Kate Johnson

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.), said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand. Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine. There are new updated American Academy of Pediatric recommendations that first-timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (ED) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. While it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said. “Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%—that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

The numbers of visits needed are overwhelming, underscoring the need for new delivery systems. DR. RAND

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.), said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand. Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine. There are new updated American Academy of Pediatric recommendations that first-timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (ED) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. While it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said. “Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%—that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

The numbers of visits needed are overwhelming, underscoring the need for new delivery systems. DR. RAND

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.), said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand. Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine. There are new updated American Academy of Pediatric recommendations that first-timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (ED) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. While it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said. “Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%—that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

The numbers of visits needed are overwhelming, underscoring the need for new delivery systems. DR. RAND

TORONTO — Parents' safety concerns about children's vaccines may negatively influence their decisions about vaccination, but physicians' recommendations can override that, study results show.

These results might “make us pay a lot more attention to the fact that safety concerns may end up being problematic with respect to eventual acceptance by parents,” Sarah Clark of the University of Michigan, Ann Arbor, said in an oral poster presentation at the annual meeting of the Pediatric Academic Societies.

The study used a Web-based survey of 1,410 parents of children aged 9–18 years to gauge the depth of parental concerns about the safety of vaccines and the extent to which these concerns influence parents' decisions to have their children vaccinated.

Parents were asked to respond on the Likert scale to the general statement, “Newly available vaccines are safe for my children,” and then were asked whether they planned to vaccinate their children in the next 5 years with the meningococcal conjugate vaccine (MCV-4), combined tetanus-diphtheria-acellular pertussis (Tdap) vaccine, and human papillomavirus vaccine (HPV).

The survey indicated that 49% of the parents had neutral opinions regarding whether vaccines were safe; 11% said they were not safe, and 40% said they were safe.

Regarding their intentions to vaccinate their children with the specific vaccines, responses were positive for MCV-4 and Tdap with 36% each, compared with 40% for HPV.

In regression analysis, adjusted for parents' age, sex, income, and education, safety concerns were strongly associated with significantly lower odds of MCV-4 adoption (odds ratio [OR] 0.23), Tdap adoption (OR 0.26), and HPV adoption (OR 0.35).

“The more concern there is with safety, the less likely people are to adopt,” coauthor Dianne Singer, also from the University of Michigan, said in an interview.

However, although 11% of parents indicated they disagreed or strongly disagreed about vaccine safety, it was the neutral 49% who interested the researchers most. “As we expected, the people who disagreed or strongly disagreed were much less likely to have received or to say they planned to receive the vaccines [for their children], but surprisingly the neutral group was also less likely to say they would accept the vaccines,” Ms. Clark said in her presentation. “The neutrals were not all that neutral … and certainly we had a lot of folks who said they needed a lot more information.”

“We saw that if physicians recommended the vaccine there was a stronger adoption of the vaccine,” said Ms. Singer.

TORONTO — Parents' safety concerns about children's vaccines may negatively influence their decisions about vaccination, but physicians' recommendations can override that, study results show.

These results might “make us pay a lot more attention to the fact that safety concerns may end up being problematic with respect to eventual acceptance by parents,” Sarah Clark of the University of Michigan, Ann Arbor, said in an oral poster presentation at the annual meeting of the Pediatric Academic Societies.

The study used a Web-based survey of 1,410 parents of children aged 9–18 years to gauge the depth of parental concerns about the safety of vaccines and the extent to which these concerns influence parents' decisions to have their children vaccinated.

Parents were asked to respond on the Likert scale to the general statement, “Newly available vaccines are safe for my children,” and then were asked whether they planned to vaccinate their children in the next 5 years with the meningococcal conjugate vaccine (MCV-4), combined tetanus-diphtheria-acellular pertussis (Tdap) vaccine, and human papillomavirus vaccine (HPV).

The survey indicated that 49% of the parents had neutral opinions regarding whether vaccines were safe; 11% said they were not safe, and 40% said they were safe.

Regarding their intentions to vaccinate their children with the specific vaccines, responses were positive for MCV-4 and Tdap with 36% each, compared with 40% for HPV.

In regression analysis, adjusted for parents' age, sex, income, and education, safety concerns were strongly associated with significantly lower odds of MCV-4 adoption (odds ratio [OR] 0.23), Tdap adoption (OR 0.26), and HPV adoption (OR 0.35).

“The more concern there is with safety, the less likely people are to adopt,” coauthor Dianne Singer, also from the University of Michigan, said in an interview.

However, although 11% of parents indicated they disagreed or strongly disagreed about vaccine safety, it was the neutral 49% who interested the researchers most. “As we expected, the people who disagreed or strongly disagreed were much less likely to have received or to say they planned to receive the vaccines [for their children], but surprisingly the neutral group was also less likely to say they would accept the vaccines,” Ms. Clark said in her presentation. “The neutrals were not all that neutral … and certainly we had a lot of folks who said they needed a lot more information.”

“We saw that if physicians recommended the vaccine there was a stronger adoption of the vaccine,” said Ms. Singer.

TORONTO — Parents' safety concerns about children's vaccines may negatively influence their decisions about vaccination, but physicians' recommendations can override that, study results show.

These results might “make us pay a lot more attention to the fact that safety concerns may end up being problematic with respect to eventual acceptance by parents,” Sarah Clark of the University of Michigan, Ann Arbor, said in an oral poster presentation at the annual meeting of the Pediatric Academic Societies.

The study used a Web-based survey of 1,410 parents of children aged 9–18 years to gauge the depth of parental concerns about the safety of vaccines and the extent to which these concerns influence parents' decisions to have their children vaccinated.

Parents were asked to respond on the Likert scale to the general statement, “Newly available vaccines are safe for my children,” and then were asked whether they planned to vaccinate their children in the next 5 years with the meningococcal conjugate vaccine (MCV-4), combined tetanus-diphtheria-acellular pertussis (Tdap) vaccine, and human papillomavirus vaccine (HPV).

The survey indicated that 49% of the parents had neutral opinions regarding whether vaccines were safe; 11% said they were not safe, and 40% said they were safe.

Regarding their intentions to vaccinate their children with the specific vaccines, responses were positive for MCV-4 and Tdap with 36% each, compared with 40% for HPV.

