosen described another case involving a 24-year-old, otherwise healthy woman who'd had a chronic eczemalike rash on her cheeks for 13 years. She had been applying steroid creams for years, to no avail.

Biopsy showed pseudoepitheliomatous hyperplasia, granulomata, and small, short budding yeast forms. The culture grew out a thick fungal plaque that turned out to be Phoma complex, an aggregate of soil fungi that normally affect celery, beets, tomatoes, potatoes, and peppers.

“We reread the original biopsy specimen from 13 years ago, and we were able to grow out the Phoma. For 13 years, this patient was smearing steroids on a plant pathogen.” The patient had spent a lot of time as a child on a pig farm, which is where she likely picked up the plant fungus.

“I asked for in vitro testing, to see what [the fungi were] sensitive to. You really need help from a good microbiologist in cases like this.” They proved sensitive to ketoconazole and itraconazole, but not to fluconazole or griseofulvin. Dr. Rosen went with ketoconazole, 200 mg, twice daily, which resulted in a clinical and histologic cure within 18 months.

With worldwide travel and immigration come new and unusual fungal infections that mimic other common skin diseases. A case in point is a 47-year-old male construction worker who Dr. Rosen saw for a scaly, horseshoe-shaped plaquelike lesion on his forearm. The presenting lesion was actually a recurrence of the original lesion, which had been excised by a physician who thought it was a skin cancer.

The surface of the lesion was coated with a blackish powdery substance. Dr. Rosen cultured it and grew out Fonsecaea pedrosoi, a soil fungus that is rare in the United States and usually seen in Central American agricultural workers. It is also common in Madagascar and parts of South America. The lesions can be dead ringers for skin cancers.

For relatively mild cases of Fonsecaea infection, itraconazole is a good choice, said Dr. Rosen. Roughly 60% of U.S. isolates are sensitive to this drug at a dose in the 200- to 400-mg range. For more severe cases, posaconazole is the most promising choice. Cryotherapy or thermotherapy can also help, in conjunction with drug treatment. But large lesions can be hard to clear and often take a year or more of continuous treatment before showing a complete resolution, he warned.

Whenever one sees something that looks a bit unusual, especially in patients who are immunocompromised or taking any medication that might impair the immune system, one should think “fungi,” said Dr. Rosen.

Novel “biologics” and anti-TNF drugs can leave patients susceptible to opportunistic fungi such as Sporothrix. Clinical conditions such as alcoholism, diabetes, and some forms of cancer can also leave patients vulnerable to odd fungi, he said.

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. “Unfortunately, the doctors seldom know this,” said Dr. Anderson, who is in private practice in Tyler, Tex.

He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%.

That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment.

“In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” Dr. Anderson explained.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” The bottom line, said Dr. Anderson, is that physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, many physicians are now facing what amounts to a significant generation gap. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity, Dr. Anderson noted.

Gen-Xers tend to be more skeptical than are the idealistic Boomers, and they demand to know why something is the way it is. They have fewer expectations about finding their fulfillment at work, and they place a high premium on their lives outside their jobs.

Dr. Anderson said many Boomers hold the misconceptions that Gen-Xers have a “you owe me” attitude and that they do not want to work hard. Both of these are untrue. In his experience, Gen-Xers are willing to work hard, but they are staunchly unwilling to be exploited, and they are more interested in personal autonomy and their pursuits outside their jobs than they are in building their careers and amassing status symbols.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way.” They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the “question authority” attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things.

“With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

“Fear-based management doesn't work with them. They respond to that with an attitude of, 'Fine, fire me!'” Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored. They prefer direct communication to indirect messages and layers of bureaucracy. Gen-Xers despise being treated like children, so at all costs, avoid resorting to a “because I said so!” stance. They simply will not buy it.

In Dr. Anderson's experience, Gen-Xers are pretty practical. “They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion.”

In terms of training, be aware that while they tend to be independent, Gen-Xers hate being thrown into situations for which they are entirely untrained or poorly prepared. “Think about what they need to know—and from their perspective, not yours,” Dr. Anderson said. Develop a more or less consistent basic training system to quickly get a new employee up to speed on the most common tasks and challenges they'll be expected to handle.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. They tend to dislike hierarchies, especially if there's no evidence that the ones at the top have earned their position. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

These generational inclinations are rough guidelines, he stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. “Find out what each employee wants, and reward them accordingly,” Dr. Anderson said.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Keeping Gen-Xers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. “Unfortunately, the doctors seldom know this,” said Dr. Anderson, who is in private practice in Tyler, Tex.

