Jane Salodof MacNeil

SANTA ANA PUEBLO, N.M. – Aripiprazole should be considered for treatment of prolonged delirium, especially in patients with significant medical comorbidity, Dr. David Straker said at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Straker reported that the atypical antipsychotic reduced Delirium Rating Scale-revised-98 scores by 50% or more for 12 of 14 patients in a case series at New York Presbyterian Hospital, Columbia University Medical Center in New York City. The average score fell from 25.1 to 9.4.

All 14 patients improved, according to Dr. Straker, now at Zucker Hillside Hospital, Long Island Jewish Medical Center, Glen Oaks, N.Y. Eight came off restraints, and six no longer required constant observation after treatment with aripiprazole (Abilify). “In this small case series, aripiprazole appeared to be safe and effective. Adverse side effects were minimal,” Dr. Straker said. “Aripiprazole may have a role in hypoactive, lethargic patients with delirium.”

Dr. Lawson R. Wulsin of the University of Cincinnati called the study much needed and urged that its results be shared with hospital physicians who are not psychiatrists. He said he hoped the “promising findings” would provide the impetus for an open-label or randomized clinical trial.

In an interview at the meeting, Dr. Straker said his schedule since completing a fellowship at Columbia did not allow him to organize a trial, but that one was needed, and he would like to participate. “I think it should be studied further,” he said. “Right now there is no drug that is Food and Drug Administration-approved for delirium. There is nothing out there.” Dr. Straker said he studied aripiprazole because it had not been tried for delirium and had the potential for fewer side effects than other antipsychotic agents. Hospital patients who develop delirium often have comorbidities, he said, presenting chart reviews of 21 patients with delirium.

In this unpublished series, he found that most had cardiovascular problems before treatment. Two-thirds had impaired glycemic control. Dyslipidemia, hypertension, and metabolic syndrome occurred in more than half. Nine were obese, and eight had QTc intervals greater than 450 milliseconds on their electrocardiograms.

“You might say in acute patients, why worry?” he challenged the audience, answering, “After delirium is resolved, we don't abruptly stop antipsychotics.” Many patients stay on antipsychotic medication long after leaving the hospital, according to Dr. Straker. Patients released to nursing homes may be kept on a drug for months before being reevaluated.

The 14 patients in the case series (eight women and six men) were 71 years old on average and had a mean score on the Clinical Global Impression (CGI) severity scale of 5.2. Dyslipidemia, hyperglycemia, hypertension, and metabolic syndrome were reported in more than half before treatment. Cardiovascular disease, cerebrovascular disease, and QTc prolongations were also reported but in a smaller proportion.

Dr. Straker said the etiology of delirium was varied. He cited medications, infection, surgery, dementia, and HIV as underlying factors. The average aripiprazole dose was 8.9 mg per day, with only two patients receiving more than 10 mg per day. Patients reached maximum treatment response in an average of 6.2 days, with a mean improvement of 2.1 on the CGI scale. Four patients had been given haloperidol during the first few days of their delirium.

Two patients died after discontinuing aripiprazole: one of sepsis, the other of respiratory failure after pneumonia. Among the adverse events that did not occur, Dr. Straker listed torsades de pointes, cardiac and cerebrovascular events, diabetic ketoacidosis, significant extrapyramidal effects or akathisia, dysphagia, and falls. He reported that average QTc decreased, with just one patient having it rise beyond 450 milliseconds. Fasting blood glucose fell from 176.1 mg/dL to 116.2 mg/dL, and no patient had a worsening of glycemic control.

SANTA ANA PUEBLO, N.M. – Aripiprazole should be considered for treatment of prolonged delirium, especially in patients with significant medical comorbidity, Dr. David Straker said at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Straker reported that the atypical antipsychotic reduced Delirium Rating Scale-revised-98 scores by 50% or more for 12 of 14 patients in a case series at New York Presbyterian Hospital, Columbia University Medical Center in New York City. The average score fell from 25.1 to 9.4.

All 14 patients improved, according to Dr. Straker, now at Zucker Hillside Hospital, Long Island Jewish Medical Center, Glen Oaks, N.Y. Eight came off restraints, and six no longer required constant observation after treatment with aripiprazole (Abilify). “In this small case series, aripiprazole appeared to be safe and effective. Adverse side effects were minimal,” Dr. Straker said. “Aripiprazole may have a role in hypoactive, lethargic patients with delirium.”

Dr. Lawson R. Wulsin of the University of Cincinnati called the study much needed and urged that its results be shared with hospital physicians who are not psychiatrists. He said he hoped the “promising findings” would provide the impetus for an open-label or randomized clinical trial.

In an interview at the meeting, Dr. Straker said his schedule since completing a fellowship at Columbia did not allow him to organize a trial, but that one was needed, and he would like to participate. “I think it should be studied further,” he said. “Right now there is no drug that is Food and Drug Administration-approved for delirium. There is nothing out there.” Dr. Straker said he studied aripiprazole because it had not been tried for delirium and had the potential for fewer side effects than other antipsychotic agents. Hospital patients who develop delirium often have comorbidities, he said, presenting chart reviews of 21 patients with delirium.

In this unpublished series, he found that most had cardiovascular problems before treatment. Two-thirds had impaired glycemic control. Dyslipidemia, hypertension, and metabolic syndrome occurred in more than half. Nine were obese, and eight had QTc intervals greater than 450 milliseconds on their electrocardiograms.

“You might say in acute patients, why worry?” he challenged the audience, answering, “After delirium is resolved, we don't abruptly stop antipsychotics.” Many patients stay on antipsychotic medication long after leaving the hospital, according to Dr. Straker. Patients released to nursing homes may be kept on a drug for months before being reevaluated.

The 14 patients in the case series (eight women and six men) were 71 years old on average and had a mean score on the Clinical Global Impression (CGI) severity scale of 5.2. Dyslipidemia, hyperglycemia, hypertension, and metabolic syndrome were reported in more than half before treatment. Cardiovascular disease, cerebrovascular disease, and QTc prolongations were also reported but in a smaller proportion.

Dr. Straker said the etiology of delirium was varied. He cited medications, infection, surgery, dementia, and HIV as underlying factors. The average aripiprazole dose was 8.9 mg per day, with only two patients receiving more than 10 mg per day. Patients reached maximum treatment response in an average of 6.2 days, with a mean improvement of 2.1 on the CGI scale. Four patients had been given haloperidol during the first few days of their delirium.

Two patients died after discontinuing aripiprazole: one of sepsis, the other of respiratory failure after pneumonia. Among the adverse events that did not occur, Dr. Straker listed torsades de pointes, cardiac and cerebrovascular events, diabetic ketoacidosis, significant extrapyramidal effects or akathisia, dysphagia, and falls. He reported that average QTc decreased, with just one patient having it rise beyond 450 milliseconds. Fasting blood glucose fell from 176.1 mg/dL to 116.2 mg/dL, and no patient had a worsening of glycemic control.

SANTA ANA PUEBLO, N.M. – Aripiprazole should be considered for treatment of prolonged delirium, especially in patients with significant medical comorbidity, Dr. David Straker said at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Straker reported that the atypical antipsychotic reduced Delirium Rating Scale-revised-98 scores by 50% or more for 12 of 14 patients in a case series at New York Presbyterian Hospital, Columbia University Medical Center in New York City. The average score fell from 25.1 to 9.4.

All 14 patients improved, according to Dr. Straker, now at Zucker Hillside Hospital, Long Island Jewish Medical Center, Glen Oaks, N.Y. Eight came off restraints, and six no longer required constant observation after treatment with aripiprazole (Abilify). “In this small case series, aripiprazole appeared to be safe and effective. Adverse side effects were minimal,” Dr. Straker said. “Aripiprazole may have a role in hypoactive, lethargic patients with delirium.”

Dr. Lawson R. Wulsin of the University of Cincinnati called the study much needed and urged that its results be shared with hospital physicians who are not psychiatrists. He said he hoped the “promising findings” would provide the impetus for an open-label or randomized clinical trial.

