Diana Mahoney

Giant cell arteritis is considered a rheumatologic emergency, but it is not always recognized as such before permanent damage occurs.

Primarily a disease of the elderly, giant cell arteritis (GCA) is a systemic vasculitis predominantly characterized by inflammation of the large- and medium-size vessels in the scalp and head, especially the arteries over the temples. Although genetic, infectious, and autoimmune factors have been implicated in the pathogenesis of the disease, its cause is still unknown. If not diagnosed and treated early, however, the self-limiting condition can lead to irreversible vision loss resulting from necrosis of the posterior ciliary branch of the ophthalmic artery.

Unfortunately, diagnostic delays are common, because many cases begin insidiously with multiple, subtle symptoms that are not unusual in elderly patients, including headache, jaw pain, scalp pain, visual loss, fevers, chills, and weight loss, according to Dr. Stephen A. Paget, program director of the Cornell Arthritis and Multipurpose Arthritis and Musculoskeletal Diseases Center (MAMDC) at the Hospital for Special Surgery in New York.

The key to early recognition of GCA lies in the treating clinician’s awareness of the characteristic ophthalmic and systemic signs and symptoms and their inclusion of the condition in the differential diagnosis when an elderly patient presents with multiple nonspecific complaints, said Dr. Paget. Because of the diversity of symptoms, however, “GCA patients may go to multiple physicians – including but not limited to internists, ophthalmologists, neurologists, otorhinolaryngologists, dentists, and rheumatologists – before a diagnosis is made,” he said, noting that the diagnosis is often missed.

In this month’s column, Dr. Paget discusses some of the important diagnostic and treatment considerations in the management of GCA.

Question: How common is GCA, and what are the telltale signs and symptoms?

Dr. Paget: GCA frequently occurs in concert with polymyalgia rheumatica (PMR). Half of patients with GCA also have the proximal, symmetrical achiness, stiffness, and soreness of PMR, and 5%-10% of those with pure PMR develop temporal arteritis within a year after the onset of the first disease. In the United States, the average annual incidence of PMR is 52.5 per 100,000 patients aged 50 years and older, and the prevalence is about 0.5%-0.7%. The incidence and prevalence of GCA are about one-third that of PMR.

These disorders occur primarily in patients over age 50 years, with risk increasing with age. GCA and PMR affect more women than men. Prominent presenting signs and symptoms of GCA include soreness, severe and persistent headache, jaw pain with eating, tongue pain, sudden visual loss, flashing lights, coming and going visual loss, fever, fatigue, and weight loss.

Question: What triggers the immune system to attack the temporal arteries in CGA?

Dr. Paget: As with other autoimmune diseases, the exact cause remains unknown. We suspect there may be an inciting antigen in the blood vessel elastica that acts as a cofactor along with an infection to trigger the illness in a genetically predisposed person.

Question: What are the diagnostic criteria for GCA?

Dr. Paget: The American College of Rheumatology 1990 criteria for the diagnosis of GCA require the presence of three of the following: age 50 years or older; new onset of localized headache; temporal artery tenderness on palpation or decreased pulsation; erythrocyte sedimentation rate of 50 mm/hr or higher; and/or abnormal temporal artery biopsy.

Question: Much has been reported recently about the use of various imaging modalities in the diagnosis of GCA, particularly the possibility that an ultrasound-detected bilateral halo sign indicating temporal artery edema may be sensitive and specific enough to prompt treatment without a temporal artery biopsy (BMC Musculoskelet. Disord. 2010;11:44). What is the role of imaging in GCA?

Dr. Paget: The temporal artery biopsy is still the gold standard for diagnosing GCA, but PET scanning and ultrasound can be helpful in supporting a clinical diagnosis before biopsy results return and in those GCA patients in whom the biopsy is negative.

Question: What is the current treatment standard for GCA? Is there a role for DMARDs?

Dr. Paget: Prednisone continues to be a superb drug for GCA and should be started once the clinical diagnosis is made, even before the biopsy results return. In fact, the characteristic dramatic improvement within 1-3 days of initiating steroid therapy helps confirm the diagnosis. The main concern with prednisone is the side effects, particularly in light of the many comorbidities of the elderly patients who get the disease. Methotrexate and azathioprine can be used for steroid sparing, but they should not be used for treatment initially. Studies of anti–tumor necrosis factor (anti-TNF) agents haven’t been successful. Finding a disease-modifying medication that works as well as steroids is a major research goal.

Question: Considering the potential for multiple system involvement with GCA, which specialist should manage the patient?

Dr. Paget: The rheumatologist is the right person to treat this condition. Consultation with other specialists might be warranted occasionally but not necessarily routinely. For example, sometimes an ophthalmologist is needed to check the patient’s eyes. Otherwise, once the diagnosis has been made, management is typically straightforward.

Question: What is the outlook for GCA patients who are diagnosed and treated effectively?

Dr. Paget: GCA tends lasts for about a year or two, after which patients can go off medication. The likelihood of recurrence is very low.

Dr. Paget is also physician-in-chief emeritus and the Joseph P. Routh Professor of Medicine at New York Hospital/Weill Cornell Medical College. He disclosed no financial conflicts of interest regarding the information presented.

Giant cell arteritis is considered a rheumatologic emergency, but it is not always recognized as such before permanent damage occurs.

Primarily a disease of the elderly, giant cell arteritis (GCA) is a systemic vasculitis predominantly characterized by inflammation of the large- and medium-size vessels in the scalp and head, especially the arteries over the temples. Although genetic, infectious, and autoimmune factors have been implicated in the pathogenesis of the disease, its cause is still unknown. If not diagnosed and treated early, however, the self-limiting condition can lead to irreversible vision loss resulting from necrosis of the posterior ciliary branch of the ophthalmic artery.

Unfortunately, diagnostic delays are common, because many cases begin insidiously with multiple, subtle symptoms that are not unusual in elderly patients, including headache, jaw pain, scalp pain, visual loss, fevers, chills, and weight loss, according to Dr. Stephen A. Paget, program director of the Cornell Arthritis and Multipurpose Arthritis and Musculoskeletal Diseases Center (MAMDC) at the Hospital for Special Surgery in New York.

The key to early recognition of GCA lies in the treating clinician’s awareness of the characteristic ophthalmic and systemic signs and symptoms and their inclusion of the condition in the differential diagnosis when an elderly patient presents with multiple nonspecific complaints, said Dr. Paget. Because of the diversity of symptoms, however, “GCA patients may go to multiple physicians – including but not limited to internists, ophthalmologists, neurologists, otorhinolaryngologists, dentists, and rheumatologists – before a diagnosis is made,” he said, noting that the diagnosis is often missed.

In this month’s column, Dr. Paget discusses some of the important diagnostic and treatment considerations in the management of GCA.

Question: How common is GCA, and what are the telltale signs and symptoms?

Dr. Paget: GCA frequently occurs in concert with polymyalgia rheumatica (PMR). Half of patients with GCA also have the proximal, symmetrical achiness, stiffness, and soreness of PMR, and 5%-10% of those with pure PMR develop temporal arteritis within a year after the onset of the first disease. In the United States, the average annual incidence of PMR is 52.5 per 100,000 patients aged 50 years and older, and the prevalence is about 0.5%-0.7%. The incidence and prevalence of GCA are about one-third that of PMR.

These disorders occur primarily in patients over age 50 years, with risk increasing with age. GCA and PMR affect more women than men. Prominent presenting signs and symptoms of GCA include soreness, severe and persistent headache, jaw pain with eating, tongue pain, sudden visual loss, flashing lights, coming and going visual loss, fever, fatigue, and weight loss.

Question: What triggers the immune system to attack the temporal arteries in CGA?

Dr. Paget: As with other autoimmune diseases, the exact cause remains unknown. We suspect there may be an inciting antigen in the blood vessel elastica that acts as a cofactor along with an infection to trigger the illness in a genetically predisposed person.

Question: What are the diagnostic criteria for GCA?