He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%.

That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment.

“In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” Dr. Anderson explained.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” The bottom line, said Dr. Anderson, is that physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, many physicians are now facing what amounts to a significant generation gap. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity, Dr. Anderson noted.

Gen-Xers tend to be more skeptical than are the idealistic Boomers, and they demand to know why something is the way it is. They have fewer expectations about finding their fulfillment at work, and they place a high premium on their lives outside their jobs.

Dr. Anderson said many Boomers hold the misconceptions that Gen-Xers have a “you owe me” attitude and that they do not want to work hard. Both of these are untrue. In his experience, Gen-Xers are willing to work hard, but they are staunchly unwilling to be exploited, and they are more interested in personal autonomy and their pursuits outside their jobs than they are in building their careers and amassing status symbols.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way.” They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the “question authority” attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things.

“With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

“Fear-based management doesn't work with them. They respond to that with an attitude of, 'Fine, fire me!'” Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored. They prefer direct communication to indirect messages and layers of bureaucracy. Gen-Xers despise being treated like children, so at all costs, avoid resorting to a “because I said so!” stance. They simply will not buy it.

In Dr. Anderson's experience, Gen-Xers are pretty practical. “They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion.”

In terms of training, be aware that while they tend to be independent, Gen-Xers hate being thrown into situations for which they are entirely untrained or poorly prepared. “Think about what they need to know—and from their perspective, not yours,” Dr. Anderson said. Develop a more or less consistent basic training system to quickly get a new employee up to speed on the most common tasks and challenges they'll be expected to handle.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. They tend to dislike hierarchies, especially if there's no evidence that the ones at the top have earned their position. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

These generational inclinations are rough guidelines, he stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. “Find out what each employee wants, and reward them accordingly,” Dr. Anderson said.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Keeping Gen-Xers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — A good office staff is essential for a thriving medical practice, and understanding generational differences is key to finding and keeping good employees, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Patient surveys show that roughly 70% of patients who change physicians do so because they feel in some way put off by office staff attitudes. “Unfortunately, the doctors seldom know this,” said Dr. Anderson, who is in private practice in Tyler, Tex.

He stressed that two major demographic trends are converging in a way that will amplify the importance of finding good staffers at the same time as it will become ever more difficult to do so.

The U.S. labor force showed nearly flat growth in the late 1990s, and this hasn't changed much in recent years. During this period the population of younger working people shrank by about 14%.

That's bad news for the 80 million Baby Boomers who will require increasing levels of services, medical or otherwise. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment.

“In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” Dr. Anderson explained.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” The bottom line, said Dr. Anderson, is that physicians need to see their employees as an asset, not a liability, and they need to develop the sort of office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, many physicians are now facing what amounts to a significant generation gap. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity, Dr. Anderson noted.

Gen-Xers tend to be more skeptical than are the idealistic Boomers, and they demand to know why something is the way it is. They have fewer expectations about finding their fulfillment at work, and they place a high premium on their lives outside their jobs.

Dr. Anderson said many Boomers hold the misconceptions that Gen-Xers have a “you owe me” attitude and that they do not want to work hard. Both of these are untrue. In his experience, Gen-Xers are willing to work hard, but they are staunchly unwilling to be exploited, and they are more interested in personal autonomy and their pursuits outside their jobs than they are in building their careers and amassing status symbols.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up. When they were younger, their mothers gave them a list of things they needed to get done, and they learned how to do them on their own, in their own way.” They carry this general approach into their professional lives. They want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

When managing Gen-X staffers, be aware that they are definitely not impressed by authority unless it is earned and backed by unquestionable competence. This generation has the “question authority” attitude in spades. Do not assume that just because you're the doctor, your Gen-X staff will automatically submit to your vision of things.

“With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

“Fear-based management doesn't work with them. They respond to that with an attitude of, 'Fine, fire me!'” Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored. They prefer direct communication to indirect messages and layers of bureaucracy. Gen-Xers despise being treated like children, so at all costs, avoid resorting to a “because I said so!” stance. They simply will not buy it.

In Dr. Anderson's experience, Gen-Xers are pretty practical. “They do understand the need for conformity, and they understand why the doctor is in charge at a medical office. But they expect fairness, balance, and inclusion.”