In an interview at the meeting, Dr. Straker said his schedule since completing a fellowship at Columbia did not allow him to organize a trial, but that one was needed, and he would like to participate. “I think it should be studied further,” he said. “Right now there is no drug that is Food and Drug Administration-approved for delirium. There is nothing out there.” Dr. Straker said he studied aripiprazole because it had not been tried for delirium and had the potential for fewer side effects than other antipsychotic agents. Hospital patients who develop delirium often have comorbidities, he said, presenting chart reviews of 21 patients with delirium.

In this unpublished series, he found that most had cardiovascular problems before treatment. Two-thirds had impaired glycemic control. Dyslipidemia, hypertension, and metabolic syndrome occurred in more than half. Nine were obese, and eight had QTc intervals greater than 450 milliseconds on their electrocardiograms.

“You might say in acute patients, why worry?” he challenged the audience, answering, “After delirium is resolved, we don't abruptly stop antipsychotics.” Many patients stay on antipsychotic medication long after leaving the hospital, according to Dr. Straker. Patients released to nursing homes may be kept on a drug for months before being reevaluated.

The 14 patients in the case series (eight women and six men) were 71 years old on average and had a mean score on the Clinical Global Impression (CGI) severity scale of 5.2. Dyslipidemia, hyperglycemia, hypertension, and metabolic syndrome were reported in more than half before treatment. Cardiovascular disease, cerebrovascular disease, and QTc prolongations were also reported but in a smaller proportion.

Dr. Straker said the etiology of delirium was varied. He cited medications, infection, surgery, dementia, and HIV as underlying factors. The average aripiprazole dose was 8.9 mg per day, with only two patients receiving more than 10 mg per day. Patients reached maximum treatment response in an average of 6.2 days, with a mean improvement of 2.1 on the CGI scale. Four patients had been given haloperidol during the first few days of their delirium.

Two patients died after discontinuing aripiprazole: one of sepsis, the other of respiratory failure after pneumonia. Among the adverse events that did not occur, Dr. Straker listed torsades de pointes, cardiac and cerebrovascular events, diabetic ketoacidosis, significant extrapyramidal effects or akathisia, dysphagia, and falls. He reported that average QTc decreased, with just one patient having it rise beyond 450 milliseconds. Fasting blood glucose fell from 176.1 mg/dL to 116.2 mg/dL, and no patient had a worsening of glycemic control.

SANTA ANA PUEBLO, N.M. – Only 4% of 164 adolescents who tried to kill themselves left a suicide note, according to a retrospective, single-institution study reported at the annual meeting of the Academy of Psychosomatic Medicine.

“This situational profile points toward rash, emotionally charged attempts, marked by a sense of immediacy,” the researchers concluded in a poster presented by Kelly Fiore, a fourth-year medical student at Robert Wood Johnson Medical School in Piscataway, N.J.

Because few suicide attempts appeared to be premeditated, Ms. Fiore and her coinvestigators from the department of psychiatry recommended that interventions for teenagers address impulsivity.

Along with programs offering “behavioral strategies for affect management and impulse control,” Ms. Fiore wrote that youngsters in high-risk groups should be made aware of emergency hotlines, drop-in centers, and other crisis resources.

The investigators reviewed charts of all adolescents admitted to a tertiary care center after confirmed suicide attempts during a 46-month period.

The adolescents ranged in age from 10 to 18 years (median 15 years) and came from a diverse population (59% white, 22% Hispanic, 16% black, 3% other). Most attended school and lived at home, which was described in nearly all cases as “conflictual.”

More than two-thirds (69%) had mood disorders. Nearly half (45%) had made a previous suicide attempt.

Overdose was the predominant method, used in 81% of attempts. Cutting was the next most common method (14%), followed by hanging, multiple methods, jumping from a height, and carbon monoxide exposure.

The leading agents for overdose were prescription drugs (24%), acetaminophen (22%), and aspirin (15%). A small group (3%) used cleaning products. Just 2% overdosed on alcohol or an opiate.

Females accounted for a large majority (79%) of attempters in the study, which also turned up gender differences. “There seems to be a different profile between female and male attempters,” Ms. Fiore said in an interview.

Suicidal boys were significantly more likely to be diagnosed with a conduct disorder and have a substance abuse problem. They were more likely to use violent methods, such as cutting, and to try to overdose on cleaning products. They were less likely, however, “to endorse familial discord … as playing a role in their suicide attempts.”

Overdose was the preferred method for girls, who were also more likely to use aspirin.

The poster reported that 77 youngsters were referred to an inpatient psychiatric facility, 72 to a psychiatric emergency room, and 12 to outpatient treatment.

No referral was made in two cases, including one teenager who refused further intervention.

Ms. Fiore said all the adolescents were admitted to the tertiary care center–some to the emergency department for 24-hour observation and others for longer periods of time. The psychiatric emergency department (called Acute Psychiatric Services) is a separate facility about 7 miles from the hospital, she said.

“Patients are sometimes sent there after being medically cleared by the regular ER,” Ms. Fiore said.

“A psych ER is specific to acute psych issues, and in this case, is completely separate from the medical facilities.”

SANTA ANA PUEBLO, N.M. – Only 4% of 164 adolescents who tried to kill themselves left a suicide note, according to a retrospective, single-institution study reported at the annual meeting of the Academy of Psychosomatic Medicine.

“This situational profile points toward rash, emotionally charged attempts, marked by a sense of immediacy,” the researchers concluded in a poster presented by Kelly Fiore, a fourth-year medical student at Robert Wood Johnson Medical School in Piscataway, N.J.

Because few suicide attempts appeared to be premeditated, Ms. Fiore and her coinvestigators from the department of psychiatry recommended that interventions for teenagers address impulsivity.

Along with programs offering “behavioral strategies for affect management and impulse control,” Ms. Fiore wrote that youngsters in high-risk groups should be made aware of emergency hotlines, drop-in centers, and other crisis resources.

The investigators reviewed charts of all adolescents admitted to a tertiary care center after confirmed suicide attempts during a 46-month period.

The adolescents ranged in age from 10 to 18 years (median 15 years) and came from a diverse population (59% white, 22% Hispanic, 16% black, 3% other). Most attended school and lived at home, which was described in nearly all cases as “conflictual.”

More than two-thirds (69%) had mood disorders. Nearly half (45%) had made a previous suicide attempt.

Overdose was the predominant method, used in 81% of attempts. Cutting was the next most common method (14%), followed by hanging, multiple methods, jumping from a height, and carbon monoxide exposure.

The leading agents for overdose were prescription drugs (24%), acetaminophen (22%), and aspirin (15%). A small group (3%) used cleaning products. Just 2% overdosed on alcohol or an opiate.

Females accounted for a large majority (79%) of attempters in the study, which also turned up gender differences. “There seems to be a different profile between female and male attempters,” Ms. Fiore said in an interview.

Suicidal boys were significantly more likely to be diagnosed with a conduct disorder and have a substance abuse problem. They were more likely to use violent methods, such as cutting, and to try to overdose on cleaning products. They were less likely, however, “to endorse familial discord … as playing a role in their suicide attempts.”

Overdose was the preferred method for girls, who were also more likely to use aspirin.

The poster reported that 77 youngsters were referred to an inpatient psychiatric facility, 72 to a psychiatric emergency room, and 12 to outpatient treatment.

No referral was made in two cases, including one teenager who refused further intervention.

Ms. Fiore said all the adolescents were admitted to the tertiary care center–some to the emergency department for 24-hour observation and others for longer periods of time. The psychiatric emergency department (called Acute Psychiatric Services) is a separate facility about 7 miles from the hospital, she said.

“Patients are sometimes sent there after being medically cleared by the regular ER,” Ms. Fiore said.

“A psych ER is specific to acute psych issues, and in this case, is completely separate from the medical facilities.”

SANTA ANA PUEBLO, N.M. – Only 4% of 164 adolescents who tried to kill themselves left a suicide note, according to a retrospective, single-institution study reported at the annual meeting of the Academy of Psychosomatic Medicine.

“This situational profile points toward rash, emotionally charged attempts, marked by a sense of immediacy,” the researchers concluded in a poster presented by Kelly Fiore, a fourth-year medical student at Robert Wood Johnson Medical School in Piscataway, N.J.

