Doug Brunk

Families looking for a board-certified pediatric rheumatologist in India—which has a population of more than 1 billion—are unlikely to find one.

“The official count is zero,” Dr. Thomas J.A. Lehman said in an interview. “They don't have any training programs for pediatric rheumatologists in India. They have a few physicians who practice pediatric rheumatology, but there is no formal training program. When you talk to physicians in India, they tell you 'we're doing pediatric rheumatology, but we all started out as pediatricians. Somebody sent us an interesting rheumatology case and we're trying to learn pediatric rheumatology as we go along.'”

In October 2009, Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, spent 1 week as a volunteer guest lecturer at the annual meeting of the Indian Pediatric Rheumatology Association in Nagpur, India, which is in the country's centrally located state of Maharashtra. Also volunteering to teach at this meeting were fellow pediatric rheumatologists Dr. Charles H. Spencer from Columbus, Ohio, Dr. Angelo Ravelli from Genoa, Italy, and Dr. Tadej Avcin from Ljubljana, Slovenia. Almost 200 pediatricians and a handful of adult rheumatologists assembled at a hotel conference center, eager to learn about the state of pediatric rheumatology in a country coping with spotty infrastructure and poverty.

Dr. Nandini Babhulkar of the department of pediatrics at the Indira Gandhi Medical College and Mayo General Hospital, Nagpur, organized the conference. In his interview, Dr. Lehman extended his congratulations for her excellent job in bringing pediatricians and pediatric rheumatologists from the United States and Europe together with physicians from India to advance the care of children with rheumatic diseases.

The attendees were “mostly in their 30s and 40s, physicians working to be the pediatric rheumatologists of this generation for their country,” Dr. Lehman said.

Physicians in India see many cases of juvenile idiopathic arthritis, but lupus and scleroderma are especially common. “That's probably due to genetics,” said Dr. Lehman, who is one of about 280 board-certified pediatric rheumatologists in the United States. “Different populations have different backgrounds.”

Topics he talked about during the meeting included recognizing and understanding common rheumatic diseases of childhood, working with physicians in other specialties in the care of patients, “and reinforcing how to take care of people when they don't have access to the newest drugs. They have nonsteroidal anti-inflammatory drugs, methotrexate, and steroids. The biologicals are available in India, but many patients can't afford them.”

“In a country with few pediatric rheumatologists, the best long-term results will come from steps that minimize the need for doctor visits and long-term medication,” he said.

“At present, too much emphasis is being placed on expensive medications that suppress chronic inflammation and too little on finding the cure. Drugs that suppress inflammation need to be continued indefinitely with repeated doctor visits and monitoring. We don't have the ability to cure any of the rheumatic diseases yet, but that's where our emphasis must be.”

During a discussion at the meeting about the risk of tuberculosis complicating immunosuppressive therapy, he learned that most physicians in India “often assume that the patient needs to be treated for TB, because TB is so rampant there.”

In spite of such obstacles, Dr. Lehman said that he returned home from the meeting inspired. “There are many children in India with rheumatic disease.”

“They're short on drugs and they're short on financing for the more expensive drugs. But this was a group of interested and enthusiastic physicians who are working hard on getting pediatric rheumatology established in that country. I'll be going back in the future to do more teaching. They need it, and I'm glad to help out.”

Dr. Lehman said his expenses were paid by the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

A group of interested and enthusiastic physicians are working hard to get pediatric rheumatology established in India, said Dr. Thomas J.A. Lehman.

Source Courtesy Dr. Thomas J.A. Lehman

Families looking for a board-certified pediatric rheumatologist in India—which has a population of more than 1 billion—are unlikely to find one.

“The official count is zero,” Dr. Thomas J.A. Lehman said in an interview. “They don't have any training programs for pediatric rheumatologists in India. They have a few physicians who practice pediatric rheumatology, but there is no formal training program. When you talk to physicians in India, they tell you 'we're doing pediatric rheumatology, but we all started out as pediatricians. Somebody sent us an interesting rheumatology case and we're trying to learn pediatric rheumatology as we go along.'”

In October 2009, Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, spent 1 week as a volunteer guest lecturer at the annual meeting of the Indian Pediatric Rheumatology Association in Nagpur, India, which is in the country's centrally located state of Maharashtra. Also volunteering to teach at this meeting were fellow pediatric rheumatologists Dr. Charles H. Spencer from Columbus, Ohio, Dr. Angelo Ravelli from Genoa, Italy, and Dr. Tadej Avcin from Ljubljana, Slovenia. Almost 200 pediatricians and a handful of adult rheumatologists assembled at a hotel conference center, eager to learn about the state of pediatric rheumatology in a country coping with spotty infrastructure and poverty.

Dr. Nandini Babhulkar of the department of pediatrics at the Indira Gandhi Medical College and Mayo General Hospital, Nagpur, organized the conference. In his interview, Dr. Lehman extended his congratulations for her excellent job in bringing pediatricians and pediatric rheumatologists from the United States and Europe together with physicians from India to advance the care of children with rheumatic diseases.

The attendees were “mostly in their 30s and 40s, physicians working to be the pediatric rheumatologists of this generation for their country,” Dr. Lehman said.

Physicians in India see many cases of juvenile idiopathic arthritis, but lupus and scleroderma are especially common. “That's probably due to genetics,” said Dr. Lehman, who is one of about 280 board-certified pediatric rheumatologists in the United States. “Different populations have different backgrounds.”

Topics he talked about during the meeting included recognizing and understanding common rheumatic diseases of childhood, working with physicians in other specialties in the care of patients, “and reinforcing how to take care of people when they don't have access to the newest drugs. They have nonsteroidal anti-inflammatory drugs, methotrexate, and steroids. The biologicals are available in India, but many patients can't afford them.”

“In a country with few pediatric rheumatologists, the best long-term results will come from steps that minimize the need for doctor visits and long-term medication,” he said.

“At present, too much emphasis is being placed on expensive medications that suppress chronic inflammation and too little on finding the cure. Drugs that suppress inflammation need to be continued indefinitely with repeated doctor visits and monitoring. We don't have the ability to cure any of the rheumatic diseases yet, but that's where our emphasis must be.”

During a discussion at the meeting about the risk of tuberculosis complicating immunosuppressive therapy, he learned that most physicians in India “often assume that the patient needs to be treated for TB, because TB is so rampant there.”

In spite of such obstacles, Dr. Lehman said that he returned home from the meeting inspired. “There are many children in India with rheumatic disease.”

“They're short on drugs and they're short on financing for the more expensive drugs. But this was a group of interested and enthusiastic physicians who are working hard on getting pediatric rheumatology established in that country. I'll be going back in the future to do more teaching. They need it, and I'm glad to help out.”

Dr. Lehman said his expenses were paid by the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

A group of interested and enthusiastic physicians are working hard to get pediatric rheumatology established in India, said Dr. Thomas J.A. Lehman.

Source Courtesy Dr. Thomas J.A. Lehman

Families looking for a board-certified pediatric rheumatologist in India—which has a population of more than 1 billion—are unlikely to find one.

“The official count is zero,” Dr. Thomas J.A. Lehman said in an interview. “They don't have any training programs for pediatric rheumatologists in India. They have a few physicians who practice pediatric rheumatology, but there is no formal training program. When you talk to physicians in India, they tell you 'we're doing pediatric rheumatology, but we all started out as pediatricians. Somebody sent us an interesting rheumatology case and we're trying to learn pediatric rheumatology as we go along.'”

In October 2009, Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York, spent 1 week as a volunteer guest lecturer at the annual meeting of the Indian Pediatric Rheumatology Association in Nagpur, India, which is in the country's centrally located state of Maharashtra. Also volunteering to teach at this meeting were fellow pediatric rheumatologists Dr. Charles H. Spencer from Columbus, Ohio, Dr. Angelo Ravelli from Genoa, Italy, and Dr. Tadej Avcin from Ljubljana, Slovenia. Almost 200 pediatricians and a handful of adult rheumatologists assembled at a hotel conference center, eager to learn about the state of pediatric rheumatology in a country coping with spotty infrastructure and poverty.

Dr. Nandini Babhulkar of the department of pediatrics at the Indira Gandhi Medical College and Mayo General Hospital, Nagpur, organized the conference. In his interview, Dr. Lehman extended his congratulations for her excellent job in bringing pediatricians and pediatric rheumatologists from the United States and Europe together with physicians from India to advance the care of children with rheumatic diseases.

The attendees were “mostly in their 30s and 40s, physicians working to be the pediatric rheumatologists of this generation for their country,” Dr. Lehman said.