In terms of training, be aware that while they tend to be independent, Gen-Xers hate being thrown into situations for which they are entirely untrained or poorly prepared. “Think about what they need to know—and from their perspective, not yours,” Dr. Anderson said. Develop a more or less consistent basic training system to quickly get a new employee up to speed on the most common tasks and challenges they'll be expected to handle.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. They tend to dislike hierarchies, especially if there's no evidence that the ones at the top have earned their position. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

These generational inclinations are rough guidelines, he stressed, and while they can give some insight, they are no substitute for getting to know the individual you are trying to hire. “Find out what each employee wants, and reward them accordingly,” Dr. Anderson said.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Keeping Gen-Xers Happy

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so whenever possible, put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — Two major converging demographic trends will amplify the importance of finding good office staffers at the same time as it will become ever more difficult to do so, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Growth of the U.S. labor force has remained nearly flat since the late 1990s. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of medical and other services. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. “In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” said Dr. Anderson, a dermatologist in private practice in Tyler, Tex.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” In response, physicians need to see their employees as an asset and develop an office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, physicians are facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41-50 years old, and 29% are 51-60 years old. “More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s,” he said. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up.” In their professional lives, they want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

This generation has the “question authority” attitude in spades. “With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Managing Gen-X Staffers

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — Two major converging demographic trends will amplify the importance of finding good office staffers at the same time as it will become ever more difficult to do so, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Growth of the U.S. labor force has remained nearly flat since the late 1990s. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of medical and other services. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. “In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” said Dr. Anderson, a dermatologist in private practice in Tyler, Tex.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” In response, physicians need to see their employees as an asset and develop an office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, physicians are facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41-50 years old, and 29% are 51-60 years old. “More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s,” he said. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up.” In their professional lives, they want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

This generation has the “question authority” attitude in spades. “With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Managing Gen-X Staffers

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

SAN DIEGO — Two major converging demographic trends will amplify the importance of finding good office staffers at the same time as it will become ever more difficult to do so, Dr. Larry Anderson said at the American Academy of Dermatology's Academy 2006 conference.

Growth of the U.S. labor force has remained nearly flat since the late 1990s. During this period the population of younger working people shrank by about 14%. That's bad news for the 80 million Baby Boomers who will require increasing levels of medical and other services. Retirees are the fastest-growing segment of the population, but the 20-something workforce is the slowest-growing segment. “In the next decade, we're expecting to see a 30% shortfall in younger workers, and this will persist for about 40 years,” said Dr. Anderson, a dermatologist in private practice in Tyler, Tex.

“During this time our services will be needed more and more, and it will be harder for us to get and keep good employees.” In response, physicians need to see their employees as an asset and develop an office culture and work environment that attracts and nurtures the best and the brightest.

In terms of employer-employee relations, physicians are facing what amounts to a significant generation gap. According to a recent AAD survey, 27% of all AAD members are 41-50 years old, and 29% are 51-60 years old. “More than 50% of all dermatologists are Boomers, with a mean age in their early 50s. Our employees, however, are in their 20s and 30s,” he said. While attitudinal differences between the Boomers, born between 1943 and 1964, and the so-called Generation X, born from the mid-1960s to the mid-1980s, may not be as great as the cultural divide between the Boomers and their Depression- and World War II-era parents, it can be much greater than many people realize, especially when it comes to matters of career and identity.

In terms of work styles, the Gen-Xers tend to be highly independent. “Remember, these are the latchkey kids all grown up.” In their professional lives, they want to know what has to be done, why it must be done, and when they must deliver. Beyond that, they want to be left alone.

This generation has the “question authority” attitude in spades. “With this generation, rules don't count unless they have input and understand the rationale,” Dr. Anderson said. In managing Gen-Xers, it is best to give them guidelines, while at the same time letting them into the planning process and allowing them to figure out the implementation.

Remember that Gen-Xers grew up in a time of unprecedented job mobility and career flexibility. They don't expect to work at any one company or office for their entire adult lives.

Gen-Xers are nearly allergic to office politics, and they resent favoritism and nepotism. They react badly to micromanagement, and they dislike it when their ideas, opinions, and suggestions are categorically ignored.

Dr. Anderson has found that team-based management works very well with Gen-X staffers, rather than top-down command and control strategies. “They view things according to the notion that a good idea is what gives power, not simply position.”

Positive feedback, constructive criticism, meaningful raises, and frequent “thank yous” go a long way with Gen-Xers. They also appreciate learning new skills and job situations that offer diverse and challenging experiences, rather than simple routines. “They like to experiment, and they want fresh experiences.”