Dr. Paget: The American College of Rheumatology 1990 criteria for the diagnosis of GCA require the presence of three of the following: age 50 years or older; new onset of localized headache; temporal artery tenderness on palpation or decreased pulsation; erythrocyte sedimentation rate of 50 mm/hr or higher; and/or abnormal temporal artery biopsy.

Question: Much has been reported recently about the use of various imaging modalities in the diagnosis of GCA, particularly the possibility that an ultrasound-detected bilateral halo sign indicating temporal artery edema may be sensitive and specific enough to prompt treatment without a temporal artery biopsy (BMC Musculoskelet. Disord. 2010;11:44). What is the role of imaging in GCA?

Dr. Paget: The temporal artery biopsy is still the gold standard for diagnosing GCA, but PET scanning and ultrasound can be helpful in supporting a clinical diagnosis before biopsy results return and in those GCA patients in whom the biopsy is negative.

Question: What is the current treatment standard for GCA? Is there a role for DMARDs?

Dr. Paget: Prednisone continues to be a superb drug for GCA and should be started once the clinical diagnosis is made, even before the biopsy results return. In fact, the characteristic dramatic improvement within 1-3 days of initiating steroid therapy helps confirm the diagnosis. The main concern with prednisone is the side effects, particularly in light of the many comorbidities of the elderly patients who get the disease. Methotrexate and azathioprine can be used for steroid sparing, but they should not be used for treatment initially. Studies of anti–tumor necrosis factor (anti-TNF) agents haven’t been successful. Finding a disease-modifying medication that works as well as steroids is a major research goal.

Question: Considering the potential for multiple system involvement with GCA, which specialist should manage the patient?

Dr. Paget: The rheumatologist is the right person to treat this condition. Consultation with other specialists might be warranted occasionally but not necessarily routinely. For example, sometimes an ophthalmologist is needed to check the patient’s eyes. Otherwise, once the diagnosis has been made, management is typically straightforward.

Question: What is the outlook for GCA patients who are diagnosed and treated effectively?

Dr. Paget: GCA tends lasts for about a year or two, after which patients can go off medication. The likelihood of recurrence is very low.

Dr. Paget is also physician-in-chief emeritus and the Joseph P. Routh Professor of Medicine at New York Hospital/Weill Cornell Medical College. He disclosed no financial conflicts of interest regarding the information presented.

Giant cell arteritis is considered a rheumatologic emergency, but it is not always recognized as such before permanent damage occurs.

Primarily a disease of the elderly, giant cell arteritis (GCA) is a systemic vasculitis predominantly characterized by inflammation of the large- and medium-size vessels in the scalp and head, especially the arteries over the temples. Although genetic, infectious, and autoimmune factors have been implicated in the pathogenesis of the disease, its cause is still unknown. If not diagnosed and treated early, however, the self-limiting condition can lead to irreversible vision loss resulting from necrosis of the posterior ciliary branch of the ophthalmic artery.

Unfortunately, diagnostic delays are common, because many cases begin insidiously with multiple, subtle symptoms that are not unusual in elderly patients, including headache, jaw pain, scalp pain, visual loss, fevers, chills, and weight loss, according to Dr. Stephen A. Paget, program director of the Cornell Arthritis and Multipurpose Arthritis and Musculoskeletal Diseases Center (MAMDC) at the Hospital for Special Surgery in New York.

The key to early recognition of GCA lies in the treating clinician’s awareness of the characteristic ophthalmic and systemic signs and symptoms and their inclusion of the condition in the differential diagnosis when an elderly patient presents with multiple nonspecific complaints, said Dr. Paget. Because of the diversity of symptoms, however, “GCA patients may go to multiple physicians – including but not limited to internists, ophthalmologists, neurologists, otorhinolaryngologists, dentists, and rheumatologists – before a diagnosis is made,” he said, noting that the diagnosis is often missed.

In this month’s column, Dr. Paget discusses some of the important diagnostic and treatment considerations in the management of GCA.

Question: How common is GCA, and what are the telltale signs and symptoms?

Dr. Paget: GCA frequently occurs in concert with polymyalgia rheumatica (PMR). Half of patients with GCA also have the proximal, symmetrical achiness, stiffness, and soreness of PMR, and 5%-10% of those with pure PMR develop temporal arteritis within a year after the onset of the first disease. In the United States, the average annual incidence of PMR is 52.5 per 100,000 patients aged 50 years and older, and the prevalence is about 0.5%-0.7%. The incidence and prevalence of GCA are about one-third that of PMR.

These disorders occur primarily in patients over age 50 years, with risk increasing with age. GCA and PMR affect more women than men. Prominent presenting signs and symptoms of GCA include soreness, severe and persistent headache, jaw pain with eating, tongue pain, sudden visual loss, flashing lights, coming and going visual loss, fever, fatigue, and weight loss.

Question: What triggers the immune system to attack the temporal arteries in CGA?

Dr. Paget: As with other autoimmune diseases, the exact cause remains unknown. We suspect there may be an inciting antigen in the blood vessel elastica that acts as a cofactor along with an infection to trigger the illness in a genetically predisposed person.

Question: What are the diagnostic criteria for GCA?

Dr. Paget: The American College of Rheumatology 1990 criteria for the diagnosis of GCA require the presence of three of the following: age 50 years or older; new onset of localized headache; temporal artery tenderness on palpation or decreased pulsation; erythrocyte sedimentation rate of 50 mm/hr or higher; and/or abnormal temporal artery biopsy.

Question: Much has been reported recently about the use of various imaging modalities in the diagnosis of GCA, particularly the possibility that an ultrasound-detected bilateral halo sign indicating temporal artery edema may be sensitive and specific enough to prompt treatment without a temporal artery biopsy (BMC Musculoskelet. Disord. 2010;11:44). What is the role of imaging in GCA?

Dr. Paget: The temporal artery biopsy is still the gold standard for diagnosing GCA, but PET scanning and ultrasound can be helpful in supporting a clinical diagnosis before biopsy results return and in those GCA patients in whom the biopsy is negative.

Question: What is the current treatment standard for GCA? Is there a role for DMARDs?

Dr. Paget: Prednisone continues to be a superb drug for GCA and should be started once the clinical diagnosis is made, even before the biopsy results return. In fact, the characteristic dramatic improvement within 1-3 days of initiating steroid therapy helps confirm the diagnosis. The main concern with prednisone is the side effects, particularly in light of the many comorbidities of the elderly patients who get the disease. Methotrexate and azathioprine can be used for steroid sparing, but they should not be used for treatment initially. Studies of anti–tumor necrosis factor (anti-TNF) agents haven’t been successful. Finding a disease-modifying medication that works as well as steroids is a major research goal.

Question: Considering the potential for multiple system involvement with GCA, which specialist should manage the patient?

Dr. Paget: The rheumatologist is the right person to treat this condition. Consultation with other specialists might be warranted occasionally but not necessarily routinely. For example, sometimes an ophthalmologist is needed to check the patient’s eyes. Otherwise, once the diagnosis has been made, management is typically straightforward.

Question: What is the outlook for GCA patients who are diagnosed and treated effectively?

Dr. Paget: GCA tends lasts for about a year or two, after which patients can go off medication. The likelihood of recurrence is very low.

Dr. Paget is also physician-in-chief emeritus and the Joseph P. Routh Professor of Medicine at New York Hospital/Weill Cornell Medical College. He disclosed no financial conflicts of interest regarding the information presented.

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual "National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents," conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school—which represents a 39% increase since last year, when 23% of middle school students reported their schools to be "drug infected." It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report.

The gap between drug and gang presence reported at public schools vs. private and religious schools is wide, the authors observed, with 57% of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence.

"The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001," they wrote. "While the percent of adolescents who say they attend drug-free private and religious schools has roughly remained steady, the number of students who report attending a drug-free public school has decreased from 62% in 2001 to 43% in 2010, a decline of 31 percent."

These findings portend "a trajectory to tragedy for millions of children and families," Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a "malignant cancer," referring to the attendant repercussions observed in the survey.

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), three times more likely to have used alcohol (39% vs. 12%), and five times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%).