Physicians in India see many cases of juvenile idiopathic arthritis, but lupus and scleroderma are especially common. “That's probably due to genetics,” said Dr. Lehman, who is one of about 280 board-certified pediatric rheumatologists in the United States. “Different populations have different backgrounds.”

Topics he talked about during the meeting included recognizing and understanding common rheumatic diseases of childhood, working with physicians in other specialties in the care of patients, “and reinforcing how to take care of people when they don't have access to the newest drugs. They have nonsteroidal anti-inflammatory drugs, methotrexate, and steroids. The biologicals are available in India, but many patients can't afford them.”

“In a country with few pediatric rheumatologists, the best long-term results will come from steps that minimize the need for doctor visits and long-term medication,” he said.

“At present, too much emphasis is being placed on expensive medications that suppress chronic inflammation and too little on finding the cure. Drugs that suppress inflammation need to be continued indefinitely with repeated doctor visits and monitoring. We don't have the ability to cure any of the rheumatic diseases yet, but that's where our emphasis must be.”

During a discussion at the meeting about the risk of tuberculosis complicating immunosuppressive therapy, he learned that most physicians in India “often assume that the patient needs to be treated for TB, because TB is so rampant there.”

In spite of such obstacles, Dr. Lehman said that he returned home from the meeting inspired. “There are many children in India with rheumatic disease.”

“They're short on drugs and they're short on financing for the more expensive drugs. But this was a group of interested and enthusiastic physicians who are working hard on getting pediatric rheumatology established in that country. I'll be going back in the future to do more teaching. They need it, and I'm glad to help out.”

Dr. Lehman said his expenses were paid by the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

A group of interested and enthusiastic physicians are working hard to get pediatric rheumatology established in India, said Dr. Thomas J.A. Lehman.

Source Courtesy Dr. Thomas J.A. Lehman

SAN DIEGO — The more advanced the stage of chronic kidney disease, the greater the risk of developing heart failure and subsequent risk of death, results from a large analysis of Medicare patients showed.

“Even a modest degree of chronic kidney disease is a very strong predictor of having cardiovascular morbidity and mortality,” Dr. Charles A. Herzog said in an interview at the annual meeting of the American Society of Nephrology.

“Chronic kidney disease is something that primary care physicians can easily detect, because it's very easy to do a serum creatinine in an office setting,” said Dr. Herzog, director of the Minneapolis–based cardiovascular special studies center of the U.S. Renal Data System Coordinating Center.

He identified just over 1 million patients aged at least 66 years from the general Medicare database and followed them during 2006-2007. Patients with heart failure and end-stage renal disease at baseline were excluded from the analysis.

The researchers used a Cox proportional hazard model to assess the patients' risk of developing incident heart failure, adjusting for demographics, comorbidities, and stage of chronic kidney disease. They used the Kaplan-Meier method to estimate the age-adjusted survival of patients after the development of incident heart failure.

At baseline, 59% of the patients were women and 88% were white. Most (95.8%) had no chronic kidney disease, 0.4% had stage I-II disease, 1.4% had stage III-IV disease, and the remainder (2.4%) had an unknown stage of disease.

After 1 year, heart failure occurred in 5.3% of patients with no chronic kidney disease at baseline, 12.7% of those with stage I-II disease, 15% of those with stage III-IV disease, and 12.3% of those whose disease stage was unknown.

Independent predictors of heart failure were age 70-74 years (hazard ratio 1.30); age 75-79 years (HR 1.75); age 80-84 years (HR 2.42); and age 85 years and older (HR 3.82). Other independent predictors included black race (HR 1.21); stage I-II chronic kidney disease (HR 1.45); stage III-IV disease (HR 1.68), and unknown stage of chronic kidney disease (HR 1.27).

Dr. Herzog also found that the the following comorbid conditions predicted heart failure: anemia (HR 1.22), diabetes (HR 1.57), ischemic heart disease (HR 1.67), and dysrhythmia (HR 1.94).

Over the 1-year period, 83% of patients with no chronic kidney disease survived, compared with 77% of those with stage I-II disease, 75% of those with stage II-IV disease, and 67% of those whose disease stage was unknown.

Dr. Herzog acknowledged that a limitation of the study was its reliance on Medicare claims data.

Dr. Herzog is a consultant for Amgen Inc., a scientific adviser for CorMedix Inc., and a trustee of the Roche Foundation for Anemia Research.

'A modest degree of chronic kidney disease is a very strong predictor' of cardiovascular morbidity and mortality,

Source DR. HERZOG

SAN DIEGO — The more advanced the stage of chronic kidney disease, the greater the risk of developing heart failure and subsequent risk of death, results from a large analysis of Medicare patients showed.

“Even a modest degree of chronic kidney disease is a very strong predictor of having cardiovascular morbidity and mortality,” Dr. Charles A. Herzog said in an interview at the annual meeting of the American Society of Nephrology.

“Chronic kidney disease is something that primary care physicians can easily detect, because it's very easy to do a serum creatinine in an office setting,” said Dr. Herzog, director of the Minneapolis–based cardiovascular special studies center of the U.S. Renal Data System Coordinating Center.

He identified just over 1 million patients aged at least 66 years from the general Medicare database and followed them during 2006-2007. Patients with heart failure and end-stage renal disease at baseline were excluded from the analysis.

The researchers used a Cox proportional hazard model to assess the patients' risk of developing incident heart failure, adjusting for demographics, comorbidities, and stage of chronic kidney disease. They used the Kaplan-Meier method to estimate the age-adjusted survival of patients after the development of incident heart failure.

At baseline, 59% of the patients were women and 88% were white. Most (95.8%) had no chronic kidney disease, 0.4% had stage I-II disease, 1.4% had stage III-IV disease, and the remainder (2.4%) had an unknown stage of disease.

After 1 year, heart failure occurred in 5.3% of patients with no chronic kidney disease at baseline, 12.7% of those with stage I-II disease, 15% of those with stage III-IV disease, and 12.3% of those whose disease stage was unknown.

Independent predictors of heart failure were age 70-74 years (hazard ratio 1.30); age 75-79 years (HR 1.75); age 80-84 years (HR 2.42); and age 85 years and older (HR 3.82). Other independent predictors included black race (HR 1.21); stage I-II chronic kidney disease (HR 1.45); stage III-IV disease (HR 1.68), and unknown stage of chronic kidney disease (HR 1.27).

Dr. Herzog also found that the the following comorbid conditions predicted heart failure: anemia (HR 1.22), diabetes (HR 1.57), ischemic heart disease (HR 1.67), and dysrhythmia (HR 1.94).

Over the 1-year period, 83% of patients with no chronic kidney disease survived, compared with 77% of those with stage I-II disease, 75% of those with stage II-IV disease, and 67% of those whose disease stage was unknown.

Dr. Herzog acknowledged that a limitation of the study was its reliance on Medicare claims data.

Dr. Herzog is a consultant for Amgen Inc., a scientific adviser for CorMedix Inc., and a trustee of the Roche Foundation for Anemia Research.

'A modest degree of chronic kidney disease is a very strong predictor' of cardiovascular morbidity and mortality,

Source DR. HERZOG

SAN DIEGO — The more advanced the stage of chronic kidney disease, the greater the risk of developing heart failure and subsequent risk of death, results from a large analysis of Medicare patients showed.

“Even a modest degree of chronic kidney disease is a very strong predictor of having cardiovascular morbidity and mortality,” Dr. Charles A. Herzog said in an interview at the annual meeting of the American Society of Nephrology.

“Chronic kidney disease is something that primary care physicians can easily detect, because it's very easy to do a serum creatinine in an office setting,” said Dr. Herzog, director of the Minneapolis–based cardiovascular special studies center of the U.S. Renal Data System Coordinating Center.

He identified just over 1 million patients aged at least 66 years from the general Medicare database and followed them during 2006-2007. Patients with heart failure and end-stage renal disease at baseline were excluded from the analysis.

The researchers used a Cox proportional hazard model to assess the patients' risk of developing incident heart failure, adjusting for demographics, comorbidities, and stage of chronic kidney disease. They used the Kaplan-Meier method to estimate the age-adjusted survival of patients after the development of incident heart failure.

At baseline, 59% of the patients were women and 88% were white. Most (95.8%) had no chronic kidney disease, 0.4% had stage I-II disease, 1.4% had stage III-IV disease, and the remainder (2.4%) had an unknown stage of disease.

After 1 year, heart failure occurred in 5.3% of patients with no chronic kidney disease at baseline, 12.7% of those with stage I-II disease, 15% of those with stage III-IV disease, and 12.3% of those whose disease stage was unknown.