In terms of financial issues, be aware that Gen-Xers are often struggling. At the same time, they tend to be less motivated by money than many Boomers are, and they strongly resist being bought off. Given that most medical office jobs in a given geographic area will pay more or less the same salaries, money is usually not an issue as long as you're paying market rates.

“You won't necessarily get a better employee by offering a few dollars more,” Dr. Anderson said. But you will if you show that you can offer a flexible, team-based work situation; a lively office atmosphere; and a culture that respects their intelligence, input, and extraoffice interests.

The single most important factor in creating a happy staff is in selecting people whose personalities and characters fit well together. Remember that technical skills can be learned and developed along the way. A candidate who is a natural fit with your office culture will, in the long run, be a much better bet than a highly skilled but difficult person who does not mesh well with the rest of the staff.

Tips for Managing Gen-X Staffers

▸ Listen with full attention, speak respectfully, and praise good work often.

▸ Create an atmosphere in which it is okay to respectfully disagree, and remember that your Gen-X staffers will be far more responsive if you explain why you do things your way.

▸ Keep in mind that many Gen-Xers don't have long attention spans, so make your communications and instructions concise and to the point.

▸ Gen-Xers are computer savvy, so put your communications, guidelines, and requests online or in electronic form.

▸ Gen-Xers are learning oriented, so conduct periodic learning inventories and ask them what they're learning during the day-to-day operations of your office.

▸ Encourage your staffers to cultivate their lives outside the office.

▸ Encourage teamwork and help foster a familial atmosphere in your office.

▸ Whatever it is that you preach, make sure you're practicing it.

▸ Lighten up and learn to be flexible.

Source: Dr. Anderson

OLD GREENWICH, CONN. — The neonatal intensive care unit is an ideal setting for delivering the trivalent influenza vaccine to parents of high-risk infants, Dr. Shetal Shah said at a meeting of the Eastern Society for Pediatric Research

Flu vaccination rates among U.S. adults remain very low. Even among high-risk adult populations such as the elderly or health care workers, full immunization rates run between 25% and 33%. Influenza is a very common and growing problem among infants in the NICU setting; the babies pick up the virus from adult caretakers. There has been a 10% increase in flu-related hospitalizations among vulnerable infants, said Dr. Shah of the Neonatal Intensive Care Unit at New York University, New York.

“If adults need to be immunized in order to protect their children, but they're not getting the vaccines, we need to look at the reasons why,” he said. While vaccine shortages have played a role, by far the most common reason for failure to receive the shots is inconvenience. Busy parents are preoccupied with so many other concerns that obtaining flu shots tends to fall to the bottom of the priority pile.

“Last year, we surveyed the parents of our NICU patients, and the flu vaccine rate was only around 33%. More than half who were not immunized cited inconvenience as the main reason.” This prompted Dr. Shah and his colleagues to consider making the shots available right in the NICU.

“It really is an ideal setting for this type of intervention. For one, we're dealing with the highest risk babies with the greatest need for protection. Most NICUs, like ours, are adopting a family-centered care model that actively engages the parents in the care of their babies. We have very liberal visiting hours at NYU: Parents can be in the NICU with their children for 22 out of every 24 hours. And we're open at times when other clinics or care delivery settings are closed,” he said.

Additionally, the NICU may be one of the few places to reach fathers. In general, men are far less likely than women to get regular medical checkups, and they tend to avoid physicians, hospitals, and clinics. “The ob.gyn. community is doing a much better job of getting the flu shots to women than the pediatric or family practice communities,” Dr. Shah said at the meeting, cosponsored by the Children's Hospital of Philadelphia. In part, this has to do with the success of prenatal care programs, which seldom reach the fathers.

The NYU NICU team undertook a pilot project to provide trivalent flu vaccines for all NICU parents from November 2005 to March 2006. As part of the admission process, staff told parents that it was now possible to get the flu vaccine, free of charge, right there in the NICU, and tried to get the parents to consent prior to delivery or soon thereafter. They also posted signs right on the babies' warmers, stating that the hospital strongly recommended that parents obtain the shot. They also posted reminders in common areas and breast-feeding rooms.

During the 4-month period, the NYU staff admitted 273 parents of 158 babies. They were able to counsel 220 about the importance of immunization, and actually gave shots to 157 (71%). Fifty-two (24%) of the parents counseled had already been immunized, and 11 (5%) refused.