Because few suicide attempts appeared to be premeditated, Ms. Fiore and her coinvestigators from the department of psychiatry recommended that interventions for teenagers address impulsivity.

Along with programs offering “behavioral strategies for affect management and impulse control,” Ms. Fiore wrote that youngsters in high-risk groups should be made aware of emergency hotlines, drop-in centers, and other crisis resources.

The investigators reviewed charts of all adolescents admitted to a tertiary care center after confirmed suicide attempts during a 46-month period.

The adolescents ranged in age from 10 to 18 years (median 15 years) and came from a diverse population (59% white, 22% Hispanic, 16% black, 3% other). Most attended school and lived at home, which was described in nearly all cases as “conflictual.”

More than two-thirds (69%) had mood disorders. Nearly half (45%) had made a previous suicide attempt.

Overdose was the predominant method, used in 81% of attempts. Cutting was the next most common method (14%), followed by hanging, multiple methods, jumping from a height, and carbon monoxide exposure.

The leading agents for overdose were prescription drugs (24%), acetaminophen (22%), and aspirin (15%). A small group (3%) used cleaning products. Just 2% overdosed on alcohol or an opiate.

Females accounted for a large majority (79%) of attempters in the study, which also turned up gender differences. “There seems to be a different profile between female and male attempters,” Ms. Fiore said in an interview.

Suicidal boys were significantly more likely to be diagnosed with a conduct disorder and have a substance abuse problem. They were more likely to use violent methods, such as cutting, and to try to overdose on cleaning products. They were less likely, however, “to endorse familial discord … as playing a role in their suicide attempts.”

Overdose was the preferred method for girls, who were also more likely to use aspirin.

The poster reported that 77 youngsters were referred to an inpatient psychiatric facility, 72 to a psychiatric emergency room, and 12 to outpatient treatment.

No referral was made in two cases, including one teenager who refused further intervention.

Ms. Fiore said all the adolescents were admitted to the tertiary care center–some to the emergency department for 24-hour observation and others for longer periods of time. The psychiatric emergency department (called Acute Psychiatric Services) is a separate facility about 7 miles from the hospital, she said.

“Patients are sometimes sent there after being medically cleared by the regular ER,” Ms. Fiore said.

“A psych ER is specific to acute psych issues, and in this case, is completely separate from the medical facilities.”

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, explained in an interview at the meeting. “It's a cost-effective way to help people start treatment.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment. Over time, the collaboration took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit. Instruments included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” Dr. Dieperink said. “That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference.”

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend they cut back, and offer to arrange follow-up with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had had some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean score on the AUDIT-C was 6.5.

In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol on average 17.3 of the 30 days before they came to the clinic, consuming a mean of 9.5 drinks per day. After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, explained in an interview at the meeting. “It's a cost-effective way to help people start treatment.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment. Over time, the collaboration took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit. Instruments included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” Dr. Dieperink said. “That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference.”

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend they cut back, and offer to arrange follow-up with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had had some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean score on the AUDIT-C was 6.5.

In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol on average 17.3 of the 30 days before they came to the clinic, consuming a mean of 9.5 drinks per day. After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

SANTA ANA PUEBLO, N.M. — A hepatitis C virus clinic in Minnesota helped alcoholic patients become eligible for antiviral therapy by integrating alcohol screening and a behavioral intervention into medical care.

Nearly half (47%) of 47 new patients flagged for “severe alcohol use” reduced their drinking after physicians warned that it could make them ineligible for antiviral treatment, according to a poster presented by Dr. Eric W. Dieperink at the annual meeting of the Academy of Psychosomatic Medicine.

Some relapsed after this initial brief intervention. But nearly two-thirds (62%) subsequently reduced their alcohol use by participating in an on-site program with a psychiatric clinical nurse-specialist. And 17 patients (36%) achieved long-term abstinence and were offered antiviral therapy.

“There was a big effect of just having the [clinic staff] address alcohol use at the initial visit,” Dr. Dieperink, a psychiatrist at the University of Minnesota, explained in an interview at the meeting. “It's a cost-effective way to help people start treatment.”

Standard practice is to refer patients to a substance abuse program and tell them to “come back in 6 months when you are sober,” Dr. Dieperink said. He and his colleagues reasoned that people facing medical consequences would be more likely to respond to an alcohol intervention than would a general population. They decided, therefore, to engage patients medically and psychiatrically at the clinic.

Gastroenterologists at the Veterans Affairs Medical Center in Minneapolis invited psychiatrists into the clinic about 6 years ago, Dr. Dieperink said, citing concerns about depression as a side effect of interferon treatment. Over time, the collaboration took on other psychiatric disorders in an ongoing attempt to address barriers to treatment.

“Alcohol is considered a barrier to treatment for hepatitis C and also hastens the fibrosis related to liver disease. So there were two reasons to address it,” Dr. Dieperink said.

The intervention began with all patients being screened for psychiatric problems at their initial clinic visit. Instruments included the Alcohol Use Disorders Identification Test-C (AUDIT-C), which the psychiatric clinical nurse-specialist reviewed. The nurse-specialist subsequently met with patients who scored above 4 on the AUDIT-C or were referred by staff members for alcohol problems.

A cornerstone of the program was having gastroenterologists discuss alcohol each time they saw the patients. “At every visit, the hepatology folks continued to address alcohol,” Dr. Dieperink said. “That was the synergistic—constantly attending to the alcohol use at every visit—which we think made a big difference.”

He described the approach as matter of fact. Physicians would compare the patients' drinking with standards and norms for their age groups, recommend they cut back, and offer to arrange follow-up with the nurse.

The nurse intervention also was brief, he said, lasting 4–10 sessions, during which the nurse would “flexibly engage” the patients. Most patients had had some alcohol treatment in the past, according to Dr. Dieperink, and many did not want to be referred to another treatment program.

The poster described the 47 veterans as 51 years old on average. Of the 47 patients, 32 were diagnosed with alcohol dependence and 15 with alcohol abuse. Most (82%) were hepatitis C genotype 1. Nearly two-thirds had stage II or higher liver fibrosis. The mean score on the AUDIT-C was 6.5.

In addition, 24 patients (51%) self-reported use of cannabis, cocaine, or methamphetamine during the previous 6 months.

The patients had consumed alcohol on average 17.3 of the 30 days before they came to the clinic, consuming a mean of 9.5 drinks per day. After the initial brief intervention, the average number of drinking days per month fell to 10.6 and the average number of drinks consumed per day declined to 5.5.

Ten patients refused referral to the nurse-specialist. Among those who participated in the follow-up program, the average number of drinking days fell to 8.8 after 3–18 months and the number of drinks per day to 3.8 after 5–22 months.

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

PARK CITY, UTAH — Make sure that patients treated with nonablative lasers have reasonable expectations of what their skin will look like after rejuvenation therapy, Dr. Thomas E. Rohrer said at a symposium sponsored by the American Society of Ophthalmic Plastic and Reconstructive Surgery.

"Improvement is gradual and subtle, but it is real," Dr. Rohrer said, warning that patients expecting dramatic skin changes after each treatment could be disappointed.

Dr. Rohrer, a Mohs and dermatologic surgeon in Chestnut Hill, Mass., described nonablative skin rejuvenation as one of the fastest-growing areas of dermatologic surgery, with a 60% increase in 2 years' time.

"What we're talking about is creating a controlled dermal injury—a thermal injury 100–400 microns deep—to get collagen remodeling," he said at the meeting, which was also sponsored by the American Society for Dermatologic Surgery and the American Academy of Facial Plastic and Reconstructive Surgery.

Infrared lasers heat the dermis to get this effect, according to Dr. Rohrer. Heating the dermis results in a wound-healing response: inflammation, proliferation, and remodeling. The process can take months.

"You are effectively changing the dermis without affecting the epidermis," he said.

The infrared lasers available today vary only slightly and have produced similar outcomes in the studies reported so far. The amount of improvement varies from patient to patient, but most do improve, he noted.