Independent predictors of heart failure were age 70-74 years (hazard ratio 1.30); age 75-79 years (HR 1.75); age 80-84 years (HR 2.42); and age 85 years and older (HR 3.82). Other independent predictors included black race (HR 1.21); stage I-II chronic kidney disease (HR 1.45); stage III-IV disease (HR 1.68), and unknown stage of chronic kidney disease (HR 1.27).

Dr. Herzog also found that the the following comorbid conditions predicted heart failure: anemia (HR 1.22), diabetes (HR 1.57), ischemic heart disease (HR 1.67), and dysrhythmia (HR 1.94).

Over the 1-year period, 83% of patients with no chronic kidney disease survived, compared with 77% of those with stage I-II disease, 75% of those with stage II-IV disease, and 67% of those whose disease stage was unknown.

Dr. Herzog acknowledged that a limitation of the study was its reliance on Medicare claims data.

Dr. Herzog is a consultant for Amgen Inc., a scientific adviser for CorMedix Inc., and a trustee of the Roche Foundation for Anemia Research.

'A modest degree of chronic kidney disease is a very strong predictor' of cardiovascular morbidity and mortality,

Source DR. HERZOG

Major Findings: One 15-mcg dose of 2009 H1N1 influenza vaccine appears adequate in 93% of infants and children.

Source of Data: In a multicenter Australian study, researchers randomized 346 infants and children to receive a two-injection regimen of H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg.

Disclosures: CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

A single 15-mcg dose of 2009 H1N1 influenza vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne. “The results are of particular added clinical significance because of the unexpected finding of the possible adequacy of a single dose given that the U.S. and U.K. governments recommend a two-dose regimen in infants and young children.”

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010;303:37–46). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The site investigator “considered that this event was possibly related to vaccination,” the researchers stated. “The data and safety monitoring board attributed the episode to a possible viral infection and the study was recommenced within 1 day of notification. This child made a full and uneventful recovery.”

The second adverse event occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompany editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that while the finding that one dose of H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2010;303:73–4).

Dr. Fiore, of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil, of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

For now, they concluded, “it remains prudent to continue to follow current recommendations for administering 2 doses to infants and young children while awaiting definitive vaccine effectiveness data.”

Major Findings: One 15-mcg dose of 2009 H1N1 influenza vaccine appears adequate in 93% of infants and children.

Source of Data: In a multicenter Australian study, researchers randomized 346 infants and children to receive a two-injection regimen of H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg.

Disclosures: CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

A single 15-mcg dose of 2009 H1N1 influenza vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne. “The results are of particular added clinical significance because of the unexpected finding of the possible adequacy of a single dose given that the U.S. and U.K. governments recommend a two-dose regimen in infants and young children.”

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010;303:37–46). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The site investigator “considered that this event was possibly related to vaccination,” the researchers stated. “The data and safety monitoring board attributed the episode to a possible viral infection and the study was recommenced within 1 day of notification. This child made a full and uneventful recovery.”

The second adverse event occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompany editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that while the finding that one dose of H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2010;303:73–4).

Dr. Fiore, of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil, of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

For now, they concluded, “it remains prudent to continue to follow current recommendations for administering 2 doses to infants and young children while awaiting definitive vaccine effectiveness data.”

Major Findings: One 15-mcg dose of 2009 H1N1 influenza vaccine appears adequate in 93% of infants and children.

Source of Data: In a multicenter Australian study, researchers randomized 346 infants and children to receive a two-injection regimen of H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg.

Disclosures: CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

A single 15-mcg dose of 2009 H1N1 influenza vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne. “The results are of particular added clinical significance because of the unexpected finding of the possible adequacy of a single dose given that the U.S. and U.K. governments recommend a two-dose regimen in infants and young children.”

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010;303:37–46). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The site investigator “considered that this event was possibly related to vaccination,” the researchers stated. “The data and safety monitoring board attributed the episode to a possible viral infection and the study was recommenced within 1 day of notification. This child made a full and uneventful recovery.”

The second adverse event occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompany editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that while the finding that one dose of H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2010;303:73–4).

Dr. Fiore, of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil, of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

For now, they concluded, “it remains prudent to continue to follow current recommendations for administering 2 doses to infants and young children while awaiting definitive vaccine effectiveness data.”

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, hardwoods, farmland, and a population of more than 101,000.

At the same time, she began to train her dog, Dizzy, a German shepherd, in search and rescue.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

Early on, however, Dizzy struggled to grasp the tasks at hand. “She was a great dog as far as being happy and friendly and having all those other attributes you'd want in a search dog, but she would much rather lay on her back and have her belly rubbed than have to work for her reward,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y.

Dr. Briggs eventually made Dizzy a family pet and acquired Boomer, a black and white border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October of 2009.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” Dr. Briggs explained. “The wilderness air scent handler would receive a map or a description of the boundaries and would figure out the best way to walk through the area to search it. The dog works off leash. The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Dr. Briggs is currently training Boomer in tracking and trailing skills with the goal of having him earn certification. She described tracking and trailing as a scent-specific job, “where the dog sniffs a scent article and follows the way the person walked, leading the handler to the subject. Every dog works for whatever motivates him. Boomer's reward is tugging with a toy. So in training, whenever he locates a subject, he gets a big party of praise and tugging,” said Dr. Briggs.

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors, which she traces back to her days as a Girl Scout.

“You're out in the woods, so you're going to have to know basic first aid and CPR,” she said. “It's helpful to have a medical background because the searchers are out there, they're exposed to the elements, they have their adrenaline pumped and they're being physically pushed, so there is the chance of illness or injury.”

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured. “Usually we have a line of people combing the area for subjects,” she said. “One time we went looking for a man who became lost exploring some property he planned to buy.”

Another time she helped a group of rescuers look for a person who had gone missing in the late fall. “When things started to melt and thaw they had searchers out,” she recalled. “Unfortunately both subjects were not alive when they were found by the search team.”

In addition to being available to assist on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I do that on my own time,” Dr. Briggs said. “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is.”

Dr. Eva Briggs trained Boomer, a border collie, in search and rescue.

Source Courtesy Rob Howard

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, hardwoods, farmland, and a population of more than 101,000.

At the same time, she began to train her dog, Dizzy, a German shepherd, in search and rescue.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

Early on, however, Dizzy struggled to grasp the tasks at hand. “She was a great dog as far as being happy and friendly and having all those other attributes you'd want in a search dog, but she would much rather lay on her back and have her belly rubbed than have to work for her reward,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y.

Dr. Briggs eventually made Dizzy a family pet and acquired Boomer, a black and white border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October of 2009.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” Dr. Briggs explained. “The wilderness air scent handler would receive a map or a description of the boundaries and would figure out the best way to walk through the area to search it. The dog works off leash. The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Dr. Briggs is currently training Boomer in tracking and trailing skills with the goal of having him earn certification. She described tracking and trailing as a scent-specific job, “where the dog sniffs a scent article and follows the way the person walked, leading the handler to the subject. Every dog works for whatever motivates him. Boomer's reward is tugging with a toy. So in training, whenever he locates a subject, he gets a big party of praise and tugging,” said Dr. Briggs.

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors, which she traces back to her days as a Girl Scout.

“You're out in the woods, so you're going to have to know basic first aid and CPR,” she said. “It's helpful to have a medical background because the searchers are out there, they're exposed to the elements, they have their adrenaline pumped and they're being physically pushed, so there is the chance of illness or injury.”

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured. “Usually we have a line of people combing the area for subjects,” she said. “One time we went looking for a man who became lost exploring some property he planned to buy.”

Another time she helped a group of rescuers look for a person who had gone missing in the late fall. “When things started to melt and thaw they had searchers out,” she recalled. “Unfortunately both subjects were not alive when they were found by the search team.”

In addition to being available to assist on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I do that on my own time,” Dr. Briggs said. “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is.”

Dr. Eva Briggs trained Boomer, a border collie, in search and rescue.

Source Courtesy Rob Howard

Five years ago, Dr. Eva Briggs became a search and rescue volunteer in Tompkins County, N.Y., a hilly region in the central part of the state marked by gorges, hardwoods, farmland, and a population of more than 101,000.

At the same time, she began to train her dog, Dizzy, a German shepherd, in search and rescue.

“I've always liked being outdoors, plus I've always liked dogs, so once my kids started getting older, I thought, 'This might be an interesting thing to try,'” said Dr. Briggs, a family physician who lives in Marcellus, N.Y., and has a master's degree in environmental forestry from the State University of New York College of Environmental Science and Forestry in Syracuse.

Early on, however, Dizzy struggled to grasp the tasks at hand. “She was a great dog as far as being happy and friendly and having all those other attributes you'd want in a search dog, but she would much rather lay on her back and have her belly rubbed than have to work for her reward,” said Dr. Briggs, who works at two urgent care centers operated by Cayuga Medical Center in nearby Ithaca, N.Y.