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use.

To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

"The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol or marijuana," the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual "National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents," conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school—which represents a 39% increase since last year, when 23% of middle school students reported their schools to be "drug infected." It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report.

The gap between drug and gang presence reported at public schools vs. private and religious schools is wide, the authors observed, with 57% of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence.

"The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001," they wrote. "While the percent of adolescents who say they attend drug-free private and religious schools has roughly remained steady, the number of students who report attending a drug-free public school has decreased from 62% in 2001 to 43% in 2010, a decline of 31 percent."

These findings portend "a trajectory to tragedy for millions of children and families," Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a "malignant cancer," referring to the attendant repercussions observed in the survey.

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), three times more likely to have used alcohol (39% vs. 12%), and five times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%).

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use.

To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

"The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol or marijuana," the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual "National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents," conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school—which represents a 39% increase since last year, when 23% of middle school students reported their schools to be "drug infected." It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report.

The gap between drug and gang presence reported at public schools vs. private and religious schools is wide, the authors observed, with 57% of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence.

"The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001," they wrote. "While the percent of adolescents who say they attend drug-free private and religious schools has roughly remained steady, the number of students who report attending a drug-free public school has decreased from 62% in 2001 to 43% in 2010, a decline of 31 percent."

These findings portend "a trajectory to tragedy for millions of children and families," Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a "malignant cancer," referring to the attendant repercussions observed in the survey.

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), three times more likely to have used alcohol (39% vs. 12%), and five times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%).

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use.

To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

"The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol or marijuana," the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

Major Finding: Emergency department visits for nonmedical use of prescription opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008.

Data Source: A review by the Centers for Disease and Prevention of 5-year data on ED visits involving the nonmedical use of prescription drugs from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network.

Disclosures: None was reported.

Emergency department visits for nonmedical use of opioids increased by nearly 112% between 2004 and 2008, with a 29% increase between 2007 and 2008 alone, according to the Centers for Disease Control and Prevention.

Together with the Substance Abuse and Mental Health Services Administration (SAMHSA), the CDC reviewed the latest available 5 years of data on emergency department (ED) visits for nonmedical use of prescription drugs from SAMHSA's Drug Abuse Warning Network (DAWN). ED visits involving nonmedical use of opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008, according to the report published in the CDC's report.

By 2008, the number of ED visits for misused prescription and over-the-counter drugs matched the number of ED visits involving illicit drugs for that year, the report noted (MMWR 2010 June 18;59:705-9).

The DAWN definition of nonmedical use of a prescription or over-the-counter drug includes taking a higher-than-recommended dose, taking a drug that was prescribed for another person, drug-facilitated assault, and misuse or abuse–all of which must be documented in a patient's medical record. It does not include suicide attempts, patients seeking detoxification, and unintentional ingestions, which are tracked in other categories.

The highest numbers of ED visits involving prescription drugs in this review were for oxycodone, hydrocodone, and methadone, each of which showed statistically significant increases during the 5-year study period.

Among these drugs, the greatest increase was noted for oxycodone, with an estimated 41,700 ED visits in 2004 and 105,200 ED visits in 2008, representing a 144% increase.

Also, ED visits for nonmedical use of benzodiazepines increased 89%, from 143,500 in 2004 to 271,700 in 2008, with significant increases observed for each of the individual benzodiazepine drugs reviewed, including alprazolam, clonazepam, diazepam, and lorazepam.

Statistically significant increases also were noted for ED visits involving the sleep aid zolpidem and the muscle relaxant carisoprodol.

Peak visit rates for both opioids and benzodiazepines were observed in the age ranges 21-24 and 25-29 years, which represents a shift from previous report periods, in which peak visit rates were seen in the 30- to 34- and 35- to 44-year age ranges, according to an editorial note accompanying the report. “As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35-54 years age group,” according to the note.

The 5-year increase in ED visits probably reflects “substantial increases in the prescribing of these classes of drugs,” the CDC authors suggested. “The increase also might reflect an increase in the rate of nonmedical use of prescription drugs per 1,000 prescriptions, as has been observed for selected opioids.”

The report is limited by a number of factors, according to the authors. “First, the drugs involved in ED visits might not all be identified and documented. The extent to which ED staff members document drug involvement might have increased over time,” they wrote.

Additionally, information on the motivation behind nonmedical drug use might be incomplete, for instance by not noting a suicide attempt; population-based rates cannot be used to establish per-patient or per-prescription risk; and the distinction between nonmedical and medical reasons for taking drugs is not always clear, particularly when other drugs are involved.

The report “reinforces the value of timely, population-based national surveillance for nonmedical use of drugs, which can be used to assess the effect of such interventions,” the authors wrote.

Major Finding: Emergency department visits for nonmedical use of prescription opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008.

Data Source: A review by the Centers for Disease and Prevention of 5-year data on ED visits involving the nonmedical use of prescription drugs from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network.

Disclosures: None was reported.

Emergency department visits for nonmedical use of opioids increased by nearly 112% between 2004 and 2008, with a 29% increase between 2007 and 2008 alone, according to the Centers for Disease Control and Prevention.

Together with the Substance Abuse and Mental Health Services Administration (SAMHSA), the CDC reviewed the latest available 5 years of data on emergency department (ED) visits for nonmedical use of prescription drugs from SAMHSA's Drug Abuse Warning Network (DAWN). ED visits involving nonmedical use of opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008, according to the report published in the CDC's report.

By 2008, the number of ED visits for misused prescription and over-the-counter drugs matched the number of ED visits involving illicit drugs for that year, the report noted (MMWR 2010 June 18;59:705-9).

The DAWN definition of nonmedical use of a prescription or over-the-counter drug includes taking a higher-than-recommended dose, taking a drug that was prescribed for another person, drug-facilitated assault, and misuse or abuse–all of which must be documented in a patient's medical record. It does not include suicide attempts, patients seeking detoxification, and unintentional ingestions, which are tracked in other categories.

The highest numbers of ED visits involving prescription drugs in this review were for oxycodone, hydrocodone, and methadone, each of which showed statistically significant increases during the 5-year study period.

Among these drugs, the greatest increase was noted for oxycodone, with an estimated 41,700 ED visits in 2004 and 105,200 ED visits in 2008, representing a 144% increase.

Also, ED visits for nonmedical use of benzodiazepines increased 89%, from 143,500 in 2004 to 271,700 in 2008, with significant increases observed for each of the individual benzodiazepine drugs reviewed, including alprazolam, clonazepam, diazepam, and lorazepam.

Statistically significant increases also were noted for ED visits involving the sleep aid zolpidem and the muscle relaxant carisoprodol.

Peak visit rates for both opioids and benzodiazepines were observed in the age ranges 21-24 and 25-29 years, which represents a shift from previous report periods, in which peak visit rates were seen in the 30- to 34- and 35- to 44-year age ranges, according to an editorial note accompanying the report. “As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35-54 years age group,” according to the note.

The 5-year increase in ED visits probably reflects “substantial increases in the prescribing of these classes of drugs,” the CDC authors suggested. “The increase also might reflect an increase in the rate of nonmedical use of prescription drugs per 1,000 prescriptions, as has been observed for selected opioids.”

The report is limited by a number of factors, according to the authors. “First, the drugs involved in ED visits might not all be identified and documented. The extent to which ED staff members document drug involvement might have increased over time,” they wrote.

Additionally, information on the motivation behind nonmedical drug use might be incomplete, for instance by not noting a suicide attempt; population-based rates cannot be used to establish per-patient or per-prescription risk; and the distinction between nonmedical and medical reasons for taking drugs is not always clear, particularly when other drugs are involved.

The report “reinforces the value of timely, population-based national surveillance for nonmedical use of drugs, which can be used to assess the effect of such interventions,” the authors wrote.

Major Finding: Emergency department visits for nonmedical use of prescription opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008.

Data Source: A review by the Centers for Disease and Prevention of 5-year data on ED visits involving the nonmedical use of prescription drugs from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network.

Disclosures: None was reported.