Despite the use of anesthetic creams and cryogenic cooling, infrared laser treatment does hurt, he said. In his practice, attempts to limit pain have involved vibratory anesthesia, the application of anesthetic cream for about an hour, and the Zimmer cooler, which he said was the most effective.

Multiple tactile pass techniques—going over the same area twice at a lower fluence—also can reduce pain. "It hurts a little bit less at each pass, but you are doubling treatment time," he said, "so I am not sure how effective or practical that is going to be."

In what may be the longest study of a nonablative therapy, patients were followed for 35 months. The investigators found that improvement peaked at 6 months after the last treatment, but at 35 months patients still had almost 30% improvement in the texture of the skin, Dr. Rohrer said.

Many patients are combining nonablative lasers with botulinum toxin treatments. Because Botox is known to work, this has raised a question as to the role of the lasers in any improvement that is seen.

"Certainly Botox works faster than nonablative [therapy] and jump starts" rejuvenation, he said, showing photographs of patients whose improvements lasted months after the Botox effect would have worn off.

He recommended infrared lasers for the treatment of scars, but again cautioned that patients have to understand that improvement will require multiple treatments over a long time. "We should let our patients know they cannot expect a whole lot after just three treatments," he said.

Visible light lasers are another nonablative option that has improved pigment and vasculature. They also have produced histologic changes and changes in skin texture over time.

Intense pulsed light systems deliver a broad band of wavelengths, some of which help with pigment while others increase collagen, according to Dr. Rohrer. He said that he is preparing to publish a series of studies on this option.

Photomodulation light-emitting diodes offer another nonablative therapy that has produced improvement in most patients studied. "Improvement is subtle, but it is there if you measure it," he said.

Dr. Rohrer disclosed that he receives compensation for research from laser manufacturers Candela Corp., Laserscope, and Palomar Medical Technologies Inc.

"We should let our patients know they cannot expect a whole lot after just three treatments." DR. ROHRER

PARK CITY, UTAH — Small fiber neuropathy plays an important role in erythromelalgia, a rare and mysterious skin condition characterized by red, hot, and painful extremities, Dr. Mark D.P. Davis said at a clinical dermatology seminar sponsored by Medicis.

Thermoregulatory sweat testing and other neurologic evaluations of 32 erythromelalgia patients showed that people with the syndrome do not sweat in all or part of their bodies, he reported.

Dr. Davis, dermatology professor at the Mayo Clinic in Rochester, Minn., illustrated his talk with diagrams of various patterns of impaired sweating, from the new study. These included regional and distal, multifocal, global, and distal areas where the patients did not sweat.

“Sweat glands are innervated by small nerves,” he explained. “If they are dysfunctional, you may not sweat normally.”

Recent papers documenting SCN9A mutations in an inherited form of erythromelalgia confirmed the neuropathic basis of the condition (J. Med. Genet. 2004;41:171–4 and J. Invest. Dermatol. 2005;124:1333–8). “Neurologists are now saying this is the prototype of a painful neuropathy,” he said.

Dr. Davis described nerves and the skin as “an underinvestigated area of dermatology that needs to be investigated” and suggested that the combination “may explain some of our unexplained conditions.”

The prevalence of neuropathy and vasculopathy in erythromelalgia suggests that “in other flushing conditions it is conceivable that the same thing is going on,” he said. He cited leprosy and brachioradial pruritus as infectious and itching skin disorders, respectively, that involve both nerves and skin.

The first description of erythromelalgia was published in 1878, Dr. Davis said. In 2000, he and his colleagues presented a natural history of the disorder based on 168 patients seen between 1970 and 1994 at the Mayo Clinic (Arch. Dermatol. 2000;136:330–6). None had other diagnoses to explain their symptoms. The patients' average age was 56 years, with a wide range of 5–91 years and average follow-up of 9 years. The majority, 72%, were female.

Two-thirds of the patients presented with abnormalities in the affected limb. These included redness (49%), acrocyanosis (10%), ulcers (6%), and reticular skin pattern (5%).

Half the patients were unable to walk long distances or stand for long periods. About 14% were unable to keep a job and 13% were unable to drive. Functional impairment was so debilitating that 3% required a wheelchair and 2% were bed-bound.

The investigators obtained Short-Form 36 Health Survey questionnaires from 98 patients. They scored poorly on all eight domains in the survey. The worst scores were for physical health and physical functioning.

All told, the patients had tried 84 different treatments with varying degrees of success. Nothing worked consistently, and the underlying cause of the condition remained elusive.

Dr. Davis cited several theories: excessive vasodilation causing high blood flow, increased local metabolism leading to hypoxia and tissue damage, and a platelet disorder with microvascular aspects.

In 2003, he and his colleagues offered a fourth, suggesting that erythromelalgia is associated with neuropathy and vasculopathy and possibly increased local cellular metabolism. They based their findings on 67 patients evaluated from 1999 through 2001 (Arch. Dermatol. 2003;139:1337–43).

Dr. Davis said that most patients in this study had neuropathy: Seventy-eight percent had small fiber neuropathy and 36% had abnormal electromyography studies. Among 57 patients for whom autonomic reflex screening was done, 49 (86%) had abnormalities. The most common abnormality was reduced or abnormal sweat production in sudomotor studies.

'Sweat glands are innervated by small nerves. If they are dysfunctional, you may not sweat normally.' DR. DAVIS

PARK CITY, UTAH — Small fiber neuropathy plays an important role in erythromelalgia, a rare and mysterious skin condition characterized by red, hot, and painful extremities, Dr. Mark D.P. Davis said at a clinical dermatology seminar sponsored by Medicis.

Thermoregulatory sweat testing and other neurologic evaluations of 32 erythromelalgia patients showed that people with the syndrome do not sweat in all or part of their bodies, he reported.

Dr. Davis, dermatology professor at the Mayo Clinic in Rochester, Minn., illustrated his talk with diagrams of various patterns of impaired sweating, from the new study. These included regional and distal, multifocal, global, and distal areas where the patients did not sweat.

“Sweat glands are innervated by small nerves,” he explained. “If they are dysfunctional, you may not sweat normally.”

Recent papers documenting SCN9A mutations in an inherited form of erythromelalgia confirmed the neuropathic basis of the condition (J. Med. Genet. 2004;41:171–4 and J. Invest. Dermatol. 2005;124:1333–8). “Neurologists are now saying this is the prototype of a painful neuropathy,” he said.

Dr. Davis described nerves and the skin as “an underinvestigated area of dermatology that needs to be investigated” and suggested that the combination “may explain some of our unexplained conditions.”

The prevalence of neuropathy and vasculopathy in erythromelalgia suggests that “in other flushing conditions it is conceivable that the same thing is going on,” he said. He cited leprosy and brachioradial pruritus as infectious and itching skin disorders, respectively, that involve both nerves and skin.

The first description of erythromelalgia was published in 1878, Dr. Davis said. In 2000, he and his colleagues presented a natural history of the disorder based on 168 patients seen between 1970 and 1994 at the Mayo Clinic (Arch. Dermatol. 2000;136:330–6). None had other diagnoses to explain their symptoms. The patients' average age was 56 years, with a wide range of 5–91 years and average follow-up of 9 years. The majority, 72%, were female.

Two-thirds of the patients presented with abnormalities in the affected limb. These included redness (49%), acrocyanosis (10%), ulcers (6%), and reticular skin pattern (5%).

Half the patients were unable to walk long distances or stand for long periods. About 14% were unable to keep a job and 13% were unable to drive. Functional impairment was so debilitating that 3% required a wheelchair and 2% were bed-bound.

The investigators obtained Short-Form 36 Health Survey questionnaires from 98 patients. They scored poorly on all eight domains in the survey. The worst scores were for physical health and physical functioning.

All told, the patients had tried 84 different treatments with varying degrees of success. Nothing worked consistently, and the underlying cause of the condition remained elusive.

Dr. Davis cited several theories: excessive vasodilation causing high blood flow, increased local metabolism leading to hypoxia and tissue damage, and a platelet disorder with microvascular aspects.