Of those vaccinated in the NICU, 61% got their shots within 2 days after their babies were admitted. “We got to most of them within 72 hours, and after that, it tended to drop off.” They also were most successful with parents of babies who were less than 28–32 weeks' gestational age at delivery. Dr. Shah attributed this to the much longer lengths of stay for this extremely premature subgroup.

Most of the parents accepted the importance of getting the shots, and Dr. Shah noted something of a peer-pressure effect. “People bond in the NICU with other people going through the same ordeal. So if one couple went for the shots, the others they had connected with often followed.”

Despite the usually frantic pace of activity in the NICU, the staff took the flu shot endeavor quite seriously and managed to find the time to talk often with the parents. “We kept track of who was and who was not getting the shots, and we would talk to the ones who had not—to see if they had any questions or concerns that we could address.”

Among the 11 who refused the vaccine, 5 stated that they simply did not believe in immunization, and 2 said they feared that the shots might induce autism. Others cited religious objections or a reluctance to add anything else to whatever medical care they were already receiving. One cited an allergy to eggs, which is a legitimate concern since the vaccine contains some egg proteins.

Overall, the NYU NICU-based flu shot program was highly successful. Dr. Shah and colleagues are hoping to do a follow-up to see if the program had any impact on the rate of influenza among the neonates. He cautioned, however, that the sample size may be too small to support any definitive conclusion.

This pilot program did, however, prove that flu shots can be effectively distributed in the NICU setting to parents who for a variety of reasons had not previously gotten immunized. The program created very little additional strain on NICU physicians or nursing staff.

“Administration of the trivalent vaccine is very possible in a busy NICU, and implementation markedly increased compliance with recommendations aimed at protecting high-risk neonates,” Dr. Shah told conference participants. “There will always be a small subset of parents who will refuse, no matter what. But we can get to many parents who are willing to take the shots.” He added that this type of program is highly replicable and could be quickly implemented in any family-centered NICU.

OLD GREENWICH, CONN. — The neonatal intensive care unit is an ideal setting for delivering the trivalent influenza vaccine to parents of high-risk infants, Dr. Shetal Shah said at a meeting of the Eastern Society for Pediatric Research

Flu vaccination rates among U.S. adults remain very low. Even among high-risk adult populations such as the elderly or health care workers, full immunization rates run between 25% and 33%. Influenza is a very common and growing problem among infants in the NICU setting; the babies pick up the virus from adult caretakers. There has been a 10% increase in flu-related hospitalizations among vulnerable infants, said Dr. Shah of the Neonatal Intensive Care Unit at New York University, New York.

“If adults need to be immunized in order to protect their children, but they're not getting the vaccines, we need to look at the reasons why,” he said. While vaccine shortages have played a role, by far the most common reason for failure to receive the shots is inconvenience. Busy parents are preoccupied with so many other concerns that obtaining flu shots tends to fall to the bottom of the priority pile.

“Last year, we surveyed the parents of our NICU patients, and the flu vaccine rate was only around 33%. More than half who were not immunized cited inconvenience as the main reason.” This prompted Dr. Shah and his colleagues to consider making the shots available right in the NICU.

“It really is an ideal setting for this type of intervention. For one, we're dealing with the highest risk babies with the greatest need for protection. Most NICUs, like ours, are adopting a family-centered care model that actively engages the parents in the care of their babies. We have very liberal visiting hours at NYU: Parents can be in the NICU with their children for 22 out of every 24 hours. And we're open at times when other clinics or care delivery settings are closed,” he said.

Additionally, the NICU may be one of the few places to reach fathers. In general, men are far less likely than women to get regular medical checkups, and they tend to avoid physicians, hospitals, and clinics. “The ob.gyn. community is doing a much better job of getting the flu shots to women than the pediatric or family practice communities,” Dr. Shah said at the meeting, cosponsored by the Children's Hospital of Philadelphia. In part, this has to do with the success of prenatal care programs, which seldom reach the fathers.

The NYU NICU team undertook a pilot project to provide trivalent flu vaccines for all NICU parents from November 2005 to March 2006. As part of the admission process, staff told parents that it was now possible to get the flu vaccine, free of charge, right there in the NICU, and tried to get the parents to consent prior to delivery or soon thereafter. They also posted signs right on the babies' warmers, stating that the hospital strongly recommended that parents obtain the shot. They also posted reminders in common areas and breast-feeding rooms.

During the 4-month period, the NYU staff admitted 273 parents of 158 babies. They were able to counsel 220 about the importance of immunization, and actually gave shots to 157 (71%). Fifty-two (24%) of the parents counseled had already been immunized, and 11 (5%) refused.