In regression analysis, adjusted for parents' age, sex, income, and education, safety concerns were strongly associated with significantly lower odds of MCV-4 adoption (odds ratio [OR] 0.23), Tdap adoption (OR 0.26), and HPV adoption (OR 0.35).

“The more concern there is with safety, the less likely people are to adopt,” coauthor Dianne Singer, also from the University of Michigan, said in an interview.

However, although 11% of parents indicated they disagreed or strongly disagreed about vaccine safety, it was the neutral 49% who interested the researchers most. “As we expected, the people who disagreed or strongly disagreed were much less likely to have received or to say they planned to receive the vaccines [for their children], but surprisingly the neutral group was also less likely to say they would accept the vaccines,” Ms. Clark said in her presentation. “The neutrals were not all that neutral … and certainly we had a lot of folks who said they needed a lot more information.”

“We saw that if physicians recommended the vaccine there was a stronger adoption of the vaccine,” said Ms. Singer.

TORONTO — Current classifications of pediatric asthma fail to capture the potential for severe exacerbations in patients with mild disease, according to Dr. Christopher Carroll of Connecticut Children's Medical Center in Hartford.

In a study of nearly 300 asthmatic children, which Dr. Carroll presented in a poster at the annual meeting of the Pediatric Academic Societies, more than half of those admitted to the intensive care unit with severe exacerbations were classified as having “mild” asthma.

National Heart, Lung, and Blood Institute (NHLBI) guidelines classify pediatric asthma as either mild intermittent, mild persistent, moderate persistent, or severe persistent, based on the frequency of baseline symptoms, Dr. Carroll said in an interview. But this classification system fails to account for children in whom mild baseline disease can progress to severe exacerbations. “These kids with mild asthma can have severe life-threatening exacerbations where they need to be put on a ventilator or admitted to the ICU—and they can stay in the ICU for 8 days, some of them.”

Dr. Carroll and his associates reviewed the charts of 298 children aged 2 years or older who were admitted to the ICU with asthma exacerbation over a 9-year period. More than half (55%) of the children were classified as having mild asthma (defined as mild intermittent or mild persistent). A comparison of children with mild asthma with those who had more severe disease showed no differences in the severity of their exacerbations at admission, their hospital or ICU length of stay, or the therapies they received.

Compared with children who had more severe baseline disease, those with mild asthma were younger (7.6 vs. 9.8 years), less likely to have been admitted to hospital previously for asthma (42% vs. 77%), less likely to have been admitted to the ICU previously for asthma (11% vs. 41%), and less likely to have public insurance (46% vs. 65%). There also were ethnic differences: equal percentages of African Americans but fewer Hispanics in the milder group (30% vs. 47%) and more whites (42% vs. 24%).

“Even kids with mild asthma are susceptible to severe exacerbations,” said Dr. Carroll. “[Some] of my adult critical care colleagues [said] only severe asthmatics end up in the ICU. I said that's not true in kids. We see kids with 'mild asthma' who are in our ICU all the time.”

TORONTO — Current classifications of pediatric asthma fail to capture the potential for severe exacerbations in patients with mild disease, according to Dr. Christopher Carroll of Connecticut Children's Medical Center in Hartford.

In a study of nearly 300 asthmatic children, which Dr. Carroll presented in a poster at the annual meeting of the Pediatric Academic Societies, more than half of those admitted to the intensive care unit with severe exacerbations were classified as having “mild” asthma.

National Heart, Lung, and Blood Institute (NHLBI) guidelines classify pediatric asthma as either mild intermittent, mild persistent, moderate persistent, or severe persistent, based on the frequency of baseline symptoms, Dr. Carroll said in an interview. But this classification system fails to account for children in whom mild baseline disease can progress to severe exacerbations. “These kids with mild asthma can have severe life-threatening exacerbations where they need to be put on a ventilator or admitted to the ICU—and they can stay in the ICU for 8 days, some of them.”

Dr. Carroll and his associates reviewed the charts of 298 children aged 2 years or older who were admitted to the ICU with asthma exacerbation over a 9-year period. More than half (55%) of the children were classified as having mild asthma (defined as mild intermittent or mild persistent). A comparison of children with mild asthma with those who had more severe disease showed no differences in the severity of their exacerbations at admission, their hospital or ICU length of stay, or the therapies they received.

Compared with children who had more severe baseline disease, those with mild asthma were younger (7.6 vs. 9.8 years), less likely to have been admitted to hospital previously for asthma (42% vs. 77%), less likely to have been admitted to the ICU previously for asthma (11% vs. 41%), and less likely to have public insurance (46% vs. 65%). There also were ethnic differences: equal percentages of African Americans but fewer Hispanics in the milder group (30% vs. 47%) and more whites (42% vs. 24%).

“Even kids with mild asthma are susceptible to severe exacerbations,” said Dr. Carroll. “[Some] of my adult critical care colleagues [said] only severe asthmatics end up in the ICU. I said that's not true in kids. We see kids with 'mild asthma' who are in our ICU all the time.”

TORONTO — Current classifications of pediatric asthma fail to capture the potential for severe exacerbations in patients with mild disease, according to Dr. Christopher Carroll of Connecticut Children's Medical Center in Hartford.

In a study of nearly 300 asthmatic children, which Dr. Carroll presented in a poster at the annual meeting of the Pediatric Academic Societies, more than half of those admitted to the intensive care unit with severe exacerbations were classified as having “mild” asthma.

National Heart, Lung, and Blood Institute (NHLBI) guidelines classify pediatric asthma as either mild intermittent, mild persistent, moderate persistent, or severe persistent, based on the frequency of baseline symptoms, Dr. Carroll said in an interview. But this classification system fails to account for children in whom mild baseline disease can progress to severe exacerbations. “These kids with mild asthma can have severe life-threatening exacerbations where they need to be put on a ventilator or admitted to the ICU—and they can stay in the ICU for 8 days, some of them.”

Dr. Carroll and his associates reviewed the charts of 298 children aged 2 years or older who were admitted to the ICU with asthma exacerbation over a 9-year period. More than half (55%) of the children were classified as having mild asthma (defined as mild intermittent or mild persistent). A comparison of children with mild asthma with those who had more severe disease showed no differences in the severity of their exacerbations at admission, their hospital or ICU length of stay, or the therapies they received.