Emergency department visits for nonmedical use of opioids increased by nearly 112% between 2004 and 2008, with a 29% increase between 2007 and 2008 alone, according to the Centers for Disease Control and Prevention.

Together with the Substance Abuse and Mental Health Services Administration (SAMHSA), the CDC reviewed the latest available 5 years of data on emergency department (ED) visits for nonmedical use of prescription drugs from SAMHSA's Drug Abuse Warning Network (DAWN). ED visits involving nonmedical use of opioid analgesics rose from 144,600 in 2004 to 305,900 in 2008, according to the report published in the CDC's report.

By 2008, the number of ED visits for misused prescription and over-the-counter drugs matched the number of ED visits involving illicit drugs for that year, the report noted (MMWR 2010 June 18;59:705-9).

The DAWN definition of nonmedical use of a prescription or over-the-counter drug includes taking a higher-than-recommended dose, taking a drug that was prescribed for another person, drug-facilitated assault, and misuse or abuse–all of which must be documented in a patient's medical record. It does not include suicide attempts, patients seeking detoxification, and unintentional ingestions, which are tracked in other categories.

The highest numbers of ED visits involving prescription drugs in this review were for oxycodone, hydrocodone, and methadone, each of which showed statistically significant increases during the 5-year study period.

Among these drugs, the greatest increase was noted for oxycodone, with an estimated 41,700 ED visits in 2004 and 105,200 ED visits in 2008, representing a 144% increase.

Also, ED visits for nonmedical use of benzodiazepines increased 89%, from 143,500 in 2004 to 271,700 in 2008, with significant increases observed for each of the individual benzodiazepine drugs reviewed, including alprazolam, clonazepam, diazepam, and lorazepam.

Statistically significant increases also were noted for ED visits involving the sleep aid zolpidem and the muscle relaxant carisoprodol.

Peak visit rates for both opioids and benzodiazepines were observed in the age ranges 21-24 and 25-29 years, which represents a shift from previous report periods, in which peak visit rates were seen in the 30- to 34- and 35- to 44-year age ranges, according to an editorial note accompanying the report. “As late as 2006, the peak mortality rate for fatal drug overdoses involving opioid analgesics had been in the 35-54 years age group,” according to the note.

The 5-year increase in ED visits probably reflects “substantial increases in the prescribing of these classes of drugs,” the CDC authors suggested. “The increase also might reflect an increase in the rate of nonmedical use of prescription drugs per 1,000 prescriptions, as has been observed for selected opioids.”

The report is limited by a number of factors, according to the authors. “First, the drugs involved in ED visits might not all be identified and documented. The extent to which ED staff members document drug involvement might have increased over time,” they wrote.

Additionally, information on the motivation behind nonmedical drug use might be incomplete, for instance by not noting a suicide attempt; population-based rates cannot be used to establish per-patient or per-prescription risk; and the distinction between nonmedical and medical reasons for taking drugs is not always clear, particularly when other drugs are involved.

The report “reinforces the value of timely, population-based national surveillance for nonmedical use of drugs, which can be used to assess the effect of such interventions,” the authors wrote.

BOSTON – Sleep disturbances may be an important target for treating posttraumatic stress disorder, according to Dr. R. Bruce Lydiard of the Medical University of South Carolina in Charleston.

Persistent, severe posttraumatic nightmares, REM sleep fragmentation, insomnia, excessive nocturnal periodic limb movements, and sleep-disordered breathing are frequently experienced by individuals with PTSD, Dr. Lydiard said. Although these sleep problems are often viewed as secondary symptoms of PTSD, “the evidence suggests that after a traumatic event, sleep disruption appears before the onset of PTSD and may be a risk factor for it,” he proposed.

Polysomnographic data from 21 individuals with traumatic injuries showed that the number of REM periods and the (shorter) duration of REM periods within 1 month after the traumatic event were predictive of PTSD symptom severity 6 weeks later (Am. J. Psychiatry 2002;159:1696-701).

Neurobiologically, the association makes sense, Dr. Lydiard said. “Sleep is regulated in part by brain areas in which PTSD-related changes occur,” which suggests that the stress response in PTSD and sleep dysfunction may be biologically linked.

Imaging studies suggest that exposure to trauma-related stimuli leads to hyperactivation in the amygdala and decreased activation in the medial prefrontal cortex/anterior cingulate cortex and hippocampus, with the magnitude of the activation correlating with the clinical severity of PTSD symptoms.

Polysomnographic investigations in patients with PTSD and sleep disturbances have revealed increased REM density, reduced REM duration, and increased motor activity, Dr. Lydiard said.

Together with clinical reports, “these data provide the basis for REM sleep dysregulation as a core feature in PTSD,” whereby increased activity in the amygdala and decreased inhibitory input from the medial prefrontal cortex lead to a persistently overactive noradrenergic system. “As a result, the usual rhythm of REM-NREM sleep is disrupted, and REM sleep is fragmented,” he said.

Based on this model, investigators have hypothesized that targeting noradrenergic signaling during or near REM episodes may normalize REM sleep, which in turn might improve PTSD sleep disturbances and, potentially, other PTSD symptoms, Dr. Lydiard said.

The alpha adrenergic antagonist prazosin has shown promise in multiple case and chart reviews, open-label trials, and placebo-controlled studies.

In one trial of 40 veterans with PTSD sleep disturbance, patients who were randomized to receive a nightly dose of prazosin–originally marketed as an antihypertensive agent–reported significant improvements in sleep quality and significant reductions in trauma nightmares, as well a better overall sense of well-being and improved daily functioning (Biol. Psychiatry 2007;61:928-34).

In another study, investigators evaluated the effect of prazosin vs. placebo on objective sleep parameters in 13 outpatients with chronic civilian trauma PTSD, frequent nightmares, and sleep disturbance. The prazosin group experienced significantly increased total sleep time as well as increased REM sleep time and mean REM period duration (Biol. Psychiatry 2008;63:629-32).

In the various studies, the therapeutic benefit of prazosin has been achieved within 1-2 weeks “with doses as low as 1 mg nightly,” Dr. Lydiard said.

In addition to improving sleep measures, prazosin may be useful for other trauma-related symptoms. In a small study of PTSD subjects whose nightmares were well controlled with the drug, the addition of small daytime doses lessened patients' reactivity to trauma cues during the day, he said (Biol. Psychiatry 2006;59:577-81). This finding “adds to the growing body of evidence that targeting sleep in PTSD is clinically relevant.”

Although some evidence exists to support the use of other antiadrenergic agents such as clonidine and guanfacine–as well as the anticonvulsant gabapentin–in PTSD, “large, randomized controlled trials are needed to clarify the role” of all of these agents, Dr. Lydiard said.

Additional studies also are warranted, he said, to investigate nonpharmacologic approaches to improving PTSD sleep disturbance, such as the use of imagery rehearsal therapy, which has demonstrated efficacy in small studies (J. Trauma Stress 2009;22:236-9).

Dr. Lydiard disclosed receiving honoraria from Reed Medical Education, the logistics collaborator for the Massachusetts General Hospital Psychiatry Academy.

BOSTON – Sleep disturbances may be an important target for treating posttraumatic stress disorder, according to Dr. R. Bruce Lydiard of the Medical University of South Carolina in Charleston.

Persistent, severe posttraumatic nightmares, REM sleep fragmentation, insomnia, excessive nocturnal periodic limb movements, and sleep-disordered breathing are frequently experienced by individuals with PTSD, Dr. Lydiard said. Although these sleep problems are often viewed as secondary symptoms of PTSD, “the evidence suggests that after a traumatic event, sleep disruption appears before the onset of PTSD and may be a risk factor for it,” he proposed.

Polysomnographic data from 21 individuals with traumatic injuries showed that the number of REM periods and the (shorter) duration of REM periods within 1 month after the traumatic event were predictive of PTSD symptom severity 6 weeks later (Am. J. Psychiatry 2002;159:1696-701).