In 2003, he and his colleagues offered a fourth, suggesting that erythromelalgia is associated with neuropathy and vasculopathy and possibly increased local cellular metabolism. They based their findings on 67 patients evaluated from 1999 through 2001 (Arch. Dermatol. 2003;139:1337–43).

Dr. Davis said that most patients in this study had neuropathy: Seventy-eight percent had small fiber neuropathy and 36% had abnormal electromyography studies. Among 57 patients for whom autonomic reflex screening was done, 49 (86%) had abnormalities. The most common abnormality was reduced or abnormal sweat production in sudomotor studies.

'Sweat glands are innervated by small nerves. If they are dysfunctional, you may not sweat normally.' DR. DAVIS

PARK CITY, UTAH — Small fiber neuropathy plays an important role in erythromelalgia, a rare and mysterious skin condition characterized by red, hot, and painful extremities, Dr. Mark D.P. Davis said at a clinical dermatology seminar sponsored by Medicis.

Thermoregulatory sweat testing and other neurologic evaluations of 32 erythromelalgia patients showed that people with the syndrome do not sweat in all or part of their bodies, he reported.

Dr. Davis, dermatology professor at the Mayo Clinic in Rochester, Minn., illustrated his talk with diagrams of various patterns of impaired sweating, from the new study. These included regional and distal, multifocal, global, and distal areas where the patients did not sweat.

“Sweat glands are innervated by small nerves,” he explained. “If they are dysfunctional, you may not sweat normally.”

Recent papers documenting SCN9A mutations in an inherited form of erythromelalgia confirmed the neuropathic basis of the condition (J. Med. Genet. 2004;41:171–4 and J. Invest. Dermatol. 2005;124:1333–8). “Neurologists are now saying this is the prototype of a painful neuropathy,” he said.

Dr. Davis described nerves and the skin as “an underinvestigated area of dermatology that needs to be investigated” and suggested that the combination “may explain some of our unexplained conditions.”

The prevalence of neuropathy and vasculopathy in erythromelalgia suggests that “in other flushing conditions it is conceivable that the same thing is going on,” he said. He cited leprosy and brachioradial pruritus as infectious and itching skin disorders, respectively, that involve both nerves and skin.

The first description of erythromelalgia was published in 1878, Dr. Davis said. In 2000, he and his colleagues presented a natural history of the disorder based on 168 patients seen between 1970 and 1994 at the Mayo Clinic (Arch. Dermatol. 2000;136:330–6). None had other diagnoses to explain their symptoms. The patients' average age was 56 years, with a wide range of 5–91 years and average follow-up of 9 years. The majority, 72%, were female.

Two-thirds of the patients presented with abnormalities in the affected limb. These included redness (49%), acrocyanosis (10%), ulcers (6%), and reticular skin pattern (5%).

Half the patients were unable to walk long distances or stand for long periods. About 14% were unable to keep a job and 13% were unable to drive. Functional impairment was so debilitating that 3% required a wheelchair and 2% were bed-bound.

The investigators obtained Short-Form 36 Health Survey questionnaires from 98 patients. They scored poorly on all eight domains in the survey. The worst scores were for physical health and physical functioning.

All told, the patients had tried 84 different treatments with varying degrees of success. Nothing worked consistently, and the underlying cause of the condition remained elusive.

Dr. Davis cited several theories: excessive vasodilation causing high blood flow, increased local metabolism leading to hypoxia and tissue damage, and a platelet disorder with microvascular aspects.

In 2003, he and his colleagues offered a fourth, suggesting that erythromelalgia is associated with neuropathy and vasculopathy and possibly increased local cellular metabolism. They based their findings on 67 patients evaluated from 1999 through 2001 (Arch. Dermatol. 2003;139:1337–43).

Dr. Davis said that most patients in this study had neuropathy: Seventy-eight percent had small fiber neuropathy and 36% had abnormal electromyography studies. Among 57 patients for whom autonomic reflex screening was done, 49 (86%) had abnormalities. The most common abnormality was reduced or abnormal sweat production in sudomotor studies.

'Sweat glands are innervated by small nerves. If they are dysfunctional, you may not sweat normally.' DR. DAVIS

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Reporting growing concern about the risks faced by professional athletes, he cited the illnesses of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January.

An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list twice during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants, while he battled a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Describing the death as tragic, Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players (9%) had MRSA infections during the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

While the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find methicillin-susceptible S. aureus bacteria in whirlpools and taping gel and in 35 of 84 nasal swabs (42%) taken from players and staff members.

“This study is particularly scary,” Mr. Donohue said at the meeting, which was sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes in team sports have many risk factors for MRSA infections, according to Mr. Donohue. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population, which receives 0.5 prescriptions per year. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Yankee manager Joe Torre added in an interview at the meeting, “With all the players so close to each other physically, you are always concerned about something. Our ball club—it's only because of Steve and Gene [head athletic trainer Eugene Monaghan]—if there is ever a danger whether it be a rash or conjunctivitis, they make sure they separate that player from the rest of the team, because they understand how dangerous [the threat of infection] could be.”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant. “At any level of sports you have to think about it,” said Dr. Rigel, a program director of the conference.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Reporting growing concern about the risks faced by professional athletes, he cited the illnesses of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January.

An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list twice during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants, while he battled a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Describing the death as tragic, Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players (9%) had MRSA infections during the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

While the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find methicillin-susceptible S. aureus bacteria in whirlpools and taping gel and in 35 of 84 nasal swabs (42%) taken from players and staff members.

“This study is particularly scary,” Mr. Donohue said at the meeting, which was sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes in team sports have many risk factors for MRSA infections, according to Mr. Donohue. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population, which receives 0.5 prescriptions per year. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Yankee manager Joe Torre added in an interview at the meeting, “With all the players so close to each other physically, you are always concerned about something. Our ball club—it's only because of Steve and Gene [head athletic trainer Eugene Monaghan]—if there is ever a danger whether it be a rash or conjunctivitis, they make sure they separate that player from the rest of the team, because they understand how dangerous [the threat of infection] could be.”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant. “At any level of sports you have to think about it,” said Dr. Rigel, a program director of the conference.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

KAPALUA, HAWAII — Bars of soap and the sharing of personal items such as razors and towels have been banned from the New York Yankees clubhouse as a prophylaxis against the spread of methicillin-resistant Staphylococcus aureus infections.

“Baseball got put on notice in 2005 when two of its biggest stars got community-acquired staph infections,” said Steve Donohue, the team's assistant trainer, as he described these and other defensive measures to physicians at the Winter Clinical Dermatology Conference, Hawaii.

Reporting growing concern about the risks faced by professional athletes, he cited the illnesses of major league players Barry Bonds and Sammy Sosa, both of whom were waylaid last year, and the death of St. Louis Rams football announcer Jack Snow in January.

An abscess and staph infection on the bottom of Mr. Sosa's left foot put him on the Baltimore Orioles' disabled list twice during the 2005 season. Mr. Bonds played only 14 games for the San Francisco Giants, while he battled a bacterial infection after knee surgery.

Mr. Donohue said the Orioles management had infectious disease experts screen the Orioles clubhouse. He reported they found methicillin-resistant Staphylococcus aureus (MRSA) in two places: a carpet in front of Mr. Sosa's locker and ripped mats in the weight room.

Mr. Snow, 62, a former star player for the Rams, died after being hospitalized for several months with a staphylococcus infection. Describing the death as tragic, Mr. Donohue said he did not know whether it was caused by MRSA.

He noted, however, that a study reported 5 of 58 Rams players (9%) had MRSA infections during the 2003 season (N. Engl. J. Med. 2005;352:468–75). Three infections were recurrent, bringing the team's total number of MRSA infections to eight.

While the authors of the Rams study did not find MRSA in nasal or environmental samples, they did find methicillin-susceptible S. aureus bacteria in whirlpools and taping gel and in 35 of 84 nasal swabs (42%) taken from players and staff members.

“This study is particularly scary,” Mr. Donohue said at the meeting, which was sponsored by the Center for Bio-Medical Communication Inc.

Professional athletes in team sports have many risk factors for MRSA infections, according to Mr. Donohue. He listed turf burns and abrasions, shared equipment, body shaving (which he said has “increased sharply with the body-building and weight-lifting culture that has taken over baseball a little bit”), and frequent antibiotic use.