Dr. Briggs eventually made Dizzy a family pet and acquired Boomer, a black and white border collie puppy, to train for search and rescue work. Now almost 3 years old, Boomer has not participated in formal search and rescue operations, but he did earn certification in wilderness air scent from the International Police Working Dog Association in October of 2009.

“In an actual search, the canine team would be assigned a specific area, say 40 acres,” Dr. Briggs explained. “The wilderness air scent handler would receive a map or a description of the boundaries and would figure out the best way to walk through the area to search it. The dog works off leash. The dog will find any person whose scent he detects. When the dog finds the subject, he comes back to me and gives his trained indication, which in the case of my dog is a bark, and then he leads me back to the subject.”

Dr. Briggs is currently training Boomer in tracking and trailing skills with the goal of having him earn certification. She described tracking and trailing as a scent-specific job, “where the dog sniffs a scent article and follows the way the person walked, leading the handler to the subject. Every dog works for whatever motivates him. Boomer's reward is tugging with a toy. So in training, whenever he locates a subject, he gets a big party of praise and tugging,” said Dr. Briggs.

Boomer may be relatively new to search and rescue, but Dr. Briggs has long been acquainted. She began her volunteer post armed with the know-how of map reading and compass navigation, thanks to her graduate work in environmental science and forestry and her love of the outdoors, which she traces back to her days as a Girl Scout.

“You're out in the woods, so you're going to have to know basic first aid and CPR,” she said. “It's helpful to have a medical background because the searchers are out there, they're exposed to the elements, they have their adrenaline pumped and they're being physically pushed, so there is the chance of illness or injury.”

As one of about 15 volunteers for Tompkins County search and rescue, Dr. Briggs has participated in several searches as a “ground pounder,” a person who combs through terrain searching for people who are lost or injured. “Usually we have a line of people combing the area for subjects,” she said. “One time we went looking for a man who became lost exploring some property he planned to buy.”

Another time she helped a group of rescuers look for a person who had gone missing in the late fall. “When things started to melt and thaw they had searchers out,” she recalled. “Unfortunately both subjects were not alive when they were found by the search team.”

In addition to being available to assist on the ground, her commitment as a search and rescue volunteer involves attending monthly training sessions and business meetings. She is a member of the committee that plans and carries out the training sessions. “We also do public relations and teaching and interacting with the public, which can be really nice,” she said. “I've even written some book reviews for the National Search Dog Alliance.”

As for working with Boomer, “I do that on my own time,” Dr. Briggs said. “I probably do something training-wise every day, and something specific to search and rescue 2–3 times a week. It makes me go outdoors no matter what the weather is.”

Dr. Eva Briggs trained Boomer, a border collie, in search and rescue.

Source Courtesy Rob Howard

PORTLAND, ORE. — Skin lesions are a hallmark of Merkel cell carcinoma, yet dermatologists are often left out of the loop in diagnosing patients with the disease, said Dr. Paul Nghiem.

“These [lesions] are typically biopsied as a cyst and the patient usually has to argue for one, two, or three doctor's visits to have the lesion biopsied,” Dr. Nghiem said at the annual meeting of the Pacific Dermatologic Association. They're usually biopsied by a physician “who thinks they're taking off a cyst. Then they may be referred to medical oncology or to surgical oncology, but rarely to dermatology.”

About 1,500 new cases of Merkel cell carcinoma (MCC) are diagnosed in the United States each year (J. Invest. Dermatol. 2007;127:2100–3), which is about the same incidence as cutaneous T-cell lymphoma or dermatofibrosarcoma protuberans, said Dr. Nghiem, an expert on the disease who is associate professor of dermatology, medicine, and pathology at the University of Washington, Seattle.

MCC is significantly more lethal than melanoma (40% vs. 15%, respectively), and its reported incidence has increased threefold since 1986 (J. Surg. Oncol. 2005;89:1–4). “A big reason for that is that it's not missed as much,” Dr. Nghiem said. “There are better tools for pathologists to use to make the diagnosis.”

The three main risk factors for MCC are prolonged sun exposure, immune suppression, and age over 50 years. “Ninety-four percent of all MCC cases are in people aged 50 or older,” he said. “There is a very strong synergy with age” (J. Am. Acad. Dermatol. 2008;58:375–81).

Dr. Nghiem said that HIV-positive patients had about a 13-fold increase of MCC in one study (Lancet 2002;359:497–8), while another study showed that solid organ transplant recipients have about a 10-fold increase (Transplantation 1999;68:1717–21).

He and his associates devised the acronym AEIOU to describe the clinical features of Merkel cell carcinoma based on an analysis of 195 patients given the diagnosis between 1980 and 2007 (J. Am. Acad. Dermatol. 2008; 58:375–81). The acronym stands for Asymptomatic, Expanding rapidly, Immune compromised, Older than 50, and UV-exposed, fair skin.

“Under no circumstances do I think that this is a highly specific test,” said Dr. Nghiem, whose clinic is based at the Fred Hutchinson Cancer Research Center in Seattle. “It's not going to be up there with the ABCDs of melanoma, but if you see these characteristics together, you may want to think about doing a biopsy.”

More than half of the lesions in the 195 patients evaluated (56%) were presumed to be benign at biopsy, and 32% presented on the head and neck, followed by the lower limb (30%), upper limb (20%), trunk (10%), and buttock (8%).

The majority of lesions (81%) presented on sun-exposed skin, but one in six was in a sun-protected site.

Nearly all of the lesions (88%) were asymptomatic (“neither tender nor itchy,” he said), 63% doubled in size in the past 3 months, and 8% of the patients were profoundly immune suppressed.

“That is a 16-fold increase over the normal population, but still a minority of all Merkel cell cases,” he said, noting that 90% of the patients studied were at least 50 years of age and that 98% were fair skinned.

“Taken together, 89% of all Merkel cell carcinomas had three or more of these clinical AEIOU features,” Dr. Nghiem said.

Optimal therapy for MCC is unique among skin cancers, he said, in that sentinel lymph node biopsy (SLNB) is usually indicated and the disease is “exquisitely sensitive” to radiation.

“If I had one modality to treat MCC, it would be radiation,” he said.

SLNB is important for prognosis, he added, because it “results in more accurate staging and has therapeutic implications. If it's microscopically positive [the cancer] will very likely develop in that node bed within a few months if you don't do anything.”

He has received funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Cancer Society.

The majority of Merkel cell carcinoma lesions appear on sun-exposed skin and are often mistaken for cysts.

Source Photos courtesy Dr. Paul Nghiem

PORTLAND, ORE. — Skin lesions are a hallmark of Merkel cell carcinoma, yet dermatologists are often left out of the loop in diagnosing patients with the disease, said Dr. Paul Nghiem.

“These [lesions] are typically biopsied as a cyst and the patient usually has to argue for one, two, or three doctor's visits to have the lesion biopsied,” Dr. Nghiem said at the annual meeting of the Pacific Dermatologic Association. They're usually biopsied by a physician “who thinks they're taking off a cyst. Then they may be referred to medical oncology or to surgical oncology, but rarely to dermatology.”

About 1,500 new cases of Merkel cell carcinoma (MCC) are diagnosed in the United States each year (J. Invest. Dermatol. 2007;127:2100–3), which is about the same incidence as cutaneous T-cell lymphoma or dermatofibrosarcoma protuberans, said Dr. Nghiem, an expert on the disease who is associate professor of dermatology, medicine, and pathology at the University of Washington, Seattle.

MCC is significantly more lethal than melanoma (40% vs. 15%, respectively), and its reported incidence has increased threefold since 1986 (J. Surg. Oncol. 2005;89:1–4). “A big reason for that is that it's not missed as much,” Dr. Nghiem said. “There are better tools for pathologists to use to make the diagnosis.”

The three main risk factors for MCC are prolonged sun exposure, immune suppression, and age over 50 years. “Ninety-four percent of all MCC cases are in people aged 50 or older,” he said. “There is a very strong synergy with age” (J. Am. Acad. Dermatol. 2008;58:375–81).

Dr. Nghiem said that HIV-positive patients had about a 13-fold increase of MCC in one study (Lancet 2002;359:497–8), while another study showed that solid organ transplant recipients have about a 10-fold increase (Transplantation 1999;68:1717–21).

He and his associates devised the acronym AEIOU to describe the clinical features of Merkel cell carcinoma based on an analysis of 195 patients given the diagnosis between 1980 and 2007 (J. Am. Acad. Dermatol. 2008; 58:375–81). The acronym stands for Asymptomatic, Expanding rapidly, Immune compromised, Older than 50, and UV-exposed, fair skin.