Neurobiologically, the association makes sense, Dr. Lydiard said. “Sleep is regulated in part by brain areas in which PTSD-related changes occur,” which suggests that the stress response in PTSD and sleep dysfunction may be biologically linked.

Imaging studies suggest that exposure to trauma-related stimuli leads to hyperactivation in the amygdala and decreased activation in the medial prefrontal cortex/anterior cingulate cortex and hippocampus, with the magnitude of the activation correlating with the clinical severity of PTSD symptoms.

Polysomnographic investigations in patients with PTSD and sleep disturbances have revealed increased REM density, reduced REM duration, and increased motor activity, Dr. Lydiard said.

Together with clinical reports, “these data provide the basis for REM sleep dysregulation as a core feature in PTSD,” whereby increased activity in the amygdala and decreased inhibitory input from the medial prefrontal cortex lead to a persistently overactive noradrenergic system. “As a result, the usual rhythm of REM-NREM sleep is disrupted, and REM sleep is fragmented,” he said.

Based on this model, investigators have hypothesized that targeting noradrenergic signaling during or near REM episodes may normalize REM sleep, which in turn might improve PTSD sleep disturbances and, potentially, other PTSD symptoms, Dr. Lydiard said.

The alpha adrenergic antagonist prazosin has shown promise in multiple case and chart reviews, open-label trials, and placebo-controlled studies.

In one trial of 40 veterans with PTSD sleep disturbance, patients who were randomized to receive a nightly dose of prazosin–originally marketed as an antihypertensive agent–reported significant improvements in sleep quality and significant reductions in trauma nightmares, as well a better overall sense of well-being and improved daily functioning (Biol. Psychiatry 2007;61:928-34).

In another study, investigators evaluated the effect of prazosin vs. placebo on objective sleep parameters in 13 outpatients with chronic civilian trauma PTSD, frequent nightmares, and sleep disturbance. The prazosin group experienced significantly increased total sleep time as well as increased REM sleep time and mean REM period duration (Biol. Psychiatry 2008;63:629-32).

In the various studies, the therapeutic benefit of prazosin has been achieved within 1-2 weeks “with doses as low as 1 mg nightly,” Dr. Lydiard said.

In addition to improving sleep measures, prazosin may be useful for other trauma-related symptoms. In a small study of PTSD subjects whose nightmares were well controlled with the drug, the addition of small daytime doses lessened patients' reactivity to trauma cues during the day, he said (Biol. Psychiatry 2006;59:577-81). This finding “adds to the growing body of evidence that targeting sleep in PTSD is clinically relevant.”

Although some evidence exists to support the use of other antiadrenergic agents such as clonidine and guanfacine–as well as the anticonvulsant gabapentin–in PTSD, “large, randomized controlled trials are needed to clarify the role” of all of these agents, Dr. Lydiard said.

Additional studies also are warranted, he said, to investigate nonpharmacologic approaches to improving PTSD sleep disturbance, such as the use of imagery rehearsal therapy, which has demonstrated efficacy in small studies (J. Trauma Stress 2009;22:236-9).

Dr. Lydiard disclosed receiving honoraria from Reed Medical Education, the logistics collaborator for the Massachusetts General Hospital Psychiatry Academy.

BOSTON – Sleep disturbances may be an important target for treating posttraumatic stress disorder, according to Dr. R. Bruce Lydiard of the Medical University of South Carolina in Charleston.

Persistent, severe posttraumatic nightmares, REM sleep fragmentation, insomnia, excessive nocturnal periodic limb movements, and sleep-disordered breathing are frequently experienced by individuals with PTSD, Dr. Lydiard said. Although these sleep problems are often viewed as secondary symptoms of PTSD, “the evidence suggests that after a traumatic event, sleep disruption appears before the onset of PTSD and may be a risk factor for it,” he proposed.

Polysomnographic data from 21 individuals with traumatic injuries showed that the number of REM periods and the (shorter) duration of REM periods within 1 month after the traumatic event were predictive of PTSD symptom severity 6 weeks later (Am. J. Psychiatry 2002;159:1696-701).

Neurobiologically, the association makes sense, Dr. Lydiard said. “Sleep is regulated in part by brain areas in which PTSD-related changes occur,” which suggests that the stress response in PTSD and sleep dysfunction may be biologically linked.

Imaging studies suggest that exposure to trauma-related stimuli leads to hyperactivation in the amygdala and decreased activation in the medial prefrontal cortex/anterior cingulate cortex and hippocampus, with the magnitude of the activation correlating with the clinical severity of PTSD symptoms.

Polysomnographic investigations in patients with PTSD and sleep disturbances have revealed increased REM density, reduced REM duration, and increased motor activity, Dr. Lydiard said.

Together with clinical reports, “these data provide the basis for REM sleep dysregulation as a core feature in PTSD,” whereby increased activity in the amygdala and decreased inhibitory input from the medial prefrontal cortex lead to a persistently overactive noradrenergic system. “As a result, the usual rhythm of REM-NREM sleep is disrupted, and REM sleep is fragmented,” he said.

Based on this model, investigators have hypothesized that targeting noradrenergic signaling during or near REM episodes may normalize REM sleep, which in turn might improve PTSD sleep disturbances and, potentially, other PTSD symptoms, Dr. Lydiard said.

The alpha adrenergic antagonist prazosin has shown promise in multiple case and chart reviews, open-label trials, and placebo-controlled studies.

In one trial of 40 veterans with PTSD sleep disturbance, patients who were randomized to receive a nightly dose of prazosin–originally marketed as an antihypertensive agent–reported significant improvements in sleep quality and significant reductions in trauma nightmares, as well a better overall sense of well-being and improved daily functioning (Biol. Psychiatry 2007;61:928-34).

In another study, investigators evaluated the effect of prazosin vs. placebo on objective sleep parameters in 13 outpatients with chronic civilian trauma PTSD, frequent nightmares, and sleep disturbance. The prazosin group experienced significantly increased total sleep time as well as increased REM sleep time and mean REM period duration (Biol. Psychiatry 2008;63:629-32).

In the various studies, the therapeutic benefit of prazosin has been achieved within 1-2 weeks “with doses as low as 1 mg nightly,” Dr. Lydiard said.

In addition to improving sleep measures, prazosin may be useful for other trauma-related symptoms. In a small study of PTSD subjects whose nightmares were well controlled with the drug, the addition of small daytime doses lessened patients' reactivity to trauma cues during the day, he said (Biol. Psychiatry 2006;59:577-81). This finding “adds to the growing body of evidence that targeting sleep in PTSD is clinically relevant.”

Although some evidence exists to support the use of other antiadrenergic agents such as clonidine and guanfacine–as well as the anticonvulsant gabapentin–in PTSD, “large, randomized controlled trials are needed to clarify the role” of all of these agents, Dr. Lydiard said.

Additional studies also are warranted, he said, to investigate nonpharmacologic approaches to improving PTSD sleep disturbance, such as the use of imagery rehearsal therapy, which has demonstrated efficacy in small studies (J. Trauma Stress 2009;22:236-9).

Dr. Lydiard disclosed receiving honoraria from Reed Medical Education, the logistics collaborator for the Massachusetts General Hospital Psychiatry Academy.

BOSTON – Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder, and developmental delay compared with the estimated incidence in the general population.

These children “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions lack a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar said in a poster presentation.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures. Data included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years (6.2 in girls and 7.0 in boys), said Dr. Indulkar, a neurology resident at the Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%–substantially higher than the estimated 1%-4% in the general pediatric population.

ADHD was seen in 11% of the seizure population, compared with an estimated prevalence rate of 3%-7% in school-aged children. Developmental delay, including pervasive developmental disorder, language disorder, and autism, was seen in 10.2% of the seizure population, and tics were noted in 5.1%. There was also a high incidence of migraine and headaches in the study population.

Investigators have postulated that there is a link between the benign and more serious epilepsy syndromes, based on the presence of epileptiform disturbances in children who have epilepsies of varying severity and learning, and other CNS-related comorbidities. However, “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive,” Dr. Indulkar said in an interview.