Compared with children who had more severe baseline disease, those with mild asthma were younger (7.6 vs. 9.8 years), less likely to have been admitted to hospital previously for asthma (42% vs. 77%), less likely to have been admitted to the ICU previously for asthma (11% vs. 41%), and less likely to have public insurance (46% vs. 65%). There also were ethnic differences: equal percentages of African Americans but fewer Hispanics in the milder group (30% vs. 47%) and more whites (42% vs. 24%).

“Even kids with mild asthma are susceptible to severe exacerbations,” said Dr. Carroll. “[Some] of my adult critical care colleagues [said] only severe asthmatics end up in the ICU. I said that's not true in kids. We see kids with 'mild asthma' who are in our ICU all the time.”

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.) said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand.

Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine.

There are new updated American Academy of Pediatric recommendations that first timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (EDs) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. Although it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said.

“Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%–-that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

In the meantime, “we need to avoid missed opportunities in primary care; give vaccines early in time to deliver a second dose before outbreaks occur; [and] continue vaccinating until the vaccine supply runs out to allow a wider vaccination interval. … Black, Asian, uninsured, and impoverished patients may need focused outreach,” she said.

'Give vaccines early in time to deliver a second dose before outbreaks occur.' DR. RAND

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.) said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand.

Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine.

There are new updated American Academy of Pediatric recommendations that first timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (EDs) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. Although it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said.

“Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%–-that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

In the meantime, “we need to avoid missed opportunities in primary care; give vaccines early in time to deliver a second dose before outbreaks occur; [and] continue vaccinating until the vaccine supply runs out to allow a wider vaccination interval. … Black, Asian, uninsured, and impoverished patients may need focused outreach,” she said.

'Give vaccines early in time to deliver a second dose before outbreaks occur.' DR. RAND

TORONTO — Alternative settings, such as schools, should be considered if universal influenza vaccination is recommended for all U.S. school-age children, Dr. Cynthia Rand said in a poster presentation at the annual meeting of the Pediatric Academic Societies

“Kids aged 6–18 years haven't yet had a recommendation for universal influenza vaccination, but we're expecting this recommendation in the flu season of 2008,” Dr. Rand of the University of Rochester (N.Y.) said in an interview.

In the study, she calculated that more that 41.5 million extra visits to pediatric offices would be needed annually to meet the increased demand.

Although the emergency department has been suggested as a potential site for universal influenza vaccination (UIV), a related study found the added value of this delivery site would be “modest,” at least from a public health perspective, her colleague Christina Albertin, also of the university, reported in another poster.

With data from the 2003–2004 Medical Expenditure Panel Survey (MEPS), Dr. Rand's study calculated the number of well-child and other primary care visits for 4,161 children. From this she estimated the number of extra visits between October and January that would be required for influenza vaccination. It was assumed that children under 9 years would need two visits rather than one visit, if it was their first influenza vaccine.

There are new updated American Academy of Pediatric recommendations that first timers who failed to get their two flu shots should get two for the following year; this would boost the number of visits still further, she commented (Pediatrics 2007;119:846–51).

By focusing specifically on the 6- to 18-year-old age group that is expected to be captured in new UIV guidelines, the study found that for children under 9 years, 33% would need one extra visit and more than 50% would need two—accounting for 16 million additional visits. For 9- to 18-year-old children and teens, 73% would need one extra visit, accounting for more than 25 million additional visits. In total, the 6- to 18-year-old age group would require 41.5 million extra visits to pediatricians during the influenza vaccination period, assuming no missed opportunities for vaccination and that 20% of the population had been vaccinated in a prior season.

Individuals who are black, Asian, uninsured, or living in poverty are more likely to need additional visits, she added. The numbers are overwhelming, underscoring the need for new delivery systems, said Dr. Rand. “School-based systems would require a lot of coordination because school nurses would also be overwhelmed. They would need help from the public health infrastructure.”

Emergency departments (EDs) have been discussed as another possible vaccination delivery site, but the benefits of implementing an ED delivery system are unclear, Ms. Albertin said in an interview.

With data from the MEPS (2002–2004), her study analyzed the number of ED visits from a sample of 10,073 children aged 6 months to 18 years between October and December, and calculated how many of them had also had a primary care visit during that period.

“Overall 3.7% of the children had an ED visit, and about half of them had no primary care visit during that time period, and therefore might have benefited from being vaccinated in the ED,” she said. Although it's a small percentage of the population, it represents half of the pediatric ED population, suggesting that the benefits of an ED vaccine delivery system may be debatable, she said.

“Of course, EDs are busy places, and vaccination probably won't happen consistently, but is 1.9%–-that's the percentage who didn't have a primary care visit—enough to start pushing for vaccination in the ED or not?” she asked.

While many pediatricians have been strong supporters of primary care vaccination, without reliance on the ED, Dr. Rand's study suggests perhaps multiple options will be needed.

In the meantime, “we need to avoid missed opportunities in primary care; give vaccines early in time to deliver a second dose before outbreaks occur; [and] continue vaccinating until the vaccine supply runs out to allow a wider vaccination interval. … Black, Asian, uninsured, and impoverished patients may need focused outreach,” she said.

'Give vaccines early in time to deliver a second dose before outbreaks occur.' DR. RAND

BANFF, ALTA. — Ultralight doses of epidural analgesia given either as a continuous infusion or as patient-controlled boluses appear to result in comparable pain and Apgar scores as well as medication usage, according to the preliminary results of an ongoing study.

“Our numbers are very small right now, but as soon as we get more I am sure we will see a statistical difference between the two in terms of patient satisfaction,” predicted Dr. Maya Suresh, chief of obstetric anesthesiology at Baylor College of Medicine, Houston. “I think patient-controlled epidural analgesia [PCEA] is advantageous to the patient because she is in control of her own pain. And, if you are not called frequently to intervene or to trouble-shoot that also adds to the provider's satisfaction,” she said in an interview.