“Under no circumstances do I think that this is a highly specific test,” said Dr. Nghiem, whose clinic is based at the Fred Hutchinson Cancer Research Center in Seattle. “It's not going to be up there with the ABCDs of melanoma, but if you see these characteristics together, you may want to think about doing a biopsy.”

More than half of the lesions in the 195 patients evaluated (56%) were presumed to be benign at biopsy, and 32% presented on the head and neck, followed by the lower limb (30%), upper limb (20%), trunk (10%), and buttock (8%).

The majority of lesions (81%) presented on sun-exposed skin, but one in six was in a sun-protected site.

Nearly all of the lesions (88%) were asymptomatic (“neither tender nor itchy,” he said), 63% doubled in size in the past 3 months, and 8% of the patients were profoundly immune suppressed.

“That is a 16-fold increase over the normal population, but still a minority of all Merkel cell cases,” he said, noting that 90% of the patients studied were at least 50 years of age and that 98% were fair skinned.

“Taken together, 89% of all Merkel cell carcinomas had three or more of these clinical AEIOU features,” Dr. Nghiem said.

Optimal therapy for MCC is unique among skin cancers, he said, in that sentinel lymph node biopsy (SLNB) is usually indicated and the disease is “exquisitely sensitive” to radiation.

“If I had one modality to treat MCC, it would be radiation,” he said.

SLNB is important for prognosis, he added, because it “results in more accurate staging and has therapeutic implications. If it's microscopically positive [the cancer] will very likely develop in that node bed within a few months if you don't do anything.”

He has received funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Cancer Society.

The majority of Merkel cell carcinoma lesions appear on sun-exposed skin and are often mistaken for cysts.

Source Photos courtesy Dr. Paul Nghiem

PORTLAND, ORE. — Skin lesions are a hallmark of Merkel cell carcinoma, yet dermatologists are often left out of the loop in diagnosing patients with the disease, said Dr. Paul Nghiem.

“These [lesions] are typically biopsied as a cyst and the patient usually has to argue for one, two, or three doctor's visits to have the lesion biopsied,” Dr. Nghiem said at the annual meeting of the Pacific Dermatologic Association. They're usually biopsied by a physician “who thinks they're taking off a cyst. Then they may be referred to medical oncology or to surgical oncology, but rarely to dermatology.”

About 1,500 new cases of Merkel cell carcinoma (MCC) are diagnosed in the United States each year (J. Invest. Dermatol. 2007;127:2100–3), which is about the same incidence as cutaneous T-cell lymphoma or dermatofibrosarcoma protuberans, said Dr. Nghiem, an expert on the disease who is associate professor of dermatology, medicine, and pathology at the University of Washington, Seattle.

MCC is significantly more lethal than melanoma (40% vs. 15%, respectively), and its reported incidence has increased threefold since 1986 (J. Surg. Oncol. 2005;89:1–4). “A big reason for that is that it's not missed as much,” Dr. Nghiem said. “There are better tools for pathologists to use to make the diagnosis.”

The three main risk factors for MCC are prolonged sun exposure, immune suppression, and age over 50 years. “Ninety-four percent of all MCC cases are in people aged 50 or older,” he said. “There is a very strong synergy with age” (J. Am. Acad. Dermatol. 2008;58:375–81).

Dr. Nghiem said that HIV-positive patients had about a 13-fold increase of MCC in one study (Lancet 2002;359:497–8), while another study showed that solid organ transplant recipients have about a 10-fold increase (Transplantation 1999;68:1717–21).

He and his associates devised the acronym AEIOU to describe the clinical features of Merkel cell carcinoma based on an analysis of 195 patients given the diagnosis between 1980 and 2007 (J. Am. Acad. Dermatol. 2008; 58:375–81). The acronym stands for Asymptomatic, Expanding rapidly, Immune compromised, Older than 50, and UV-exposed, fair skin.

“Under no circumstances do I think that this is a highly specific test,” said Dr. Nghiem, whose clinic is based at the Fred Hutchinson Cancer Research Center in Seattle. “It's not going to be up there with the ABCDs of melanoma, but if you see these characteristics together, you may want to think about doing a biopsy.”

More than half of the lesions in the 195 patients evaluated (56%) were presumed to be benign at biopsy, and 32% presented on the head and neck, followed by the lower limb (30%), upper limb (20%), trunk (10%), and buttock (8%).

The majority of lesions (81%) presented on sun-exposed skin, but one in six was in a sun-protected site.

Nearly all of the lesions (88%) were asymptomatic (“neither tender nor itchy,” he said), 63% doubled in size in the past 3 months, and 8% of the patients were profoundly immune suppressed.

“That is a 16-fold increase over the normal population, but still a minority of all Merkel cell cases,” he said, noting that 90% of the patients studied were at least 50 years of age and that 98% were fair skinned.

“Taken together, 89% of all Merkel cell carcinomas had three or more of these clinical AEIOU features,” Dr. Nghiem said.

Optimal therapy for MCC is unique among skin cancers, he said, in that sentinel lymph node biopsy (SLNB) is usually indicated and the disease is “exquisitely sensitive” to radiation.

“If I had one modality to treat MCC, it would be radiation,” he said.

SLNB is important for prognosis, he added, because it “results in more accurate staging and has therapeutic implications. If it's microscopically positive [the cancer] will very likely develop in that node bed within a few months if you don't do anything.”

He has received funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Cancer Society.

The majority of Merkel cell carcinoma lesions appear on sun-exposed skin and are often mistaken for cysts.

Source Photos courtesy Dr. Paul Nghiem

The way Dr. Anne Schuchat sees it, physicians and other clinicians have more influence than anybody else on a patient's decision to be vaccinated against the pandemic influenza A(H1N1) virus.

“A recommendation from a doctor or a nurse has more clout than anything that we do in Atlanta or Washington,” Dr. Schuchat, director of the National Center for Immunization and Respiratory Diseases, Atlanta, said during a Webcast on H1N1 sponsored by the Department of Health and Human Services. “As health care providers, each of us has a responsibility to talk to our patients about the risks and benefits of vaccination, and to let them know the real risks of disease.”

The Centers for Disease Control and Prevention estimates that about 1 in 6 Americans—about 47 million people—have become ill from the virus since last spring. “We think over 200,000 people have been hospitalized, and about 10,000 have died,” Dr. Schuchat said. “A disproportionate amount of those hospitalizations and deaths have been in people under 65 years of age.”

The good news is that the prevalence of H1N1 disease continues to wane, with 14 states reporting widespread activity at present, down from 32 states that reported such activity Dec. 1.

“That's still a lot of states, and the virus hasn't gone away,” Dr. Schuchat cautioned. “We know from the past that there can be an increase after the holidays—another wave of disease, for instance—but right now we're in pretty good shape, with less disease than we had a month or so ago”

Despite the positive turn of events, U.S. Surgeon General Regina Benjamin said, many populations aren't seeking vaccination against H1N1, particularly school-aged children, pregnant women, and racial and ethnic minorities. “For some reason people in minority groups are not taking the vaccine as much as we would like them to,” she said. “Everyone should get vaccinated.”

Dr. Nicole Lurie, Health and Human Services assistant secretary for preparedness and response, said that while increasing numbers of her patients seem to understand there is a difference between H1N1 vaccine and seasonal influenza vaccine, “they're not always sure they need to have both. They continue to have some questions that are typical for flu shots: Is it safe? Am I going to get sick if I get a flu shot? Do I really need to do this? My answer is, 'I think you really need to do this.'”

Other phrases she uses to motivate patients to get vaccinated include: “If you don't want to miss work and as a result miss a paycheck, by all means get the flu shot,” and “No one can predict who's going to get sick enough to end up in the hospital or in an intensive care unit, and you don't want to be there. But we have a very strong prediction that if you get your flu shot, you won't be there.”

Dr. Schuchat emphasized that getting vaccinated will help protect people from spreading the virus to others. “As a health care provider, the last thing I want to do is spread an infection to my patients,” she said.

The Webcast moderator asked if it's advisable to offer H1N1 vaccine to people who had a respiratory illness during the fall but didn't get a laboratory confirmation that it was H1N1. “We do recommend that,” Dr. Schuchat said. “We've told providers that they don't need to test everyone. Many of the tests that are done are not specific. You usually have to go to a reference lab in your state to confirm that it's H1N1 virus. So what we're telling people is that even if you've had two or three respiratory illness this fall, we still recommend the vaccine.”

Dr. Lurie fielded an e-mail question from a clinician who works in a nursing home. The person asked if nursing home residents or just the staff should receive the H1N1 vaccine. “It's terribly important for nursing home staff to get both [influenza vaccines],” Dr. Lurie said. “If nursing home residents also want to get vaccinated—particularly those who are out and about—I think it would be a great idea now that the [H1N1] vaccine is widely available.”