The investigators did not consider the influence of antiseizure medications on children in this study. “Not all children with BECTS are treated, as most seizures are rare, occur nocturnally, and are self-limited, so it's unlikely that medications alone could explain the cognitive problems,” she said.

Dr. Indulkar reported no conflicts of interest with respect to her presentation.

BOSTON – Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder, and developmental delay compared with the estimated incidence in the general population.

These children “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions lack a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar said in a poster presentation.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures. Data included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years (6.2 in girls and 7.0 in boys), said Dr. Indulkar, a neurology resident at the Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%–substantially higher than the estimated 1%-4% in the general pediatric population.

ADHD was seen in 11% of the seizure population, compared with an estimated prevalence rate of 3%-7% in school-aged children. Developmental delay, including pervasive developmental disorder, language disorder, and autism, was seen in 10.2% of the seizure population, and tics were noted in 5.1%. There was also a high incidence of migraine and headaches in the study population.

Investigators have postulated that there is a link between the benign and more serious epilepsy syndromes, based on the presence of epileptiform disturbances in children who have epilepsies of varying severity and learning, and other CNS-related comorbidities. However, “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive,” Dr. Indulkar said in an interview.

The investigators did not consider the influence of antiseizure medications on children in this study. “Not all children with BECTS are treated, as most seizures are rare, occur nocturnally, and are self-limited, so it's unlikely that medications alone could explain the cognitive problems,” she said.

Dr. Indulkar reported no conflicts of interest with respect to her presentation.

BOSTON – Children with benign focal epilepsy with centro-temporal spikes had a higher incidence of psychiatric illnesses, attention-deficit/hyperactivity disorder, and developmental delay compared with the estimated incidence in the general population.

These children “are not sufficiently screened for psychological and other cognitive problems. The nocturnal seizures are often missed, unless the child generalizes; and most institutions lack a good neuropsychiatry division to assess for learning difficulties. Subtle learning difficulties often go undetected,” Dr. Shalaka Indulkar said in a poster presentation.

Dr. Indulkar and colleagues reviewed consecutive routine EEGs from 1995 through 2004 for pediatric patients with benign focal epileptiform discharges. They identified 117 whose seizures were consistent with benign focal epilepsy with centro-temporal spikes (BECTS). These features included either typical brief hemifacial seizures associated with speech arrest, drooling, and preservation of consciousness; gurgling or grunting noises with loss of consciousness and terminating in vomiting; or nocturnal secondarily generalized seizures. Data included general demographics and neurologic, behavioral, and psychiatric disorders and used descriptive data and the Fisher's exact test for analysis.

Of the 117 patients, 51 were girls and 66 were boys. Mean age at initial diagnosis of EEG abnormality was 6.8 years (6.2 in girls and 7.0 in boys), said Dr. Indulkar, a neurology resident at the Cleveland Clinic.

The prevalence of co-existing psychiatric problems, including anxiety, schizophrenia, obsessive compulsive disorder, and depression in the study population was 9.4%–substantially higher than the estimated 1%-4% in the general pediatric population.

ADHD was seen in 11% of the seizure population, compared with an estimated prevalence rate of 3%-7% in school-aged children. Developmental delay, including pervasive developmental disorder, language disorder, and autism, was seen in 10.2% of the seizure population, and tics were noted in 5.1%. There was also a high incidence of migraine and headaches in the study population.

Investigators have postulated that there is a link between the benign and more serious epilepsy syndromes, based on the presence of epileptiform disturbances in children who have epilepsies of varying severity and learning, and other CNS-related comorbidities. However, “children with typical [BECTS] do not necessarily have abnormal EEGs in sleep, but they still may have learning difficulties, so the mechanism [for the CNS-related comorbidities] remains elusive,” Dr. Indulkar said in an interview.

The investigators did not consider the influence of antiseizure medications on children in this study. “Not all children with BECTS are treated, as most seizures are rare, occur nocturnally, and are self-limited, so it's unlikely that medications alone could explain the cognitive problems,” she said.

Dr. Indulkar reported no conflicts of interest with respect to her presentation.

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual “National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents,” conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school–which represents a 39% increase since last year, when 23% of middle school students reported their schools to be “drug infected.” It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report (www.casacolumbia.org/templates/publications_reports.aspx

“These data are particularly troubling,” Dr. Mark S. Gold said in an interview when asked about the CASA report. “It is difficult enough to learn and compete in this global economy without having drugs on school grounds, gangs, and likely sales and use in schools,” said Dr. Gold, the Donald R. Dizney Eminent Scholar and Distinguished Professor at the McKnight Brain Institute of the University of Florida, Gainesville. “Experts across the United States who evaluate and treat adolescents are rapidly developing programs for dual disorders and drug problems to keep up with the ominous calls from parents and children.”

The study found a wide gap between drug and gang presence reported at public schools vs. private and religious schools. Fifty-seven percent of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence. “The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001,” they wrote.

These findings portend “a trajectory to tragedy for millions of children and families,” Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a “malignant cancer.”

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), 3 times more likely to have used alcohol (39% vs. 12%), and 5 times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use, and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%), the report showed.

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use. To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

“The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol, or marijuana,” the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

In addition to the standard telephone-based survey administered to a nationally representative sample of 1,000 12- to 17-year-olds, CASA's 2010 back-to-school report also relied, for the first time, on an Internet-based survey administered to a nationally representative sample of 1,055 12- to 17-year-olds and 456 parents of these adolescents, the authors noted.

Dr. Robert L. DuPont, who serves as president of the Institute for Behavior and Health, Rockville, Md., and was the first director of the National Institute on Drug Abuse, said in an interview that wider use of random student drug testing might be a good way to reduce drug use and to identify drug-using students in an effort to help them become and stay drug-free.

The only 100% safe and effective treatment is prevention, said Dr. Gold, who also serves as chair of the psychiatry department at the University of Florida. “More of our experts' time and energy need to be focused on these trends and data … and on prevention.”

Adolescents reporting drugs and gangs at their schools were five times more likely to have used marijuana.

Source ©Jabejon/Istockphoto.Com

My Take

Strong Social Fabric Offers Protection

The ray of hope in the [CASA] survey results is the association between the strength of the family bond and substance use. Students who feel valued, supported, and connected at home are less likely than are those who do not to smoke, drink, or use illegal drugs, even in schools in which gang and drug activity is reported. This finding confirms the importance of children having adults in their lives to help them gain self-control over their urges. The more that educators, administrators, and public health–minded pediatric clinicians begin to understand that it is the social fabric surrounding youth that helps them avoid risky behaviors, the more likely they will be to support efforts that rebuild villages and foster connectedness between families and their offspring.

CARL C. BELL, M.D., is president and chief executive officer of Community Mental Health Council Inc. in Chicago, acting director of the Institute for Juvenile Research, and professor of psychiatry and public health at the University of Illinois at Chicago.

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual “National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents,” conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school–which represents a 39% increase since last year, when 23% of middle school students reported their schools to be “drug infected.” It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report (www.casacolumbia.org/templates/publications_reports.aspx

“These data are particularly troubling,” Dr. Mark S. Gold said in an interview when asked about the CASA report. “It is difficult enough to learn and compete in this global economy without having drugs on school grounds, gangs, and likely sales and use in schools,” said Dr. Gold, the Donald R. Dizney Eminent Scholar and Distinguished Professor at the McKnight Brain Institute of the University of Florida, Gainesville. “Experts across the United States who evaluate and treat adolescents are rapidly developing programs for dual disorders and drug problems to keep up with the ominous calls from parents and children.”

The study found a wide gap between drug and gang presence reported at public schools vs. private and religious schools. Fifty-seven percent of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence. “The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001,” they wrote.

These findings portend “a trajectory to tragedy for millions of children and families,” Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a “malignant cancer.”

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), 3 times more likely to have used alcohol (39% vs. 12%), and 5 times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use, and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%), the report showed.