The study, presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, is the first to compare outcomes using an ultralight epidural solution of 0.0625% bupivacaine plus 2 mcg/mL fentanyl. Fifteen nulliparous parturients requesting epidural were randomized to the continuous-infusion epidural analgesia (CIEA) arm and received the solution at a dose of 14 L/hr. Another 15 women were randomized to PCEA and received an 8-mL/hr background infusion of the same solution with the option for 5-mL boluses on demand at a 5-minute lockout interval, and an hourly limit of 26 mL, reported Dr. LaToya Mason from the same institution, who presented the study.

There was no statistically significant difference between the groups in umbilical artery pH scores, Apgar scores, or pain scores, said Dr. Mason. All patients had spontaneous vaginal deliveries except for four who had cesareans (two in each group).

BANFF, ALTA. — Ultralight doses of epidural analgesia given either as a continuous infusion or as patient-controlled boluses appear to result in comparable pain and Apgar scores as well as medication usage, according to the preliminary results of an ongoing study.

“Our numbers are very small right now, but as soon as we get more I am sure we will see a statistical difference between the two in terms of patient satisfaction,” predicted Dr. Maya Suresh, chief of obstetric anesthesiology at Baylor College of Medicine, Houston. “I think patient-controlled epidural analgesia [PCEA] is advantageous to the patient because she is in control of her own pain. And, if you are not called frequently to intervene or to trouble-shoot that also adds to the provider's satisfaction,” she said in an interview.

The study, presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, is the first to compare outcomes using an ultralight epidural solution of 0.0625% bupivacaine plus 2 mcg/mL fentanyl. Fifteen nulliparous parturients requesting epidural were randomized to the continuous-infusion epidural analgesia (CIEA) arm and received the solution at a dose of 14 L/hr. Another 15 women were randomized to PCEA and received an 8-mL/hr background infusion of the same solution with the option for 5-mL boluses on demand at a 5-minute lockout interval, and an hourly limit of 26 mL, reported Dr. LaToya Mason from the same institution, who presented the study.

There was no statistically significant difference between the groups in umbilical artery pH scores, Apgar scores, or pain scores, said Dr. Mason. All patients had spontaneous vaginal deliveries except for four who had cesareans (two in each group).

BANFF, ALTA. — Ultralight doses of epidural analgesia given either as a continuous infusion or as patient-controlled boluses appear to result in comparable pain and Apgar scores as well as medication usage, according to the preliminary results of an ongoing study.

“Our numbers are very small right now, but as soon as we get more I am sure we will see a statistical difference between the two in terms of patient satisfaction,” predicted Dr. Maya Suresh, chief of obstetric anesthesiology at Baylor College of Medicine, Houston. “I think patient-controlled epidural analgesia [PCEA] is advantageous to the patient because she is in control of her own pain. And, if you are not called frequently to intervene or to trouble-shoot that also adds to the provider's satisfaction,” she said in an interview.

The study, presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, is the first to compare outcomes using an ultralight epidural solution of 0.0625% bupivacaine plus 2 mcg/mL fentanyl. Fifteen nulliparous parturients requesting epidural were randomized to the continuous-infusion epidural analgesia (CIEA) arm and received the solution at a dose of 14 L/hr. Another 15 women were randomized to PCEA and received an 8-mL/hr background infusion of the same solution with the option for 5-mL boluses on demand at a 5-minute lockout interval, and an hourly limit of 26 mL, reported Dr. LaToya Mason from the same institution, who presented the study.

There was no statistically significant difference between the groups in umbilical artery pH scores, Apgar scores, or pain scores, said Dr. Mason. All patients had spontaneous vaginal deliveries except for four who had cesareans (two in each group).

BANFF, ALTA. — The routine practice of giving oxytocin boluses to reduce the risk of postpartum hemorrhage appears to be of limited benefit even in high-risk patients after cesarean section, as long as an appropriate oxytocin infusion is given, according to the first randomized, placebo-controlled trial of the practice, said Dr. Kylie King from Maitland (Australia) Hospital.

The practice of administering oxytocin boluses has recently come under scrutiny. “Although the adverse hemodynamic effects [of oxytocin boluses] are well documented, one recently reported death associated with a 10-U bolus in the U.K. has prompted a change in dose from 10 to 5 units given slowly,” she said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. “This begs the question: Is a bolus necessary? Is 5 U the right dose? How slowly should it be given? And might an infusion be sufficient?”

Her study, which was conducted at British Columbia Women's Hospital in Vancouver, compared 143 subjects: 70 received an intravenous 5-U bolus of oxytocin, and 73 received normal saline, given over 30 seconds following cesarean section and cord clamping.

Both groups also received an identical infusion of 40 U of oxytocin in 500 mL of normal saline over 30 minutes, followed by 20 U of oxytocin in 1 L of saline over the next 8 hours.

“Our hypothesis was that the bolus, given in addition to the infusion, would reduce the need for additional drugs to contract the uterus,” said Dr. King. Because previous studies have suggested that oxytocin may have little or no effect in a low-risk population, study subjects were specifically selected as being high risk for postpartum hemorrhage. “Multiple gestations and macrosomia were the most common risk factors.”

Overall, 53% of the cesarean sections were elective, with 47% classified as emergency procedures. The need for additional uterotonics was high—between 30% and 40% overall—confirming that the population was indeed high risk, but need for more uterotonics was similar in both groups as assessed by a surgeon who was blinded to the patients' randomization. In addition, there was no difference between groups in the secondary outcomes of estimated blood loss, need for blood transfusion or hypotension.

“Even in a high-risk group, a 5-U bolus is of limited additional benefit provided that an adequate infusion is given,” concluded Dr. King. “Getting a stronger initial contraction at 1 minute doesn't reduce the need for additional uterotonics over the next 24 hours.”

BANFF, ALTA. — The routine practice of giving oxytocin boluses to reduce the risk of postpartum hemorrhage appears to be of limited benefit even in high-risk patients after cesarean section, as long as an appropriate oxytocin infusion is given, according to the first randomized, placebo-controlled trial of the practice, said Dr. Kylie King from Maitland (Australia) Hospital.