The way Dr. Anne Schuchat sees it, physicians and other clinicians have more influence than anybody else on a patient's decision to be vaccinated against the pandemic influenza A(H1N1) virus.

“A recommendation from a doctor or a nurse has more clout than anything that we do in Atlanta or Washington,” Dr. Schuchat, director of the National Center for Immunization and Respiratory Diseases, Atlanta, said during a Webcast on H1N1 sponsored by the Department of Health and Human Services. “As health care providers, each of us has a responsibility to talk to our patients about the risks and benefits of vaccination, and to let them know the real risks of disease.”

The Centers for Disease Control and Prevention estimates that about 1 in 6 Americans—about 47 million people—have become ill from the virus since last spring. “We think over 200,000 people have been hospitalized, and about 10,000 have died,” Dr. Schuchat said. “A disproportionate amount of those hospitalizations and deaths have been in people under 65 years of age.”

The good news is that the prevalence of H1N1 disease continues to wane, with 14 states reporting widespread activity at present, down from 32 states that reported such activity Dec. 1.

“That's still a lot of states, and the virus hasn't gone away,” Dr. Schuchat cautioned. “We know from the past that there can be an increase after the holidays—another wave of disease, for instance—but right now we're in pretty good shape, with less disease than we had a month or so ago”

Despite the positive turn of events, U.S. Surgeon General Regina Benjamin said, many populations aren't seeking vaccination against H1N1, particularly school-aged children, pregnant women, and racial and ethnic minorities. “For some reason people in minority groups are not taking the vaccine as much as we would like them to,” she said. “Everyone should get vaccinated.”

Dr. Nicole Lurie, Health and Human Services assistant secretary for preparedness and response, said that while increasing numbers of her patients seem to understand there is a difference between H1N1 vaccine and seasonal influenza vaccine, “they're not always sure they need to have both. They continue to have some questions that are typical for flu shots: Is it safe? Am I going to get sick if I get a flu shot? Do I really need to do this? My answer is, 'I think you really need to do this.'”

Other phrases she uses to motivate patients to get vaccinated include: “If you don't want to miss work and as a result miss a paycheck, by all means get the flu shot,” and “No one can predict who's going to get sick enough to end up in the hospital or in an intensive care unit, and you don't want to be there. But we have a very strong prediction that if you get your flu shot, you won't be there.”

Dr. Schuchat emphasized that getting vaccinated will help protect people from spreading the virus to others. “As a health care provider, the last thing I want to do is spread an infection to my patients,” she said.

The Webcast moderator asked if it's advisable to offer H1N1 vaccine to people who had a respiratory illness during the fall but didn't get a laboratory confirmation that it was H1N1. “We do recommend that,” Dr. Schuchat said. “We've told providers that they don't need to test everyone. Many of the tests that are done are not specific. You usually have to go to a reference lab in your state to confirm that it's H1N1 virus. So what we're telling people is that even if you've had two or three respiratory illness this fall, we still recommend the vaccine.”

Dr. Lurie fielded an e-mail question from a clinician who works in a nursing home. The person asked if nursing home residents or just the staff should receive the H1N1 vaccine. “It's terribly important for nursing home staff to get both [influenza vaccines],” Dr. Lurie said. “If nursing home residents also want to get vaccinated—particularly those who are out and about—I think it would be a great idea now that the [H1N1] vaccine is widely available.”

The way Dr. Anne Schuchat sees it, physicians and other clinicians have more influence than anybody else on a patient's decision to be vaccinated against the pandemic influenza A(H1N1) virus.

“A recommendation from a doctor or a nurse has more clout than anything that we do in Atlanta or Washington,” Dr. Schuchat, director of the National Center for Immunization and Respiratory Diseases, Atlanta, said during a Webcast on H1N1 sponsored by the Department of Health and Human Services. “As health care providers, each of us has a responsibility to talk to our patients about the risks and benefits of vaccination, and to let them know the real risks of disease.”

The Centers for Disease Control and Prevention estimates that about 1 in 6 Americans—about 47 million people—have become ill from the virus since last spring. “We think over 200,000 people have been hospitalized, and about 10,000 have died,” Dr. Schuchat said. “A disproportionate amount of those hospitalizations and deaths have been in people under 65 years of age.”

The good news is that the prevalence of H1N1 disease continues to wane, with 14 states reporting widespread activity at present, down from 32 states that reported such activity Dec. 1.

“That's still a lot of states, and the virus hasn't gone away,” Dr. Schuchat cautioned. “We know from the past that there can be an increase after the holidays—another wave of disease, for instance—but right now we're in pretty good shape, with less disease than we had a month or so ago”

Despite the positive turn of events, U.S. Surgeon General Regina Benjamin said, many populations aren't seeking vaccination against H1N1, particularly school-aged children, pregnant women, and racial and ethnic minorities. “For some reason people in minority groups are not taking the vaccine as much as we would like them to,” she said. “Everyone should get vaccinated.”

Dr. Nicole Lurie, Health and Human Services assistant secretary for preparedness and response, said that while increasing numbers of her patients seem to understand there is a difference between H1N1 vaccine and seasonal influenza vaccine, “they're not always sure they need to have both. They continue to have some questions that are typical for flu shots: Is it safe? Am I going to get sick if I get a flu shot? Do I really need to do this? My answer is, 'I think you really need to do this.'”

Other phrases she uses to motivate patients to get vaccinated include: “If you don't want to miss work and as a result miss a paycheck, by all means get the flu shot,” and “No one can predict who's going to get sick enough to end up in the hospital or in an intensive care unit, and you don't want to be there. But we have a very strong prediction that if you get your flu shot, you won't be there.”

Dr. Schuchat emphasized that getting vaccinated will help protect people from spreading the virus to others. “As a health care provider, the last thing I want to do is spread an infection to my patients,” she said.

The Webcast moderator asked if it's advisable to offer H1N1 vaccine to people who had a respiratory illness during the fall but didn't get a laboratory confirmation that it was H1N1. “We do recommend that,” Dr. Schuchat said. “We've told providers that they don't need to test everyone. Many of the tests that are done are not specific. You usually have to go to a reference lab in your state to confirm that it's H1N1 virus. So what we're telling people is that even if you've had two or three respiratory illness this fall, we still recommend the vaccine.”

Dr. Lurie fielded an e-mail question from a clinician who works in a nursing home. The person asked if nursing home residents or just the staff should receive the H1N1 vaccine. “It's terribly important for nursing home staff to get both [influenza vaccines],” Dr. Lurie said. “If nursing home residents also want to get vaccinated—particularly those who are out and about—I think it would be a great idea now that the [H1N1] vaccine is widely available.”

A single 15-mcg dose of pandemic influenza A(H1N1) vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne.

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010; Jan. 6 [doi:10.1001/JAMA.2009/1911]). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose, all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study, but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The second occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompanying editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that, although the finding that one dose of the H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2009 Dec. 21 [doi:10.1001/jama.2009.1929]).

Dr. Fiore of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

PATH is an international nonprofit organization that creates sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health.

CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

One 15-mcg dose of vaccine protected children against H1N1 (above).

Source ©CDC

A single 15-mcg dose of pandemic influenza A(H1N1) vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne.

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010; Jan. 6 [doi:10.1001/JAMA.2009/1911]). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose, all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study, but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The second occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompanying editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that, although the finding that one dose of the H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2009 Dec. 21 [doi:10.1001/jama.2009.1929]).

Dr. Fiore of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

PATH is an international nonprofit organization that creates sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health.

CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

One 15-mcg dose of vaccine protected children against H1N1 (above).

Source ©CDC

A single 15-mcg dose of pandemic influenza A(H1N1) vaccine provided hemagglutination titers of 1:40 or greater in 93% of infants and children, results from a multicenter study in Australia showed.

The findings “have important public health implications given that young children are at the highest risk for hospitalization and requirement for intensive care,” wrote the researchers led by Terry Nolan, Ph.D., of the Melbourne School of Population Health at the University of Melbourne.

Between Aug. 3 and Sept. 4, 2009, the researchers randomized 346 infants and children aged 6 months to 9 years to receive a two-injection regimen of monovalent, unadjuvanted H1N1 vaccine 21 days apart in doses of either 15 mcg or 30 mcg (JAMA 2010; Jan. 6 [doi:10.1001/JAMA.2009/1911]). The vaccine was produced by CSL Ltd., of Parkville, Australia.

The researchers used hemagglutination inhibition to measure antibody titers to the H1N1 antigen at enrollment and at 21–25 days after each vaccination.