“In sports, players tend to be treated more aggressively, because they can't miss any time,” Mr. Donohue said.

In the football study, the investigators calculated that the Rams players received an average of 2.6 antimicrobial drug prescriptions per year, according to entries in a team pharmacy log during 2002. This was described as more than 10 times the rate for men of the same age in the general population, which receives 0.5 prescriptions per year. During the 2003 season, about 60% of Rams players surveyed reported they had taken or received antimicrobial drugs.

Mr. Donohue said the Yankee trainers have taken aggressive countermeasures to control and prevent MRSA infection from spreading in locker rooms at home or on the road. These include limiting the activity of anyone with an infection, providing alcohol-based hand rubs and antimicrobial soaps, banning the sharing of personal items such as towels and razors (which must be disposable), and being vigilant about surface and spa infection.

Players are educated about proper hand washing, he said, and trainers are alert to the risk from skin infections. Especially worrisome are situations when “a player complains of bug bites without seeing any bugs.”

The team may need to do more, Mr. Donohue speculated, as he threw out two questions for his physician audience to ponder: “One, should nasal swab surveys be part of our spring training routine physical? Two, if we have a player who is infected with MRSA, would you prophylactically use [mupirocin] Bactroban nasally on the rest of the team to try and prevent colonization?”

Yankee manager Joe Torre added in an interview at the meeting, “With all the players so close to each other physically, you are always concerned about something. Our ball club—it's only because of Steve and Gene [head athletic trainer Eugene Monaghan]—if there is ever a danger whether it be a rash or conjunctivitis, they make sure they separate that player from the rest of the team, because they understand how dangerous [the threat of infection] could be.”

Dr. Darrell S. Rigel, clinical professor at New York University, New York, also observed that MRSA is becoming a serious concern for the Yankee team, to which he is a dermatologic consultant. “At any level of sports you have to think about it,” said Dr. Rigel, a program director of the conference.

In the Orioles clubhouse, MRSA was found on the carpet in front of Mr. Sosa's locker and on mats in the weight room. MR. DONOHUE

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as it has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20 IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Wild Animals Pose Main Threat in U.S.

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz said. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks and 1,300 bats.

Although rabid bats are far less common than rabid raccoons, Dr. Seltz said that they are more dispersed and more likely to come in contact with people. Hence, rabid bats are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, Dr. Seltz continued, except for Hawaii. It is the only state with no reports.

In Arizona, where Dr. Seltz practices and where the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded. These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 racoon.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as it has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20 IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Wild Animals Pose Main Threat in U.S.

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz said. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks and 1,300 bats.

Although rabid bats are far less common than rabid raccoons, Dr. Seltz said that they are more dispersed and more likely to come in contact with people. Hence, rabid bats are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, Dr. Seltz continued, except for Hawaii. It is the only state with no reports.

In Arizona, where Dr. Seltz practices and where the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded. These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 racoon.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever there is reason to suspect exposure to the rabies virus.

Exposure is not always easy to document. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats.

From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated within this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said, warning that bat bites also can be difficult to verify. As examples of patients he would vaccinate in the absence of certain exposure, Dr. Seltz cited the person who was asleep when a bat flew into a room or a young child who cannot give a reliable history.

Other than a bite from a rabid animal, he said virus transmission can occur via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.” Cornea transplantation or solid organ transplantation from an infected donor also can transmit the virus.

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period, but Dr. Seltz said one long-term case has been reported. That involved a boy who became ill 6 years after he emigrated from the Philippines. The rabies strain came from a dog native to the Philippines.

Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

All told, six patients have survived after the onset of rabies worldwide, he said. Five had been vaccinated.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, laboratory workers, people moving to areas where dog rabies is common, and those who engage in activities that bring them in frequent contact with wildlife.

The postexposure protocol is three pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The three vaccines currently available in the United States are all inactivated viruses. Dr. Seltz advised that they should be given in five doses on days 0, 3, 7, 14, and 28. These should not be injected in the gluteal area, he warned, as it has been associated with lower response and prophylaxis failure.

Exposed patients should receive a 20- IU/kg dose—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added. “Do not give more,” he said. “It will inhibit antibody response.”

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20 IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

“You spread it around,” he said. “Do as much as you can.”

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Wild Animals Pose Main Threat in U.S.

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz said. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks and 1,300 bats.

Although rabid bats are far less common than rabid raccoons, Dr. Seltz said that they are more dispersed and more likely to come in contact with people. Hence, rabid bats are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, Dr. Seltz continued, except for Hawaii. It is the only state with no reports.

In Arizona, where Dr. Seltz practices and where the meeting took place, he said there were 169 cases of animal rabies in 2005—the most ever recorded. These rabid animals included 84 bats, 67 skunks, 12 foxes, 2 bobcats, and 1 racoon.

SCOTTSDALE, ARIZ. — With many more infants surviving congenital heart disease, pediatric cardiologists have a new challenge, Dr. Alan H. Friedman told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

Many more survivors must be followed through adolescence and into adulthood with noninvasive cardiac monitoring, said Dr. Friedman, director of pediatric cardiovascular imaging services at Yale-New Haven (Conn.) Children's Hospital, and of Yale University, New Haven.

Four-dimensional magnetic resonance imaging is “where the future of cardiology is going to be,” he predicted. It is safer than methods that expose them to radiation, and it has the potential to provide more graphic information than can be obtained with any other technology.

“The future will be to take three-dimensional imaging in time and rotate it so we can provide to our surgeons the most graphic information,” he said.

In the meantime, new and better tools have already expanded the physician's ability to image the heart and other structures within small pediatric patients.

“This is not a competition between these different imaging technologies, but rather that they complement each other,” he said, comparing the options.

The chest x-ray remains a part of everyday practice, he said, praising its accuracy in depicting the relationship between the heart and lungs: in particular, cardiac size, pulmonary blood flow, and pulmonary edema. Radiation exposure is minimal with chest x-rays, he continued. But they are not specific enough to assess certain forms of congenital heart disease (CHD).

Dr. Friedman described ultrasound as the workhorse of pediatric cardiology. Transthoracic echocardiography is safe and portable with the use of laptops that can be brought directly to the bedside.

Echocardiography allows physicians to take a disciplined, segmental approach to imaging the heart, he continued. After determining whether the heart is in the correct position, they can assess systemic venous drainage, pulmonary venous drainage, atrioventricular connections, ventriculoarterial connections, and intra- and extracardiac structures.

Ultrasound is useful for assessing virtually every type of congenital heart defect, including ventricular septal defects, the most common form of CHD, according to Dr. Friedman. Physicians can confirm the clinical diagnosis and see the defect's location in the ventricular septum. They can measure size, flow, and pressure across the defect. Small probes enable the use of transesophageal echocardiography (TEE) in children of all ages. Dr. Friedman said TEE provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging.

“We are looking right at the back of the heart from the esophagus. There is nothing in between,” he said.

Dr. Friedman recommended TEE for assessing very small, hard-to-see abnormalities. “If endocarditis is suspected, transesophageal electrocardiogram might be the way to go.”

It is also useful, he added, for the Fontan patient and others who require surgery. Whereas thoracic echo is not practical in the operating room, he said a probe in the esophagus can provide information during surgery and assess the adequacy of repair for better postoperative management.

TEE is also useful in the cath lab, he continued. It helps define pathophysiology and is an alternative to imaging methods that expose the patient to radiation.

With three-dimensional echocardiography, he said, physicians can obtain beautiful, real-time pictures of the atrial septum, mitral valve, and aortic valve structure.

Three advances—radionuclide imaging, positron emission tomography, and computed tomography—are increasingly used, but Dr. Friedman urged caution because they expose children to ionizing radiation.

Radionuclide imaging allows accurate measurement of right and left ventricular function. Unlike echocardiography, its results are not subject to variable interobserver interpretation. He recommended PET scanning for assessing myocardial metabolism, perfusion, and viability.