The practice of administering oxytocin boluses has recently come under scrutiny. “Although the adverse hemodynamic effects [of oxytocin boluses] are well documented, one recently reported death associated with a 10-U bolus in the U.K. has prompted a change in dose from 10 to 5 units given slowly,” she said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. “This begs the question: Is a bolus necessary? Is 5 U the right dose? How slowly should it be given? And might an infusion be sufficient?”

Her study, which was conducted at British Columbia Women's Hospital in Vancouver, compared 143 subjects: 70 received an intravenous 5-U bolus of oxytocin, and 73 received normal saline, given over 30 seconds following cesarean section and cord clamping.

Both groups also received an identical infusion of 40 U of oxytocin in 500 mL of normal saline over 30 minutes, followed by 20 U of oxytocin in 1 L of saline over the next 8 hours.

“Our hypothesis was that the bolus, given in addition to the infusion, would reduce the need for additional drugs to contract the uterus,” said Dr. King. Because previous studies have suggested that oxytocin may have little or no effect in a low-risk population, study subjects were specifically selected as being high risk for postpartum hemorrhage. “Multiple gestations and macrosomia were the most common risk factors.”

Overall, 53% of the cesarean sections were elective, with 47% classified as emergency procedures. The need for additional uterotonics was high—between 30% and 40% overall—confirming that the population was indeed high risk, but need for more uterotonics was similar in both groups as assessed by a surgeon who was blinded to the patients' randomization. In addition, there was no difference between groups in the secondary outcomes of estimated blood loss, need for blood transfusion or hypotension.

“Even in a high-risk group, a 5-U bolus is of limited additional benefit provided that an adequate infusion is given,” concluded Dr. King. “Getting a stronger initial contraction at 1 minute doesn't reduce the need for additional uterotonics over the next 24 hours.”

BANFF, ALTA. — The routine practice of giving oxytocin boluses to reduce the risk of postpartum hemorrhage appears to be of limited benefit even in high-risk patients after cesarean section, as long as an appropriate oxytocin infusion is given, according to the first randomized, placebo-controlled trial of the practice, said Dr. Kylie King from Maitland (Australia) Hospital.

The practice of administering oxytocin boluses has recently come under scrutiny. “Although the adverse hemodynamic effects [of oxytocin boluses] are well documented, one recently reported death associated with a 10-U bolus in the U.K. has prompted a change in dose from 10 to 5 units given slowly,” she said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. “This begs the question: Is a bolus necessary? Is 5 U the right dose? How slowly should it be given? And might an infusion be sufficient?”

Her study, which was conducted at British Columbia Women's Hospital in Vancouver, compared 143 subjects: 70 received an intravenous 5-U bolus of oxytocin, and 73 received normal saline, given over 30 seconds following cesarean section and cord clamping.

Both groups also received an identical infusion of 40 U of oxytocin in 500 mL of normal saline over 30 minutes, followed by 20 U of oxytocin in 1 L of saline over the next 8 hours.

“Our hypothesis was that the bolus, given in addition to the infusion, would reduce the need for additional drugs to contract the uterus,” said Dr. King. Because previous studies have suggested that oxytocin may have little or no effect in a low-risk population, study subjects were specifically selected as being high risk for postpartum hemorrhage. “Multiple gestations and macrosomia were the most common risk factors.”

Overall, 53% of the cesarean sections were elective, with 47% classified as emergency procedures. The need for additional uterotonics was high—between 30% and 40% overall—confirming that the population was indeed high risk, but need for more uterotonics was similar in both groups as assessed by a surgeon who was blinded to the patients' randomization. In addition, there was no difference between groups in the secondary outcomes of estimated blood loss, need for blood transfusion or hypotension.

“Even in a high-risk group, a 5-U bolus is of limited additional benefit provided that an adequate infusion is given,” concluded Dr. King. “Getting a stronger initial contraction at 1 minute doesn't reduce the need for additional uterotonics over the next 24 hours.”

BANFF, ALTA. — Some women who develop fever during labor may have a predisposition to labor-associated fever and may be identifiable by their higher baseline body temperatures, Tiffany Gelfand, D.O., said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

And among women predisposed to labor-associated fever, epidural analgesia may have an additive effect, suggested Dr. Gelfand of Brigham and Women's Hospital, Boston.

“Maternal fever is not a benign thing; it's been related to neonatal cognitive deficits and cerebral encephalopathy, and even cognitive deficits 6 years out,” she said in an interview. “We don't really know what the interaction is between the epidural and the patients who are predisposed to have a fever, but we really need to find those risk factors before we go ahead and say that certain patients shouldn't have an epidural.”

Her prospective study followed 107 women in labor, at term, with maternal temperature measured every hour from admittance until delivery. It found that among 86 women who received epidural, and 21 who received either opioids or no analgesia, 35% developed a temperature above 99.5° F, and 17% had a temperature above 100.4° F. Fever was much more common in women who received epidural, compared with those who did not (37% vs. 14%), she said. But a common characteristic of all women who became febrile was a higher baseline body temperature.

“What was so interesting about this study was that these patients were already different the second they walked through the door. Even before they had an epidural, their baseline temperature, although afebrile, was significantly different. We don't know why they are different, and we need to figure that out.”

The study shows that the gradual, steady rise in temperature that has been previously reported with epidural analgesia is actually an artifact, due to averaging patients who develop clinical fever and those who do not, explained Dr. Gelfand. When women who became febrile were removed from the analysis, the rest demonstrated consistently low temperatures throughout labor, she said. “We think it might be some of type of inflammatory cause—perhaps an undisclosed infectious source,” she speculated, and noted that the nature of the fever was also different in women who received epidural, compared with those who did not. “Among women undergoing natural childbirth, we saw fever that responded well to acetaminophen, whereas in women who received the epidural, their fever did not respond to acetaminophen. We think it might be a different mechanism.”

A further analysis of the study, presented as a poster, looked at only the 86 women who received analgesia and found that, compared with the afebrile women, women who became febrile had some known obstetric risk factors such as longer time from rupture of membranes and a higher number of vaginal exams.

BANFF, ALTA. — Some women who develop fever during labor may have a predisposition to labor-associated fever and may be identifiable by their higher baseline body temperatures, Tiffany Gelfand, D.O., said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

And among women predisposed to labor-associated fever, epidural analgesia may have an additive effect, suggested Dr. Gelfand of Brigham and Women's Hospital, Boston.