After the first dose, antibody titers of 1:40 or greater were observed in 161 of 174 (93%) infants and children in the 15-mcg group and in 168 of the 172 (98%) infants in children in the 30-mcg group. After the second dose, all study participants in both groups demonstrated antibody titers of 1:40 or greater.

No deaths occurred during the study, but two serious adverse events were reported. The first was a 4-day episode of fluctuating fever in an 8-year-old child in the 30-mcg dose group.

The second occurred in a 1-year-old child in the 15-mcg dose group, a case of viral gastroenteritis that “was considered unrelated to vaccination.”

In an accompanying editorial, Dr. Anthony E. Fiore and Dr. Kathleen M. Neuzil said that, although the finding that one dose of the H1N1 vaccine was immunogenic in most young children “is encouraging, it is premature to assume that only 1 dose will be needed to provide adequate protection for all young children based on these data” (JAMA 2009 Dec. 21 [doi:10.1001/jama.2009.1929]).

Dr. Fiore of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, Atlanta, and Dr. Neuzil of PATH, Seattle, emphasized that the antigen content administered to infants and children in the study was 15 mcg, “the equivalent of two doses of the 7.5 microgram vaccine currently licensed in the United States for this age group.”

PATH is an international nonprofit organization that creates sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health.

CSL Ltd. sponsored the trial with funding from the Australian government's Department of Health and Aging. Dr. Nolan disclosed that he has been an investigator on vaccine studies sponsored by CSL and other companies, but stated that he does not own shares in CSL. Dr. Fiore and Dr. Neuzil had no financial conflicts of interest to disclose.

One 15-mcg dose of vaccine protected children against H1N1 (above).

Source ©CDC

A method of modeling global pandemic patterns has found that local commuting patterns provide a strong correlation and synchrony in the evolution of an emerging disease at the local level and during the tail end of disease spread.

The finding runs counter to previous studies that have suggested that long-range airline traffic marks the primary predictor of global disease spread, researchers led by Alessandro Vespignani, Ph.D., reported (PNAS 2009 Dec. 14 [doi:10.1073/pnas.0906910106]).

“On the one hand, the global epidemic behavior is governed by the long-range airline traffic that determines the arrival of infectious individuals on a worldwide scale,” the researchers stated. “At the local level, however, the short-range epidemic coupling induced by commuting flows creates a synchrony between neighboring regions and a local diffusive pattern with the epidemic flowing from subpopulations with major hubs into the neighboring subpopulations.”

Dr. Vespignani of the Indiana University School of Informatics and Computing, Bloomington, and his associates collected short-range commuting data (defined as a distance of up to 300 km) from 29 countries on five continents.

They used the information to create a mathematical model of the commuting behavior of specific populations of people in 220 countries living near 3,362 airports. The model included a seasonal dependence of disease transmission.

The researchers found that while commuting flows were, on average, one order of magnitude larger than the long-range airline traffic, “the global spatiotemporal patterns of disease-spreading are mainly determined by the airline network. Short-range commuting interactions have, on the other hand, a role in defining a larger degree of synchronization of nearby subpopulations and specific regions, which can be considered weakly connected by the airline” network.

Dr. Vespignani and his colleagues concluded that their model offers “an initial understanding of the level of data integration required to obtain reliable results in large-scale modeling of infectious diseases.”

The study was supported by funds from the National Institutes of Health and the Lilly Endowment Grant. In addition, Dr. Vespignani was supported by a Defense Threat Reduction Agency Grant and by a Future Emerging Technologies contract from Epiwork, while a coauthor was supported by a contract from the European Research Council.

A method of modeling global pandemic patterns has found that local commuting patterns provide a strong correlation and synchrony in the evolution of an emerging disease at the local level and during the tail end of disease spread.

The finding runs counter to previous studies that have suggested that long-range airline traffic marks the primary predictor of global disease spread, researchers led by Alessandro Vespignani, Ph.D., reported (PNAS 2009 Dec. 14 [doi:10.1073/pnas.0906910106]).

“On the one hand, the global epidemic behavior is governed by the long-range airline traffic that determines the arrival of infectious individuals on a worldwide scale,” the researchers stated. “At the local level, however, the short-range epidemic coupling induced by commuting flows creates a synchrony between neighboring regions and a local diffusive pattern with the epidemic flowing from subpopulations with major hubs into the neighboring subpopulations.”

Dr. Vespignani of the Indiana University School of Informatics and Computing, Bloomington, and his associates collected short-range commuting data (defined as a distance of up to 300 km) from 29 countries on five continents.

They used the information to create a mathematical model of the commuting behavior of specific populations of people in 220 countries living near 3,362 airports. The model included a seasonal dependence of disease transmission.

The researchers found that while commuting flows were, on average, one order of magnitude larger than the long-range airline traffic, “the global spatiotemporal patterns of disease-spreading are mainly determined by the airline network. Short-range commuting interactions have, on the other hand, a role in defining a larger degree of synchronization of nearby subpopulations and specific regions, which can be considered weakly connected by the airline” network.

Dr. Vespignani and his colleagues concluded that their model offers “an initial understanding of the level of data integration required to obtain reliable results in large-scale modeling of infectious diseases.”

The study was supported by funds from the National Institutes of Health and the Lilly Endowment Grant. In addition, Dr. Vespignani was supported by a Defense Threat Reduction Agency Grant and by a Future Emerging Technologies contract from Epiwork, while a coauthor was supported by a contract from the European Research Council.

A method of modeling global pandemic patterns has found that local commuting patterns provide a strong correlation and synchrony in the evolution of an emerging disease at the local level and during the tail end of disease spread.

The finding runs counter to previous studies that have suggested that long-range airline traffic marks the primary predictor of global disease spread, researchers led by Alessandro Vespignani, Ph.D., reported (PNAS 2009 Dec. 14 [doi:10.1073/pnas.0906910106]).

“On the one hand, the global epidemic behavior is governed by the long-range airline traffic that determines the arrival of infectious individuals on a worldwide scale,” the researchers stated. “At the local level, however, the short-range epidemic coupling induced by commuting flows creates a synchrony between neighboring regions and a local diffusive pattern with the epidemic flowing from subpopulations with major hubs into the neighboring subpopulations.”

Dr. Vespignani of the Indiana University School of Informatics and Computing, Bloomington, and his associates collected short-range commuting data (defined as a distance of up to 300 km) from 29 countries on five continents.

They used the information to create a mathematical model of the commuting behavior of specific populations of people in 220 countries living near 3,362 airports. The model included a seasonal dependence of disease transmission.

The researchers found that while commuting flows were, on average, one order of magnitude larger than the long-range airline traffic, “the global spatiotemporal patterns of disease-spreading are mainly determined by the airline network. Short-range commuting interactions have, on the other hand, a role in defining a larger degree of synchronization of nearby subpopulations and specific regions, which can be considered weakly connected by the airline” network.

Dr. Vespignani and his colleagues concluded that their model offers “an initial understanding of the level of data integration required to obtain reliable results in large-scale modeling of infectious diseases.”

The study was supported by funds from the National Institutes of Health and the Lilly Endowment Grant. In addition, Dr. Vespignani was supported by a Defense Threat Reduction Agency Grant and by a Future Emerging Technologies contract from Epiwork, while a coauthor was supported by a contract from the European Research Council.

SAN DIEGO – During short-term abstinence from nicotine, alcohol-dependent cigarette smokers experience greater negative affect-related craving to smoke and more persistent negative affect, compared with cigarette smokers who are not alcohol dependent.

“Our [preliminary] findings suggest the experience of nicotine withdrawal and associated urge to smoke may be different for smokers with alcohol dependence even when severity of nicotine dependence is taken into account,” researchers led by Jaimee L. Heffner, Ph.D., noted at a poster session at the annual scientific conference of the Research Society on Alcoholism.“Negative reinforcement motives for smoking may be a critical factor [in designing] intervention strategies for smokers with alcohol dependence.”

In what they believe to be the first study of its kind, the researchers, from the Cincinnati VA Medical Center and Tri-State Tobacco and Alcohol Research Center at the University of Cincinnati, enrolled 39 alcohol-dependent smokers and 19 control smokers who were in a substance abuse treatment program. They were abstinent from alcohol and other non–nicotine drugs for at least 60 days before testing. Those with Axis I disorders were excluded.

During a 6-hour session, each participant underwent the Semi-Structured Assessment for the Genetics of Alcoholism, the Fagerstrm Test for Nicotine Dependence, the Questionnaire on Smoking Urges–Brief (QSU), and the Profile of Mood States (POMS). To assess smoking urges, the QSU was done at baseline, 150 minutes, and 300 minutes; the POMS was done at baseline, 60 minutes, 180 minutes, and 300 minutes to assess negative affect.