Dr. Friedman said ultrafast CT scanning produces very-high-resolution images that can provide excellent information on blood flow and cardiac function. It also can assess areas of stenosis, particularly in the distal pulmonary artery, that are missed by echocardiography.

Although not yet portable, MRI and MR angiography also offer excellent resolution, according to Dr. Friedman, but without the high doses of radiation with CT scanning. Three-dimensional images are already available for surgical planning, he said, and MR cardiac catheterization laboratories are being developed.

'This is not a competition between these different imaging technologies … they complement each other.' DR. FRIEDMAN

A CT scan with three-dimensional reconstruction shows a stent placed in this patient to aortic coarctation. With three-dimensional echocardiography, physicians can obtain real-time images of the atrial septum, mitral valve, and aortic valve structure.

A transesophageal echocardiogram shows a secundum atrial septal defect (ASD) in a toddler. This technology provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging (LA, left atrium; RA, right atrium; RV, right ventricle). Photos courtesy Dr. Alan Friedman

SCOTTSDALE, ARIZ. — With many more infants surviving congenital heart disease, pediatric cardiologists have a new challenge, Dr. Alan H. Friedman told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

Many more survivors must be followed through adolescence and into adulthood with noninvasive cardiac monitoring, said Dr. Friedman, director of pediatric cardiovascular imaging services at Yale-New Haven (Conn.) Children's Hospital, and of Yale University, New Haven.

Four-dimensional magnetic resonance imaging is “where the future of cardiology is going to be,” he predicted. It is safer than methods that expose them to radiation, and it has the potential to provide more graphic information than can be obtained with any other technology.

“The future will be to take three-dimensional imaging in time and rotate it so we can provide to our surgeons the most graphic information,” he said.

In the meantime, new and better tools have already expanded the physician's ability to image the heart and other structures within small pediatric patients.

“This is not a competition between these different imaging technologies, but rather that they complement each other,” he said, comparing the options.

The chest x-ray remains a part of everyday practice, he said, praising its accuracy in depicting the relationship between the heart and lungs: in particular, cardiac size, pulmonary blood flow, and pulmonary edema. Radiation exposure is minimal with chest x-rays, he continued. But they are not specific enough to assess certain forms of congenital heart disease (CHD).

Dr. Friedman described ultrasound as the workhorse of pediatric cardiology. Transthoracic echocardiography is safe and portable with the use of laptops that can be brought directly to the bedside.

Echocardiography allows physicians to take a disciplined, segmental approach to imaging the heart, he continued. After determining whether the heart is in the correct position, they can assess systemic venous drainage, pulmonary venous drainage, atrioventricular connections, ventriculoarterial connections, and intra- and extracardiac structures.

Ultrasound is useful for assessing virtually every type of congenital heart defect, including ventricular septal defects, the most common form of CHD, according to Dr. Friedman. Physicians can confirm the clinical diagnosis and see the defect's location in the ventricular septum. They can measure size, flow, and pressure across the defect. Small probes enable the use of transesophageal echocardiography (TEE) in children of all ages. Dr. Friedman said TEE provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging.

“We are looking right at the back of the heart from the esophagus. There is nothing in between,” he said.

Dr. Friedman recommended TEE for assessing very small, hard-to-see abnormalities. “If endocarditis is suspected, transesophageal electrocardiogram might be the way to go.”

It is also useful, he added, for the Fontan patient and others who require surgery. Whereas thoracic echo is not practical in the operating room, he said a probe in the esophagus can provide information during surgery and assess the adequacy of repair for better postoperative management.

TEE is also useful in the cath lab, he continued. It helps define pathophysiology and is an alternative to imaging methods that expose the patient to radiation.

With three-dimensional echocardiography, he said, physicians can obtain beautiful, real-time pictures of the atrial septum, mitral valve, and aortic valve structure.

Three advances—radionuclide imaging, positron emission tomography, and computed tomography—are increasingly used, but Dr. Friedman urged caution because they expose children to ionizing radiation.

Radionuclide imaging allows accurate measurement of right and left ventricular function. Unlike echocardiography, its results are not subject to variable interobserver interpretation. He recommended PET scanning for assessing myocardial metabolism, perfusion, and viability.

Dr. Friedman said ultrafast CT scanning produces very-high-resolution images that can provide excellent information on blood flow and cardiac function. It also can assess areas of stenosis, particularly in the distal pulmonary artery, that are missed by echocardiography.

Although not yet portable, MRI and MR angiography also offer excellent resolution, according to Dr. Friedman, but without the high doses of radiation with CT scanning. Three-dimensional images are already available for surgical planning, he said, and MR cardiac catheterization laboratories are being developed.

'This is not a competition between these different imaging technologies … they complement each other.' DR. FRIEDMAN

A CT scan with three-dimensional reconstruction shows a stent placed in this patient to aortic coarctation. With three-dimensional echocardiography, physicians can obtain real-time images of the atrial septum, mitral valve, and aortic valve structure.

A transesophageal echocardiogram shows a secundum atrial septal defect (ASD) in a toddler. This technology provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging (LA, left atrium; RA, right atrium; RV, right ventricle). Photos courtesy Dr. Alan Friedman

SCOTTSDALE, ARIZ. — With many more infants surviving congenital heart disease, pediatric cardiologists have a new challenge, Dr. Alan H. Friedman told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

Many more survivors must be followed through adolescence and into adulthood with noninvasive cardiac monitoring, said Dr. Friedman, director of pediatric cardiovascular imaging services at Yale-New Haven (Conn.) Children's Hospital, and of Yale University, New Haven.

Four-dimensional magnetic resonance imaging is “where the future of cardiology is going to be,” he predicted. It is safer than methods that expose them to radiation, and it has the potential to provide more graphic information than can be obtained with any other technology.

“The future will be to take three-dimensional imaging in time and rotate it so we can provide to our surgeons the most graphic information,” he said.

In the meantime, new and better tools have already expanded the physician's ability to image the heart and other structures within small pediatric patients.

“This is not a competition between these different imaging technologies, but rather that they complement each other,” he said, comparing the options.

The chest x-ray remains a part of everyday practice, he said, praising its accuracy in depicting the relationship between the heart and lungs: in particular, cardiac size, pulmonary blood flow, and pulmonary edema. Radiation exposure is minimal with chest x-rays, he continued. But they are not specific enough to assess certain forms of congenital heart disease (CHD).

Dr. Friedman described ultrasound as the workhorse of pediatric cardiology. Transthoracic echocardiography is safe and portable with the use of laptops that can be brought directly to the bedside.

Echocardiography allows physicians to take a disciplined, segmental approach to imaging the heart, he continued. After determining whether the heart is in the correct position, they can assess systemic venous drainage, pulmonary venous drainage, atrioventricular connections, ventriculoarterial connections, and intra- and extracardiac structures.

Ultrasound is useful for assessing virtually every type of congenital heart defect, including ventricular septal defects, the most common form of CHD, according to Dr. Friedman. Physicians can confirm the clinical diagnosis and see the defect's location in the ventricular septum. They can measure size, flow, and pressure across the defect. Small probes enable the use of transesophageal echocardiography (TEE) in children of all ages. Dr. Friedman said TEE provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging.

“We are looking right at the back of the heart from the esophagus. There is nothing in between,” he said.

Dr. Friedman recommended TEE for assessing very small, hard-to-see abnormalities. “If endocarditis is suspected, transesophageal electrocardiogram might be the way to go.”

It is also useful, he added, for the Fontan patient and others who require surgery. Whereas thoracic echo is not practical in the operating room, he said a probe in the esophagus can provide information during surgery and assess the adequacy of repair for better postoperative management.

TEE is also useful in the cath lab, he continued. It helps define pathophysiology and is an alternative to imaging methods that expose the patient to radiation.

With three-dimensional echocardiography, he said, physicians can obtain beautiful, real-time pictures of the atrial septum, mitral valve, and aortic valve structure.

Three advances—radionuclide imaging, positron emission tomography, and computed tomography—are increasingly used, but Dr. Friedman urged caution because they expose children to ionizing radiation.