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use. To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

“The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol, or marijuana,” the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

In addition to the standard telephone-based survey administered to a nationally representative sample of 1,000 12- to 17-year-olds, CASA's 2010 back-to-school report also relied, for the first time, on an Internet-based survey administered to a nationally representative sample of 1,055 12- to 17-year-olds and 456 parents of these adolescents, the authors noted.

Dr. Robert L. DuPont, who serves as president of the Institute for Behavior and Health, Rockville, Md., and was the first director of the National Institute on Drug Abuse, said in an interview that wider use of random student drug testing might be a good way to reduce drug use and to identify drug-using students in an effort to help them become and stay drug-free.

The only 100% safe and effective treatment is prevention, said Dr. Gold, who also serves as chair of the psychiatry department at the University of Florida. “More of our experts' time and energy need to be focused on these trends and data … and on prevention.”

Adolescents reporting drugs and gangs at their schools were five times more likely to have used marijuana.

Source ©Jabejon/Istockphoto.Com

My Take

Strong Social Fabric Offers Protection

The ray of hope in the [CASA] survey results is the association between the strength of the family bond and substance use. Students who feel valued, supported, and connected at home are less likely than are those who do not to smoke, drink, or use illegal drugs, even in schools in which gang and drug activity is reported. This finding confirms the importance of children having adults in their lives to help them gain self-control over their urges. The more that educators, administrators, and public health–minded pediatric clinicians begin to understand that it is the social fabric surrounding youth that helps them avoid risky behaviors, the more likely they will be to support efforts that rebuild villages and foster connectedness between families and their offspring.

CARL C. BELL, M.D., is president and chief executive officer of Community Mental Health Council Inc. in Chicago, acting director of the Institute for Juvenile Research, and professor of psychiatry and public health at the University of Illinois at Chicago.

More than one-quarter of the nation's school students say drugs and gangs are rampant in their middle and high schools, and almost half report that they are aware of drugs being sold or used on school grounds, a Columbia University report shows.

The 15th annual “National Survey of American Attitudes on Substance Abuse XV: Adolescents and Parents,” conducted by the university's National Center on Addiction and Substance Abuse (CASA), found that 5.7 million (27%) of the country's 12- to 17-year-old public school students attend schools where drugs are used, kept, or sold and where gangs are present.

The study also found that 32% of middle school students specifically said drugs are used, kept, or sold at their school–which represents a 39% increase since last year, when 23% of middle school students reported their schools to be “drug infected.” It also found that about 66% of high school students reported attending drug-infected schools, which represents a slight but steady rise since 2006.

Gang activity, which was included in the survey for the first time this year, appears to be an important marker of drug activity. Compared with their counterparts, adolescents in schools with gangs were nearly twice as likely to report that drugs are used, kept, or sold on school grounds (30% vs. 58%), according to the report (www.casacolumbia.org/templates/publications_reports.aspx

“These data are particularly troubling,” Dr. Mark S. Gold said in an interview when asked about the CASA report. “It is difficult enough to learn and compete in this global economy without having drugs on school grounds, gangs, and likely sales and use in schools,” said Dr. Gold, the Donald R. Dizney Eminent Scholar and Distinguished Professor at the McKnight Brain Institute of the University of Florida, Gainesville. “Experts across the United States who evaluate and treat adolescents are rapidly developing programs for dual disorders and drug problems to keep up with the ominous calls from parents and children.”

The study found a wide gap between drug and gang presence reported at public schools vs. private and religious schools. Fifty-seven percent of adolescents at public schools and 22% at private or religious schools reporting drug activity at their schools, and 46% of adolescents in public schools and 2% in private or religious schools reporting gang presence. “The gap between drug-free public schools, and drug-free private and religious schools has nearly doubled since its narrowest point in 2001,” they wrote.

These findings portend “a trajectory to tragedy for millions of children and families,” Joseph A. Califano Jr. wrote in a statement accompanying the 2010 report. The CASA founder and chairman called the combination of gangs and drugs in school a “malignant cancer.”

For example, compared with 12- to 17-year-olds at drug- and gang-free schools, those reporting drugs and gangs at their school were nearly 12 times more likely to have used tobacco (23% vs. 2%), 3 times more likely to have used alcohol (39% vs. 12%), and 5 times more likely to have used marijuana (21% vs. 4%), according to the report. Importantly, the associations between tobacco, alcohol, and marijuana use, and indicators of gangs and drugs in school remained significant and meaningful in logistic regression analyses controlling for socioeconomic status, the authors wrote.

The potential social impact of attending a school with gang and drug activity also was assessed. Relative to adolescents in drug- and gang-free schools, adolescents in gang- and drug-infected schools were nearly three times more likely to have friends who drink alcohol regularly (62% vs. 22%), nearly four times more likely to have friends who smoke marijuana (49% vs. 13%), six times more likely to know a friend or classmate who abuses prescription drugs (30% vs. 5%), and nearly five times more likely to know a friend or classmate who uses illegal drugs such as cocaine, heroin, methamphetamines, or hallucinogens (50% vs. 11%), the report showed.

This year, for the first time, the CASA investigators sought to evaluate the effect that an adolescent's relationship with his or her family has on his or her risk for smoking, drinking, and drug use. To do this, they used factor analysis, scoring the adolescents on the strength of their family ties based on their responses to survey questions about their relationships with their parents, the degree to which they felt their parents listened to them, attendance at religious services, and the frequency of family dinners.

“The stronger the family ties, the less likely adolescents are to have used tobacco, alcohol, or marijuana,” the authors concluded. Compared with adolescents in families with strong family ties, those with weak family ties were four times more likely to have tried tobacco (20% vs. 5%); nearly three times more likely to have tried alcohol (35% vs. 12%); and four times more likely to have tried marijuana (20% vs. 5%).

In addition to the standard telephone-based survey administered to a nationally representative sample of 1,000 12- to 17-year-olds, CASA's 2010 back-to-school report also relied, for the first time, on an Internet-based survey administered to a nationally representative sample of 1,055 12- to 17-year-olds and 456 parents of these adolescents, the authors noted.

Dr. Robert L. DuPont, who serves as president of the Institute for Behavior and Health, Rockville, Md., and was the first director of the National Institute on Drug Abuse, said in an interview that wider use of random student drug testing might be a good way to reduce drug use and to identify drug-using students in an effort to help them become and stay drug-free.

The only 100% safe and effective treatment is prevention, said Dr. Gold, who also serves as chair of the psychiatry department at the University of Florida. “More of our experts' time and energy need to be focused on these trends and data … and on prevention.”

Adolescents reporting drugs and gangs at their schools were five times more likely to have used marijuana.

Source ©Jabejon/Istockphoto.Com

My Take

Strong Social Fabric Offers Protection

The ray of hope in the [CASA] survey results is the association between the strength of the family bond and substance use. Students who feel valued, supported, and connected at home are less likely than are those who do not to smoke, drink, or use illegal drugs, even in schools in which gang and drug activity is reported. This finding confirms the importance of children having adults in their lives to help them gain self-control over their urges. The more that educators, administrators, and public health–minded pediatric clinicians begin to understand that it is the social fabric surrounding youth that helps them avoid risky behaviors, the more likely they will be to support efforts that rebuild villages and foster connectedness between families and their offspring.

CARL C. BELL, M.D., is president and chief executive officer of Community Mental Health Council Inc. in Chicago, acting director of the Institute for Juvenile Research, and professor of psychiatry and public health at the University of Illinois at Chicago.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Emergency general surgery procedures are associated with high overall morbidity and serious morbidity/mortality, as well as widely varying quality of care among hospitals, a large national study has shown.

Dr. Angela M. Ingraham, a clinical scholar-in-residence at the American College of Surgeons in Chicago, and her colleagues used the 2005-2008 ACS National Surgical Quality Improvement Project (NSQIP) database to assess the 30-day outcomes of three common emergency general surgery procedures as well as hospital-level performance across procedures. They identified 45,602 patients who underwent emergency appendectomy, cholecystectomy, or colorectal resection at 222 NSQIP-participating hospitals nationwide.

“We selected these procedures because appendectomy and cholecystectomy represent two of the most commonly performed emergency surgery procedures, and emergency colorectal resections are associated with a high risk of adverse events,” the investigators said in the August issue of the journal Surgery.