“Maternal fever is not a benign thing; it's been related to neonatal cognitive deficits and cerebral encephalopathy, and even cognitive deficits 6 years out,” she said in an interview. “We don't really know what the interaction is between the epidural and the patients who are predisposed to have a fever, but we really need to find those risk factors before we go ahead and say that certain patients shouldn't have an epidural.”

Her prospective study followed 107 women in labor, at term, with maternal temperature measured every hour from admittance until delivery. It found that among 86 women who received epidural, and 21 who received either opioids or no analgesia, 35% developed a temperature above 99.5° F, and 17% had a temperature above 100.4° F. Fever was much more common in women who received epidural, compared with those who did not (37% vs. 14%), she said. But a common characteristic of all women who became febrile was a higher baseline body temperature.

“What was so interesting about this study was that these patients were already different the second they walked through the door. Even before they had an epidural, their baseline temperature, although afebrile, was significantly different. We don't know why they are different, and we need to figure that out.”

The study shows that the gradual, steady rise in temperature that has been previously reported with epidural analgesia is actually an artifact, due to averaging patients who develop clinical fever and those who do not, explained Dr. Gelfand. When women who became febrile were removed from the analysis, the rest demonstrated consistently low temperatures throughout labor, she said. “We think it might be some of type of inflammatory cause—perhaps an undisclosed infectious source,” she speculated, and noted that the nature of the fever was also different in women who received epidural, compared with those who did not. “Among women undergoing natural childbirth, we saw fever that responded well to acetaminophen, whereas in women who received the epidural, their fever did not respond to acetaminophen. We think it might be a different mechanism.”

A further analysis of the study, presented as a poster, looked at only the 86 women who received analgesia and found that, compared with the afebrile women, women who became febrile had some known obstetric risk factors such as longer time from rupture of membranes and a higher number of vaginal exams.

BANFF, ALTA. — Some women who develop fever during labor may have a predisposition to labor-associated fever and may be identifiable by their higher baseline body temperatures, Tiffany Gelfand, D.O., said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

And among women predisposed to labor-associated fever, epidural analgesia may have an additive effect, suggested Dr. Gelfand of Brigham and Women's Hospital, Boston.

“Maternal fever is not a benign thing; it's been related to neonatal cognitive deficits and cerebral encephalopathy, and even cognitive deficits 6 years out,” she said in an interview. “We don't really know what the interaction is between the epidural and the patients who are predisposed to have a fever, but we really need to find those risk factors before we go ahead and say that certain patients shouldn't have an epidural.”

Her prospective study followed 107 women in labor, at term, with maternal temperature measured every hour from admittance until delivery. It found that among 86 women who received epidural, and 21 who received either opioids or no analgesia, 35% developed a temperature above 99.5° F, and 17% had a temperature above 100.4° F. Fever was much more common in women who received epidural, compared with those who did not (37% vs. 14%), she said. But a common characteristic of all women who became febrile was a higher baseline body temperature.

“What was so interesting about this study was that these patients were already different the second they walked through the door. Even before they had an epidural, their baseline temperature, although afebrile, was significantly different. We don't know why they are different, and we need to figure that out.”

The study shows that the gradual, steady rise in temperature that has been previously reported with epidural analgesia is actually an artifact, due to averaging patients who develop clinical fever and those who do not, explained Dr. Gelfand. When women who became febrile were removed from the analysis, the rest demonstrated consistently low temperatures throughout labor, she said. “We think it might be some of type of inflammatory cause—perhaps an undisclosed infectious source,” she speculated, and noted that the nature of the fever was also different in women who received epidural, compared with those who did not. “Among women undergoing natural childbirth, we saw fever that responded well to acetaminophen, whereas in women who received the epidural, their fever did not respond to acetaminophen. We think it might be a different mechanism.”

A further analysis of the study, presented as a poster, looked at only the 86 women who received analgesia and found that, compared with the afebrile women, women who became febrile had some known obstetric risk factors such as longer time from rupture of membranes and a higher number of vaginal exams.

BANFF, ALTA. — The much publicized death from spinal meningitis of Washington-area resident Julie LeMoult within hours of labor epidural and delivery has focused the attention of many obstetric anesthesiologists on the issue of infection control, according to Dr. Samuel Hughes, professor of anesthesia at the University of California, San Francisco, and director of obstetric anesthesia at San Francisco General Hospital.

“This tragic case was certainly disconcerting and brought many of our patients in to us with questions,” said Dr. Hughes, speaking at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. He stressed that the courts have not yet ruled on the source of the infection.

Potential guidelines or a practice advisory regarding neuraxial infection control techniques have been under discussion within the American Society of Anesthesiologists (ASA) since 2005, said Dr. Hughes, who is former chair of the ASA's obstetric anesthesia committee. However, currently, there remains a void, with no standard of care in this area, he said. “We must institute uniform sterile safety practices. I think coming to some sort of broad guidelines would be a purposeful thing,” he said

But it is unlikely that studies will ever be able to show that more rigid, uniform infection control procedures will reduce the risk of neuraxial infection—because the incidence of such infections is so low, he said. The two most serious complications resulting from neuraxial anesthesia—epidural abscess and meningitis—are both rare and underreported, making determination of their true incidence difficult. The best literature review identified 15 cases of bacterial meningitis and 8 cases of epidural abscess associated with obstetrical regional anesthesia over a 32-year period (1966–1998), with a further five abscesses attributed to spontaneous infection, he said. And a more recent meta-analysis covering 1966–2005 suggested an incidence of deep epidural infection of 7 per million (Anesthesiology 2006;105:394–9).

“We must be cautious in quoting the incidence of such extremely rare events because, in fact, we just do not know and likely will not—not without an extremely large survey with mandatory reporting, even with as many as 2.4 million women per year in the United States having a regional anesthetic!” he wrote in the ASA Newsletter (2007 Feb;71:No 2).