Radionuclide imaging allows accurate measurement of right and left ventricular function. Unlike echocardiography, its results are not subject to variable interobserver interpretation. He recommended PET scanning for assessing myocardial metabolism, perfusion, and viability.

Dr. Friedman said ultrafast CT scanning produces very-high-resolution images that can provide excellent information on blood flow and cardiac function. It also can assess areas of stenosis, particularly in the distal pulmonary artery, that are missed by echocardiography.

Although not yet portable, MRI and MR angiography also offer excellent resolution, according to Dr. Friedman, but without the high doses of radiation with CT scanning. Three-dimensional images are already available for surgical planning, he said, and MR cardiac catheterization laboratories are being developed.

'This is not a competition between these different imaging technologies … they complement each other.' DR. FRIEDMAN

A CT scan with three-dimensional reconstruction shows a stent placed in this patient to aortic coarctation. With three-dimensional echocardiography, physicians can obtain real-time images of the atrial septum, mitral valve, and aortic valve structure.

A transesophageal echocardiogram shows a secundum atrial septal defect (ASD) in a toddler. This technology provides excellent anatomic definition because lungs, bone, and muscle do not interfere with the imaging (LA, left atrium; RA, right atrium; RV, right ventricle). Photos courtesy Dr. Alan Friedman

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“When we say children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” she said.

Dr. Turkel speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days. Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms. Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance. “These are not things you see in children,” Dr. Turkel said. When children do hallucinate, she added, the experience is more likely to be auditory than visual.

Dr. Turkel has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents, and adults, but maybe at different rates,” she said, noting the articles on adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate deliriumn

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“When we say children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” she said.

Dr. Turkel speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days. Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms. Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance. “These are not things you see in children,” Dr. Turkel said. When children do hallucinate, she added, the experience is more likely to be auditory than visual.

Dr. Turkel has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents, and adults, but maybe at different rates,” she said, noting the articles on adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate deliriumn

SANTA ANA PUEBLO, N.M. — Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“When we say children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” she said.

Dr. Turkel speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days. Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms. Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance. “These are not things you see in children,” Dr. Turkel said. When children do hallucinate, she added, the experience is more likely to be auditory than visual.

Dr. Turkel has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents, and adults, but maybe at different rates,” she said, noting the articles on adults were not consistent with each other in reporting data.

Many adult diagnostic techniques cannot be used with very young children, so she suggested asking pediatric hospital patients where they are. “If they tell you they are at home or at school, you can tell they are disoriented,” she said. Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, she gives the child a small dose of an atypical antipsychotic. Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate deliriumn

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever exposure to the rabies virus is suspected.

Exposure may not be easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats. From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated in this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said. As examples of patients he would vaccinate in the absence of certain exposure, he cited the person who was asleep when a bat flew into a room or a child who cannot give a reliable history.

Other than a bite, he said the virus can be transmitted via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.”

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period in humans. Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, lab workers, people moving to areas where dog rabies is common, and those who make frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The vaccines available in the U.S. are all inactivated viruses. Do not inject them in the gluteal area, he warned, as it has been associated with prophylaxis failure.

Exposed patients should receive a dose of 20 IU/kg—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added.

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Bats vs. Raccoons

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats. Because bats are more likely to come in contact with people, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, he continued, except for Hawaii. It is the only state with no reports.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever exposure to the rabies virus is suspected.

Exposure may not be easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats. From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated in this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said. As examples of patients he would vaccinate in the absence of certain exposure, he cited the person who was asleep when a bat flew into a room or a child who cannot give a reliable history.

Other than a bite, he said the virus can be transmitted via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.”

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period in humans. Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, lab workers, people moving to areas where dog rabies is common, and those who make frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The vaccines available in the U.S. are all inactivated viruses. Do not inject them in the gluteal area, he warned, as it has been associated with prophylaxis failure.

Exposed patients should receive a dose of 20 IU/kg—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added.

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Bats vs. Raccoons

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats. Because bats are more likely to come in contact with people, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, he continued, except for Hawaii. It is the only state with no reports.

SCOTTSDALE, ARIZ. — Despite the first known survival of an unvaccinated rabies patient, prophylaxis still is the only proven defense after rabies exposure, Dr. L. Barry Seltz told physicians at a pediatric update sponsored by Phoenix Children's Hospital.

“There is no established, effective treatment,” Dr. Seltz of the University of Arizona in Tucson warned in a talk that addressed misconceptions about human rabies risk and why current thinking discourages vaccination in the gluteal area.

The treatment that saved the Wisconsin teenager (N. Engl. J. Med. 2005;352:2508–14) needs to be duplicated, according to Dr. Seltz. Vaccination can be before or after exposure, he said, but it must be done whenever exposure to the rabies virus is suspected.

Exposure may not be easy to document, however. For Dr. Seltz, a key lesson from the survival of the 15-year-old girl is the importance of taking a good patient history.

“She said she had been bitten by a bat. She didn't think anything of it,” he said, crediting careful questioning by the teenager's primary care physician with unearthing this crucial piece of information after the patient became ill. She had not previously reported the bite.

Despite public fear of rabid dogs and widespread rabies in wild raccoons on the Eastern seaboard, Dr. Seltz said that most human rabies cases in the United States involve bats. From 1990 to 2004, he said there were 47 cases, including 10 cases acquired abroad. Of the 37 infections that originated in this country, 34 were determined to involve a bat variant of the rabies virus. Only one came from a raccoon.

“Bat bites are not dramatic. You may not recognize them when they occur,” Dr. Seltz said. As examples of patients he would vaccinate in the absence of certain exposure, he cited the person who was asleep when a bat flew into a room or a child who cannot give a reliable history.

Other than a bite, he said the virus can be transmitted via “contamination of nonintact skin or mucous membranes with saliva from a rabid animal.”

“Petting a rabid animal is not an exposure. Contact with blood, urine, or feces of an infected animal is not exposure,” he said.

The virus has a 20- to 60-day incubation period in humans. Ten days is adequate for observation of a dog that appears healthy after it has bitten someone in the United States, according to Dr. Seltz. If the dog has been infected, the virus will present itself quickly.

To control rabies in humans, he urged preexposure vaccination of veterinarians, animal handlers, lab workers, people moving to areas where dog rabies is common, and those who make frequent contact with wildlife.

The postexposure protocol is three-pronged, he said: local wound care, active immunization, and passive immunization with immune globulin. “Cleaning [the wound] is critically important,” he said. “Animal studies show that wound cleaning can reduce the risk of rabies by 50%.”

The vaccines available in the U.S. are all inactivated viruses. Do not inject them in the gluteal area, he warned, as it has been associated with prophylaxis failure.

Exposed patients should receive a dose of 20 IU/kg—no more, no less—of immune globulin prepared from the plasma of immunized human donors, Dr. Seltz added.

In five cases of children who died despite receiving the full postexposure protocol for multiple bites, their wounds were not sufficiently infiltrated with immune globulin, according to Dr. Seltz. If a child has multiple wounds, he said to dilute the 20-IU/kg dose in normal saline solution and use the extra volume to make sure all the wounds are infiltrated.

'Petting a rabid animal is not an exposure'—nor is contact with its blood, urine, or feces. DR. SELTZ

Bats vs. Raccoons

Dogs are the first animal that comes to mind when most people think about rabies, but Dr. Seltz said they are not much of a threat in the United States.

In 2004, only 94 rabid dogs were reported in this country, according to Dr. Seltz. Among domestic animals, there were more cases of rabid cats and rabid cattle: 281 and 115 animals, respectively.

Dog bites do account for most of the 50,000 human rabies cases worldwide each year, he said. In the United States, however, 92%–94% of animal rabies comes from wild animals.

The largest concentration of infected animals has been identified to date on the East Coast, Dr. Seltz reported. Nationwide, in 2004, there were 2,400 rabid raccoons, 1,800 skunks, and 1,300 bats. Because bats are more likely to come in contact with people, they are most often implicated in human infections. Squirrels are rarely found to be rabid, he said, as they generally do not survive the initial attack of a rabid animal.

Rabies has been found throughout the country, he continued, except for Hawaii. It is the only state with no reports.