For the analysis, the outcomes of interest included overall morbidity and serious morbidity/mortality (defined as documentation of at least one of the following NSQIP complications: organ space surgical-site infection, wound dehiscence, neurologic event, cardiac arrest, MI, bleeding that requires transfusion of more than 4 units of blood, pulmonary embolism, ventilator dependence for more than 48 hours, and progressive or acute renal insufficiency or sepsis or septic shock).

Not unexpectedly, patients undergoing emergency colorectal resection fared the worst: Overall, 4,202 of 8,990 colorectal resection patients (46.74%) experienced any morbidity within 30 days of the procedure, and 3,736 (41.56%) experienced serious morbidity or death, the investigators reported. Of the 30,788 patients who underwent appendectomies, 1,984 (6.44%) had any morbidity and 1,140 (3.70%) experienced serious morbidity or death. And of 5,824 patients who had emergency cholecystectomies, 503 (8.64%) had any morbidity and 371 (6.37%) experienced serious morbidity or death, they said (Surgery 2010;148: 217-38).

The investigators used stepwise logistic regression to identify predictors of any morbidity and of serious mortality/morbidity, and to generate patient-level predicted probabilities of an outcome. They used expected probabilities to calculate observed:expected ratios for overall morbidity and serious morbidity/mortality for each hospital.

The risk factors identified as strong predictors of overall morbidity and serious morbidity/mortality following all three procedures were American Society of Anesthesiologists (ASA) class, functional status, and preoperative sepsis, the investigators said. For appendectomies, the presence of abscesses or peritonitis was associated with a significantly higher risk of both overall morbidity and serious morbidity/mortality. Following cholecystectomy, the highest risks of overall morbidity and serious morbidity/mortality were observed with postoperative diagnoses of acute cholecystitis and “other” findings; and for colorectal resection, hemorrhage was associated with the highest risk of overall morbidity.

More favorable outcomes were observed in patients whose emergency appendectomies and cholecystectomies were performed laparoscopically, they noted.

The observed:expected ratio ranges for overall morbidity were 0.26-2.36 for appendectomy, 0-3.04 for cholecystectomy, and 0.45-1.51 for colorectal resection. For serious morbidity/mortality, the ratio ranges were 0.23-2.54 for appendectomy, 0-4.28 for cholecystectomy, and 0.59-1.75 for colorectal resection.

To evaluate the consistency of hospital-level performance across procedures, the investigators included patient outcome information from 95 of the 222 NSQIP hospitals that submitted at least 20 cases of each of the three procedures. Using weighted kappa statistics, they demonstrated substantial variability across emergency cases for most hospitals, which were divided into tertiles based on observed:expected ratios. For overall morbidity for all procedures, seven hospitals (7.4%) were rated in the highest, or best, tertile and eight (8.4%) were rated in the lowest tertile. For serious morbidity/mortality for all procedures, nine hospitals (9.5%) were rated in the highest tertile and eight (8.4%) were rated in the lowest tertile, they reported.

The finding of consistent performance for only a significant minority of the hospitals suggests that most hospitals have areas in which care can be improved, the investigators said. “Given the high-risk nature of emergency surgery, the best practices of hospitals with consistently favorable outcomes should be identified and disseminated to facilitate targeted quality improvement initiatives at hospitals with more variable or worse outcomes.”

The investigators acknowledged that the study included only hospitals participating in NSQIP and, for hospital-level comparisons, only those hospitals submitting the required minimum number of emergency surgery cases across all three procedures. As a result, the generalizability of the findings may be limited, the investigators said.

The investigators reported no financial conflicts of interest relevant to this study.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The "incredible variation" indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, "it is relatively meaningless to try to summarize [influenza burden] with one number," Dr. Shay stressed. "There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion."

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, "the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not," the authors reported. "The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not."

The numbers "confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year," Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The "incredible variation" indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, "it is relatively meaningless to try to summarize [influenza burden] with one number," Dr. Shay stressed. "There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion."

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, "the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not," the authors reported. "The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not."

The numbers "confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year," Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The "incredible variation" indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, "it is relatively meaningless to try to summarize [influenza burden] with one number," Dr. Shay stressed. "There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion."

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, "the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not," the authors reported. "The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not."

The numbers "confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year," Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The “incredible variation” indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, “it is relatively meaningless to try to summarize [influenza burden] with one number,” Dr. Shay stressed. “There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion.”

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, “the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not,” the authors reported. “The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not.”

The numbers “confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year,” Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The “incredible variation” indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, “it is relatively meaningless to try to summarize [influenza burden] with one number,” Dr. Shay stressed. “There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion.”

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, “the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not,” the authors reported. “The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not.”

The numbers “confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year,” Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.

Annual estimates of influenza-associated deaths from 1976-2007 varied substantially by season, influenza virus type, underlying cause of death, and age group, according to revised statistical models, the Centers for Disease Control and Prevention reported August 27 in its Morbidity and Mortality Weekly Report.

The “incredible variation” indicates that using a single, average estimate insufficiently communicates the mortality burden of influenza, Dr. David Shay, medical officer with the CDC’s National Center for Immunization and Respiratory Diseases, said in a media briefing.

With a low of 3,349 estimated deaths in 1986-87 and a high of 48,614 deaths in 2003-2004, the estimated annual rate of influenza-associated deaths in the United States from 1976-2007 ranged from 1.4 to 16.7 deaths per 100,000 persons, according to the new models, which update the CDC’s previously published estimates for 1976-2003 and include new data from 2006-2007.

Because of the wide variability across influenza seasons, “it is relatively meaningless to try to summarize [influenza burden] with one number,” Dr. Shay stressed. “There are very few average seasons, so providing a simple average fails to communicate the impact of flu in an understandable fashion.”

For this reason, the CDC advises quantifying influenza-associated deaths in the context of circulating virus strains and underlying causes of death among age groups. Toward this end, the influenza-associated mortality estimates in the CDC’s revised models are provided for three age groups (younger than 19 years, 19–64 years, and 65 years or older) and for two categories of underlying cause of death codes: pneumonia and influenza causes and respiratory and circulatory causes.

For pneumonia and influenza causes, the respective estimated annual average of influenza-associated deaths and the rate of influenza-associated deaths per 100,000 people were 6,309 and 2.4 for the U.S. population overall; 97 and 0.1 for persons younger than 19 years; 666 and 0.4 for adults age 19-64 years; and 5,546 and 17.0 for adults 65 years and older, the report states.

For deaths with underlying respiratory and circulatory causes, the respective estimated number and rate of influenza-associated deaths per 100,000 was 23,607 and 9.0 for the U.S. population overall; 124 and 0.2 for persons younger than age 19 years; 2,385 and 1.5 among adults age 19–64 years; and 21,098 and 66.1 among adults age 65 years and older (MMWR 2010;33:1057-62).

For both causes, “the average mortality rates for the 22 seasons during which influenza A(H3N2) was a prominent strain were 2.7 times higher than for the nine seasons that it was not,” the authors reported. “The average annual number of influenza-associated deaths during influenza A(H3N2) prominent seasons was 7,722 for pneumonia and influenza causes and 28,909 for respiratory and circulatory causes, compared with 2,856 deaths for pneumonia and influenza causes and 10,648 deaths for respiratory and circulatory causes in seasons in which it was not.”

The numbers “confirm that influenza has a substantial burden of mortality each year, but also that the burden can change substantially from year to year,” Dr. Shay stated.

The findings represented in the revised model are limited by a number of factors, including the failure to account for co-circulating pathogens such as respiratory syncytial virus; the possibility that changing virus surveillance data may reduce the relevance of comparing estimates over time; and the possibility that the increase in the number of adults older than age 65 years during the study period could have contributed to an increase in influenza-associated mortality, according to the authors. Also, because the models rely on national death certificate data through 2007, preliminary estimates of 2009 influenza A(H1N1)-associated deaths are not comparable, they wrote.