Of those vaccinated in the NICU, 61% got their shots within 2 days after their babies were admitted. “We got to most of them within 72 hours, and after that, it tended to drop off.” They also were most successful with parents of babies who were less than 28–32 weeks' gestational age at delivery. Dr. Shah attributed this to the much longer lengths of stay for this extremely premature subgroup.

Most of the parents accepted the importance of getting the shots, and Dr. Shah noted something of a peer-pressure effect. “People bond in the NICU with other people going through the same ordeal. So if one couple went for the shots, the others they had connected with often followed.”

Despite the usually frantic pace of activity in the NICU, the staff took the flu shot endeavor quite seriously and managed to find the time to talk often with the parents. “We kept track of who was and who was not getting the shots, and we would talk to the ones who had not—to see if they had any questions or concerns that we could address.”

Among the 11 who refused the vaccine, 5 stated that they simply did not believe in immunization, and 2 said they feared that the shots might induce autism. Others cited religious objections or a reluctance to add anything else to whatever medical care they were already receiving. One cited an allergy to eggs, which is a legitimate concern since the vaccine contains some egg proteins.

Overall, the NYU NICU-based flu shot program was highly successful. Dr. Shah and colleagues are hoping to do a follow-up to see if the program had any impact on the rate of influenza among the neonates. He cautioned, however, that the sample size may be too small to support any definitive conclusion.

This pilot program did, however, prove that flu shots can be effectively distributed in the NICU setting to parents who for a variety of reasons had not previously gotten immunized. The program created very little additional strain on NICU physicians or nursing staff.

“Administration of the trivalent vaccine is very possible in a busy NICU, and implementation markedly increased compliance with recommendations aimed at protecting high-risk neonates,” Dr. Shah told conference participants. “There will always be a small subset of parents who will refuse, no matter what. But we can get to many parents who are willing to take the shots.” He added that this type of program is highly replicable and could be quickly implemented in any family-centered NICU.

OLD GREENWICH, CONN. — The neonatal intensive care unit is an ideal setting for delivering the trivalent influenza vaccine to parents of high-risk infants, Dr. Shetal Shah said at a meeting of the Eastern Society for Pediatric Research

Flu vaccination rates among U.S. adults remain very low. Even among high-risk adult populations such as the elderly or health care workers, full immunization rates run between 25% and 33%. Influenza is a very common and growing problem among infants in the NICU setting; the babies pick up the virus from adult caretakers. There has been a 10% increase in flu-related hospitalizations among vulnerable infants, said Dr. Shah of the Neonatal Intensive Care Unit at New York University, New York.

“If adults need to be immunized in order to protect their children, but they're not getting the vaccines, we need to look at the reasons why,” he said. While vaccine shortages have played a role, by far the most common reason for failure to receive the shots is inconvenience. Busy parents are preoccupied with so many other concerns that obtaining flu shots tends to fall to the bottom of the priority pile.

“Last year, we surveyed the parents of our NICU patients, and the flu vaccine rate was only around 33%. More than half who were not immunized cited inconvenience as the main reason.” This prompted Dr. Shah and his colleagues to consider making the shots available right in the NICU.

“It really is an ideal setting for this type of intervention. For one, we're dealing with the highest risk babies with the greatest need for protection. Most NICUs, like ours, are adopting a family-centered care model that actively engages the parents in the care of their babies. We have very liberal visiting hours at NYU: Parents can be in the NICU with their children for 22 out of every 24 hours. And we're open at times when other clinics or care delivery settings are closed,” he said.

Additionally, the NICU may be one of the few places to reach fathers. In general, men are far less likely than women to get regular medical checkups, and they tend to avoid physicians, hospitals, and clinics. “The ob.gyn. community is doing a much better job of getting the flu shots to women than the pediatric or family practice communities,” Dr. Shah said at the meeting, cosponsored by the Children's Hospital of Philadelphia. In part, this has to do with the success of prenatal care programs, which seldom reach the fathers.

The NYU NICU team undertook a pilot project to provide trivalent flu vaccines for all NICU parents from November 2005 to March 2006. As part of the admission process, staff told parents that it was now possible to get the flu vaccine, free of charge, right there in the NICU, and tried to get the parents to consent prior to delivery or soon thereafter. They also posted signs right on the babies' warmers, stating that the hospital strongly recommended that parents obtain the shot. They also posted reminders in common areas and breast-feeding rooms.