While academics and medical societies debate the intricacies of future infection control guidelines, Dr. Hughes urged clinicians not to forget common sense, and the most basic of infection control practices, hand-washing. Thorough hand-washing with an alcohol-based antiseptic solution is the first recommendation from the American Society of Regional Anesthesia and Pain Medicine (ASRA), which released recommendations on infection control last year (Reg. Anesth. Pain Med. 2006;31:311–323), although not specifically for obstetric anesthesia, he said. The second and third recommendations are the removal of jewelry and the use of sterile gloves (after, not instead of, hand-washing). “Now that the ASRA recommendations are out there, they may slowly become the standard of care if nothing else supersedes them,” he suggested.

Perhaps the most controversial ASRA recommendation is for the wearing of masks—something Dr. Hughes strongly agrees with. While studies suggest that surgical wound infection is not reduced by mask-wearing, “more than 50% of the cases of meningitis related to anesthesia are caused by streptococcal organisms which live in the upper airway,” he said. “There have been case reports linking practitioners' specific upper airway infections to infections in patients—so anything that reduce s bacterial dispersion is a good idea. Certainly masks are a way to protect the practitioner and the patient at very little cost.”

Surveys in the United States and around the world underscore the fact that sterile technique varies widely among providers of regional anesthesia, said Dr. Hughes.

BANFF, ALTA. — The much publicized death from spinal meningitis of Washington-area resident Julie LeMoult within hours of labor epidural and delivery has focused the attention of many obstetric anesthesiologists on the issue of infection control, according to Dr. Samuel Hughes, professor of anesthesia at the University of California, San Francisco, and director of obstetric anesthesia at San Francisco General Hospital.

“This tragic case was certainly disconcerting and brought many of our patients in to us with questions,” said Dr. Hughes, speaking at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. He stressed that the courts have not yet ruled on the source of the infection.

Potential guidelines or a practice advisory regarding neuraxial infection control techniques have been under discussion within the American Society of Anesthesiologists (ASA) since 2005, said Dr. Hughes, who is former chair of the ASA's obstetric anesthesia committee. However, currently, there remains a void, with no standard of care in this area, he said. “We must institute uniform sterile safety practices. I think coming to some sort of broad guidelines would be a purposeful thing,” he said

But it is unlikely that studies will ever be able to show that more rigid, uniform infection control procedures will reduce the risk of neuraxial infection—because the incidence of such infections is so low, he said. The two most serious complications resulting from neuraxial anesthesia—epidural abscess and meningitis—are both rare and underreported, making determination of their true incidence difficult. The best literature review identified 15 cases of bacterial meningitis and 8 cases of epidural abscess associated with obstetrical regional anesthesia over a 32-year period (1966–1998), with a further five abscesses attributed to spontaneous infection, he said. And a more recent meta-analysis covering 1966–2005 suggested an incidence of deep epidural infection of 7 per million (Anesthesiology 2006;105:394–9).

“We must be cautious in quoting the incidence of such extremely rare events because, in fact, we just do not know and likely will not—not without an extremely large survey with mandatory reporting, even with as many as 2.4 million women per year in the United States having a regional anesthetic!” he wrote in the ASA Newsletter (2007 Feb;71:No 2).

While academics and medical societies debate the intricacies of future infection control guidelines, Dr. Hughes urged clinicians not to forget common sense, and the most basic of infection control practices, hand-washing. Thorough hand-washing with an alcohol-based antiseptic solution is the first recommendation from the American Society of Regional Anesthesia and Pain Medicine (ASRA), which released recommendations on infection control last year (Reg. Anesth. Pain Med. 2006;31:311–323), although not specifically for obstetric anesthesia, he said. The second and third recommendations are the removal of jewelry and the use of sterile gloves (after, not instead of, hand-washing). “Now that the ASRA recommendations are out there, they may slowly become the standard of care if nothing else supersedes them,” he suggested.

Perhaps the most controversial ASRA recommendation is for the wearing of masks—something Dr. Hughes strongly agrees with. While studies suggest that surgical wound infection is not reduced by mask-wearing, “more than 50% of the cases of meningitis related to anesthesia are caused by streptococcal organisms which live in the upper airway,” he said. “There have been case reports linking practitioners' specific upper airway infections to infections in patients—so anything that reduce s bacterial dispersion is a good idea. Certainly masks are a way to protect the practitioner and the patient at very little cost.”

Surveys in the United States and around the world underscore the fact that sterile technique varies widely among providers of regional anesthesia, said Dr. Hughes.

BANFF, ALTA. — The much publicized death from spinal meningitis of Washington-area resident Julie LeMoult within hours of labor epidural and delivery has focused the attention of many obstetric anesthesiologists on the issue of infection control, according to Dr. Samuel Hughes, professor of anesthesia at the University of California, San Francisco, and director of obstetric anesthesia at San Francisco General Hospital.

“This tragic case was certainly disconcerting and brought many of our patients in to us with questions,” said Dr. Hughes, speaking at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. He stressed that the courts have not yet ruled on the source of the infection.

Potential guidelines or a practice advisory regarding neuraxial infection control techniques have been under discussion within the American Society of Anesthesiologists (ASA) since 2005, said Dr. Hughes, who is former chair of the ASA's obstetric anesthesia committee. However, currently, there remains a void, with no standard of care in this area, he said. “We must institute uniform sterile safety practices. I think coming to some sort of broad guidelines would be a purposeful thing,” he said

But it is unlikely that studies will ever be able to show that more rigid, uniform infection control procedures will reduce the risk of neuraxial infection—because the incidence of such infections is so low, he said. The two most serious complications resulting from neuraxial anesthesia—epidural abscess and meningitis—are both rare and underreported, making determination of their true incidence difficult. The best literature review identified 15 cases of bacterial meningitis and 8 cases of epidural abscess associated with obstetrical regional anesthesia over a 32-year period (1966–1998), with a further five abscesses attributed to spontaneous infection, he said. And a more recent meta-analysis covering 1966–2005 suggested an incidence of deep epidural infection of 7 per million (Anesthesiology 2006;105:394–9).

“We must be cautious in quoting the incidence of such extremely rare events because, in fact, we just do not know and likely will not—not without an extremely large survey with mandatory reporting, even with as many as 2.4 million women per year in the United States having a regional anesthetic!” he wrote in the ASA Newsletter (2007 Feb;71:No 2).

While academics and medical societies debate the intricacies of future infection control guidelines, Dr. Hughes urged clinicians not to forget common sense, and the most basic of infection control practices, hand-washing. Thorough hand-washing with an alcohol-based antiseptic solution is the first recommendation from the American Society of Regional Anesthesia and Pain Medicine (ASRA), which released recommendations on infection control last year (Reg. Anesth. Pain Med. 2006;31:311–323), although not specifically for obstetric anesthesia, he said. The second and third recommendations are the removal of jewelry and the use of sterile gloves (after, not instead of, hand-washing). “Now that the ASRA recommendations are out there, they may slowly become the standard of care if nothing else supersedes them,” he suggested.

Perhaps the most controversial ASRA recommendation is for the wearing of masks—something Dr. Hughes strongly agrees with. While studies suggest that surgical wound infection is not reduced by mask-wearing, “more than 50% of the cases of meningitis related to anesthesia are caused by streptococcal organisms which live in the upper airway,” he said. “There have been case reports linking practitioners' specific upper airway infections to infections in patients—so anything that reduce s bacterial dispersion is a good idea. Certainly masks are a way to protect the practitioner and the patient at very little cost.”

Surveys in the United States and around the world underscore the fact that sterile technique varies widely among providers of regional anesthesia, said Dr. Hughes.

HOUSTON — Although most pediatric vaginal infections require treatment, asymptomatic condyloma acuminatum and molluscum contagiosum are exceptions, according to Dr. Abbey B. Berenson.

“It's counter to our training, but sometimes a little benign neglect is the best option,” said Dr. Berenson, a professor of obstetrics and gynecology at the University of Texas at Galveston.

Condyloma acuminatum, caused by the human papillomavirus (usually a low-risk type), is different in children than in adults, “not by presentation but by etiology,” she said. In adults, this infection is often sexually transmitted, but children can acquire it at birth; it may first manifest up to 3 years later. They also can autotransmit cutaneous types from their hands to their genitalia, she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital, Houston.

Treatment is warranted if the warts are persistent or symptomatic, but otherwise, observation is recommended, particularly because there is a high rate of recurrence after treatment, she said.

HOUSTON — Although most pediatric vaginal infections require treatment, asymptomatic condyloma acuminatum and molluscum contagiosum are exceptions, according to Dr. Abbey B. Berenson.

“It's counter to our training, but sometimes a little benign neglect is the best option,” said Dr. Berenson, a professor of obstetrics and gynecology at the University of Texas at Galveston.

Condyloma acuminatum, caused by the human papillomavirus (usually a low-risk type), is different in children than in adults, “not by presentation but by etiology,” she said. In adults, this infection is often sexually transmitted, but children can acquire it at birth; it may first manifest up to 3 years later. They also can autotransmit cutaneous types from their hands to their genitalia, she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital, Houston.

Treatment is warranted if the warts are persistent or symptomatic, but otherwise, observation is recommended, particularly because there is a high rate of recurrence after treatment, she said.

HOUSTON — Although most pediatric vaginal infections require treatment, asymptomatic condyloma acuminatum and molluscum contagiosum are exceptions, according to Dr. Abbey B. Berenson.

“It's counter to our training, but sometimes a little benign neglect is the best option,” said Dr. Berenson, a professor of obstetrics and gynecology at the University of Texas at Galveston.

Condyloma acuminatum, caused by the human papillomavirus (usually a low-risk type), is different in children than in adults, “not by presentation but by etiology,” she said. In adults, this infection is often sexually transmitted, but children can acquire it at birth; it may first manifest up to 3 years later. They also can autotransmit cutaneous types from their hands to their genitalia, she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital, Houston.

Treatment is warranted if the warts are persistent or symptomatic, but otherwise, observation is recommended, particularly because there is a high rate of recurrence after treatment, she said.

TORONTO — Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% girls, mean age 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%),

▸ Urinary frequency (45%),

▸ Abdominal pain (45%),

▸ Hematuria (29%),

▸ Back pain (29%),

▸ Urgency (27%),

▸ Genital discharge (17%),

▸ Fever (17%), and

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago.

“There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in men “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STI). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia. Of the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55 % of patients who were not investigated for an STI represent “a missed opportunity for diagnosis and treatment of STI,” said Dr. Musacchio.

“First … we're not thinking about it, and then there are also a number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult—[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents—15- to 25-year-olds have the highest rates of these diseases in the United States—and the consequences can be devastating. In addition, adolescents who seek help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone, she advised.

TORONTO — Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% girls, mean age 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%),

▸ Urinary frequency (45%),

▸ Abdominal pain (45%),

▸ Hematuria (29%),

▸ Back pain (29%),

▸ Urgency (27%),

▸ Genital discharge (17%),

▸ Fever (17%), and

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago.

“There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in men “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STI). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia. Of the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55 % of patients who were not investigated for an STI represent “a missed opportunity for diagnosis and treatment of STI,” said Dr. Musacchio.

“First … we're not thinking about it, and then there are also a number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult—[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents—15- to 25-year-olds have the highest rates of these diseases in the United States—and the consequences can be devastating. In addition, adolescents who seek help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone, she advised.

TORONTO — Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.

“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”

In a retrospective chart review of 163 adolescents (82% girls, mean age 16 years) presenting to the ED, the patients had the following symptoms:

▸ Dysuria (87%),

▸ Urinary frequency (45%),

▸ Abdominal pain (45%),

▸ Hematuria (29%),

▸ Back pain (29%),

▸ Urgency (27%),

▸ Genital discharge (17%),

▸ Fever (17%), and

▸ Vomiting (10%).

Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago.

“There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in men “so we have to have a really high index of suspicion for an STI in males with those symptoms.”

Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).

Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STI). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia. Of the 41 sexually active patients who were not tested for STI, 24 had a UTI.

The 55 % of patients who were not investigated for an STI represent “a missed opportunity for diagnosis and treatment of STI,” said Dr. Musacchio.

“First … we're not thinking about it, and then there are also a number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult—[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”

The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents—15- to 25-year-olds have the highest rates of these diseases in the United States—and the consequences can be devastating. In addition, adolescents who seek help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.

Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone, she advised.