During the 4-month period, the NYU staff admitted 273 parents of 158 babies. They were able to counsel 220 about the importance of immunization, and actually gave shots to 157 (71%). Fifty-two (24%) of the parents counseled had already been immunized, and 11 (5%) refused.

Of those vaccinated in the NICU, 61% got their shots within 2 days after their babies were admitted. “We got to most of them within 72 hours, and after that, it tended to drop off.” They also were most successful with parents of babies who were less than 28–32 weeks' gestational age at delivery. Dr. Shah attributed this to the much longer lengths of stay for this extremely premature subgroup.

Most of the parents accepted the importance of getting the shots, and Dr. Shah noted something of a peer-pressure effect. “People bond in the NICU with other people going through the same ordeal. So if one couple went for the shots, the others they had connected with often followed.”

Despite the usually frantic pace of activity in the NICU, the staff took the flu shot endeavor quite seriously and managed to find the time to talk often with the parents. “We kept track of who was and who was not getting the shots, and we would talk to the ones who had not—to see if they had any questions or concerns that we could address.”

Among the 11 who refused the vaccine, 5 stated that they simply did not believe in immunization, and 2 said they feared that the shots might induce autism. Others cited religious objections or a reluctance to add anything else to whatever medical care they were already receiving. One cited an allergy to eggs, which is a legitimate concern since the vaccine contains some egg proteins.

Overall, the NYU NICU-based flu shot program was highly successful. Dr. Shah and colleagues are hoping to do a follow-up to see if the program had any impact on the rate of influenza among the neonates. He cautioned, however, that the sample size may be too small to support any definitive conclusion.

This pilot program did, however, prove that flu shots can be effectively distributed in the NICU setting to parents who for a variety of reasons had not previously gotten immunized. The program created very little additional strain on NICU physicians or nursing staff.

“Administration of the trivalent vaccine is very possible in a busy NICU, and implementation markedly increased compliance with recommendations aimed at protecting high-risk neonates,” Dr. Shah told conference participants. “There will always be a small subset of parents who will refuse, no matter what. But we can get to many parents who are willing to take the shots.” He added that this type of program is highly replicable and could be quickly implemented in any family-centered NICU.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study reported by Dr. Vivencio Barrios at the annual meeting of the European Society of Hypertension.

Regression of electrocardiographic left ventricular hypertrophy (LVH) has been shown to improve the prognosis of hypertensive patients in several recently published controlled randomized trials, “but information on LVH regression in clinical practice has been very scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios conducted an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The investigators assessed LVH via electrocardiography, using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The investigators had the option of adding on other antihypertensive medications if the pressure values did not drop into the target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Dr. Barrios noted that 19% of those with LVH showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec, and the QRS interval was reduced by 2.95 msec; both indicate a trend away from LVH.

The Spanish investigators found that the VDP changes were larger in older patients, and in those with higher baseline VDP values, suggesting that candesartan offers the greatest potential benefit in those patients with the most advanced LVH.

Earlier detection and reversal of LVH has become a burning concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the two most important risk factors.

“We have data from the 1970s showing that if you do a standard ECG and there are signs of LVH, the risk [of heart failure] is two- to fivefold greater. You really need to do the ECGs, look for LVH, and treat much more intensively,” said Dr. Thomas Kahan of the cardiology section at Karolinska Institutet, Stockholm, who chaired a session on heart failure prevention.

“There's a stepwise progression from hypertension to LVH to heart failure. My impression is that we have a lot of risk markers, but we tend not to use them in clinical practice.” He insisted that physicians increase their level of scrutiny for LVH whenever they do ECGs or echocardiograms.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study reported by Dr. Vivencio Barrios at the annual meeting of the European Society of Hypertension.

Regression of electrocardiographic left ventricular hypertrophy (LVH) has been shown to improve the prognosis of hypertensive patients in several recently published controlled randomized trials, “but information on LVH regression in clinical practice has been very scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios conducted an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The investigators assessed LVH via electrocardiography, using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The investigators had the option of adding on other antihypertensive medications if the pressure values did not drop into the target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Dr. Barrios noted that 19% of those with LVH showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec, and the QRS interval was reduced by 2.95 msec; both indicate a trend away from LVH.

The Spanish investigators found that the VDP changes were larger in older patients, and in those with higher baseline VDP values, suggesting that candesartan offers the greatest potential benefit in those patients with the most advanced LVH.

Earlier detection and reversal of LVH has become a burning concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the two most important risk factors.

“We have data from the 1970s showing that if you do a standard ECG and there are signs of LVH, the risk [of heart failure] is two- to fivefold greater. You really need to do the ECGs, look for LVH, and treat much more intensively,” said Dr. Thomas Kahan of the cardiology section at Karolinska Institutet, Stockholm, who chaired a session on heart failure prevention.

“There's a stepwise progression from hypertension to LVH to heart failure. My impression is that we have a lot of risk markers, but we tend not to use them in clinical practice.” He insisted that physicians increase their level of scrutiny for LVH whenever they do ECGs or echocardiograms.

MADRID — Antihypertensive therapy with candesartan was shown to reverse left ventricular hypertrophy in a study reported by Dr. Vivencio Barrios at the annual meeting of the European Society of Hypertension.

Regression of electrocardiographic left ventricular hypertrophy (LVH) has been shown to improve the prognosis of hypertensive patients in several recently published controlled randomized trials, “but information on LVH regression in clinical practice has been very scarce,” said Dr. Barrios of the cardiology institute at Ramon y Cajal Hospital, Madrid.

Dr. Barrios conducted an open-label, 12-month study evaluating the impact of candesartan, an angiotensin-1 receptor blocker, on LVH in a real-world practice setting. The study involved 276 patients with uncontrolled essential hypertension. The mean blood pressure at baseline was 164/92 mm Hg. The patients' average age was 62 years, and 18% had diabetes.

The investigators assessed LVH via electrocardiography, using the Cornell voltage duration product (VDP) measurement, as well as QRS-segment duration. The baseline and posttreatment ECG tracings were assessed by a single lab, by a blinded investigator. At the outset of the study, 24% of the patients had LVH.

Patients were treated with candesartan 8 mg/day or 16 mg/day, with the objective of reaching pressures below 140/90 mm Hg for nondiabetics or 130/80 for diabetic patients. The investigators had the option of adding on other antihypertensive medications if the pressure values did not drop into the target ranges after several months.

At 12 months, the angiotensin-1 receptor blocker produced the expected degree of pressure reduction, decreasing the baseline mean values of 164/92 mm Hg to 143/84 mm Hg. It also produced a significant decrease in the prevalence of LVH. By the end of the study, 20% of the study population had ECG evidence of LVH, down from 24% at the outset. Dr. Barrios noted that 19% of those with LVH showed observable LVH regressions.

On average, the VDP was significantly reduced by 132.88 mm × msec, and the QRS interval was reduced by 2.95 msec; both indicate a trend away from LVH.

The Spanish investigators found that the VDP changes were larger in older patients, and in those with higher baseline VDP values, suggesting that candesartan offers the greatest potential benefit in those patients with the most advanced LVH.

Earlier detection and reversal of LVH has become a burning concern among hypertension specialists who hope that primary care physicians will join them in their efforts to prevent heart failure, for which advanced age and presence of LVH are the two most important risk factors.

“We have data from the 1970s showing that if you do a standard ECG and there are signs of LVH, the risk [of heart failure] is two- to fivefold greater. You really need to do the ECGs, look for LVH, and treat much more intensively,” said Dr. Thomas Kahan of the cardiology section at Karolinska Institutet, Stockholm, who chaired a session on heart failure prevention.

“There's a stepwise progression from hypertension to LVH to heart failure. My impression is that we have a lot of risk markers, but we tend not to use them in clinical practice.” He insisted that physicians increase their level of scrutiny for LVH whenever they do ECGs or echocardiograms.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging.

He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen.

What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between.”

What Can Health Care Learn From 401(k) Retirement Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. “I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference.”

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging.

He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen.

What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between.”

What Can Health Care Learn From 401(k) Retirement Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. “I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference.”

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging.

He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen.

What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between.”

What Can Health Care Learn From 401(k) Retirement Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. “I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference.”

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug (brand name Rasilez) is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150-mg aliskiren plus 5-mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0 and 10.7 mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients—55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination—underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin.

About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.”This was definitely not expected,” said Dr. Uresin. Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug (brand name Rasilez) is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150-mg aliskiren plus 5-mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0 and 10.7 mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients—55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination—underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin.

About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.”This was definitely not expected,” said Dr. Uresin. Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug (brand name Rasilez) is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150-mg aliskiren plus 5-mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0 and 10.7 mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients—55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination—underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin.

About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.”This was definitely not expected,” said Dr. Uresin. Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.