Alcohol-dependent smokers were similar to the control smokers in age (a mean of 40 years vs. 39 years, respectively), gender (56% vs. 53% male), and race (69% vs. 79% white), and in terms of their severity of nicotine dependence (92% vs. 84%) and mean number of cigarettes smoked per day (21 vs. 18). Alcohol-dependent smokers had significantly higher rates of cannabis use (59% vs. 21%) and other drug use disorders (62% vs. 11%).

After controlling for nicotine dependence, alcohol-dependent smokers reported significantly greater craving for negative affect relief, compared with control smokers (P = .022), but no group by time interaction was seen.

“The main effect of time was contrary to what had been expected,” they wrote. “POMS scores tended to decrease over the course of the testing session. A significant group by time interaction was detected, indicating that negative affect declined more precipitously for control than for alcohol-dependent smokers [P = .005].”

Vitals

Major Finding: Negative affect declined more precipitously for control than for alcohol-dependent smokers (P = .005).

Data Source: Substance-abuse program participants without Axis I disorders: 39 alcohol-dependent but alcohol-abstinent smokers and 19 control smokers.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism and the Department of Veterans Affairs Research Service supported the study with grants.

SAN DIEGO – During short-term abstinence from nicotine, alcohol-dependent cigarette smokers experience greater negative affect-related craving to smoke and more persistent negative affect, compared with cigarette smokers who are not alcohol dependent.

“Our [preliminary] findings suggest the experience of nicotine withdrawal and associated urge to smoke may be different for smokers with alcohol dependence even when severity of nicotine dependence is taken into account,” researchers led by Jaimee L. Heffner, Ph.D., noted at a poster session at the annual scientific conference of the Research Society on Alcoholism.“Negative reinforcement motives for smoking may be a critical factor [in designing] intervention strategies for smokers with alcohol dependence.”

In what they believe to be the first study of its kind, the researchers, from the Cincinnati VA Medical Center and Tri-State Tobacco and Alcohol Research Center at the University of Cincinnati, enrolled 39 alcohol-dependent smokers and 19 control smokers who were in a substance abuse treatment program. They were abstinent from alcohol and other non–nicotine drugs for at least 60 days before testing. Those with Axis I disorders were excluded.

During a 6-hour session, each participant underwent the Semi-Structured Assessment for the Genetics of Alcoholism, the Fagerstrm Test for Nicotine Dependence, the Questionnaire on Smoking Urges–Brief (QSU), and the Profile of Mood States (POMS). To assess smoking urges, the QSU was done at baseline, 150 minutes, and 300 minutes; the POMS was done at baseline, 60 minutes, 180 minutes, and 300 minutes to assess negative affect.

Alcohol-dependent smokers were similar to the control smokers in age (a mean of 40 years vs. 39 years, respectively), gender (56% vs. 53% male), and race (69% vs. 79% white), and in terms of their severity of nicotine dependence (92% vs. 84%) and mean number of cigarettes smoked per day (21 vs. 18). Alcohol-dependent smokers had significantly higher rates of cannabis use (59% vs. 21%) and other drug use disorders (62% vs. 11%).

After controlling for nicotine dependence, alcohol-dependent smokers reported significantly greater craving for negative affect relief, compared with control smokers (P = .022), but no group by time interaction was seen.

“The main effect of time was contrary to what had been expected,” they wrote. “POMS scores tended to decrease over the course of the testing session. A significant group by time interaction was detected, indicating that negative affect declined more precipitously for control than for alcohol-dependent smokers [P = .005].”

Vitals

Major Finding: Negative affect declined more precipitously for control than for alcohol-dependent smokers (P = .005).

Data Source: Substance-abuse program participants without Axis I disorders: 39 alcohol-dependent but alcohol-abstinent smokers and 19 control smokers.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism and the Department of Veterans Affairs Research Service supported the study with grants.

SAN DIEGO – During short-term abstinence from nicotine, alcohol-dependent cigarette smokers experience greater negative affect-related craving to smoke and more persistent negative affect, compared with cigarette smokers who are not alcohol dependent.

“Our [preliminary] findings suggest the experience of nicotine withdrawal and associated urge to smoke may be different for smokers with alcohol dependence even when severity of nicotine dependence is taken into account,” researchers led by Jaimee L. Heffner, Ph.D., noted at a poster session at the annual scientific conference of the Research Society on Alcoholism.“Negative reinforcement motives for smoking may be a critical factor [in designing] intervention strategies for smokers with alcohol dependence.”

In what they believe to be the first study of its kind, the researchers, from the Cincinnati VA Medical Center and Tri-State Tobacco and Alcohol Research Center at the University of Cincinnati, enrolled 39 alcohol-dependent smokers and 19 control smokers who were in a substance abuse treatment program. They were abstinent from alcohol and other non–nicotine drugs for at least 60 days before testing. Those with Axis I disorders were excluded.

During a 6-hour session, each participant underwent the Semi-Structured Assessment for the Genetics of Alcoholism, the Fagerstrm Test for Nicotine Dependence, the Questionnaire on Smoking Urges–Brief (QSU), and the Profile of Mood States (POMS). To assess smoking urges, the QSU was done at baseline, 150 minutes, and 300 minutes; the POMS was done at baseline, 60 minutes, 180 minutes, and 300 minutes to assess negative affect.

Alcohol-dependent smokers were similar to the control smokers in age (a mean of 40 years vs. 39 years, respectively), gender (56% vs. 53% male), and race (69% vs. 79% white), and in terms of their severity of nicotine dependence (92% vs. 84%) and mean number of cigarettes smoked per day (21 vs. 18). Alcohol-dependent smokers had significantly higher rates of cannabis use (59% vs. 21%) and other drug use disorders (62% vs. 11%).

After controlling for nicotine dependence, alcohol-dependent smokers reported significantly greater craving for negative affect relief, compared with control smokers (P = .022), but no group by time interaction was seen.

“The main effect of time was contrary to what had been expected,” they wrote. “POMS scores tended to decrease over the course of the testing session. A significant group by time interaction was detected, indicating that negative affect declined more precipitously for control than for alcohol-dependent smokers [P = .005].”

Vitals

Major Finding: Negative affect declined more precipitously for control than for alcohol-dependent smokers (P = .005).

Data Source: Substance-abuse program participants without Axis I disorders: 39 alcohol-dependent but alcohol-abstinent smokers and 19 control smokers.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism and the Department of Veterans Affairs Research Service supported the study with grants.

SAN DIEGO – Alcohol-dependent patients with a supportive significant other have a greater reduction in drinking-related consequences over time, compared with those without such support, results from an exploratory analysis demonstrate.

The finding underscores the importance of social support in treatment and recovery from alcohol problems, Lisa Berger, Ph.D., said during the annual scientific conference of the Research Society on Alcoholism.

“There is a body of literature that positively supports the involvement of family members–in particular, spouses or cohabiting partners–in the treatment of individuals with alcoholism,” said Dr. Berger, a scientist in the University of Wisconsin, Milwaukee's Center for Addiction and Behavioral Health Research. “Yet to date, not as much work has been done on family member or supportive significant other involvement in combined behavioral and medication alcoholism treatments, especially in terms of the newer medications: naltrexone and acamprosate.”

She and her associates explored the effects of a supportive significant other (SSO) on drinking behavior in a cohort of patients from the Combined Pharmacotherapies and Behavioral Interventions study (COMBINE). For the current study, participants were treatment seeking, and the involvement of an SSO was a component of the combined behavioral intervention psychotherapy.

“A supportive significant other did not necessarily have to be a spouse or a partner, although we believe most were,” Dr. Berger said. “An ideal SSO candidate was an individual who supported a participant's sobriety and their treatment, an individual who the participant sees regularly, and an individual who is important to the participant.”

The mean age of the 619 study participants was 45 years, and 69% were men. Most (89%) had at least a high school education, 44% were married, 76% were white and 24% reported being black, Hispanic, or of another racial identity.

Alcohol outcome study measures included percentage of days abstinent and drinks per drinking day as derived from Form 90, a structured assessment interview for drinking and related behaviors. They used the Drinker Inventory of Consequences to measured alcohol-related problems.

Dr. Berger said that 161 study participants (26%) had an SSO involved in their treatment. Slightly more than half of SSOs (54%) attended one combined behavioral intervention session, 22% attended 2–3 sessions, and 24% attended 4 or more sessions.

Mixed-model repeated measures of variance revealed a significant main effect for time in the study and a significant three-way interaction effect for naltrexone, by SSO, and by time in the reduction of the number of drinks per drinking day.

“Participants who did not receive naltrexone but had SSO involvement had a higher average number of drinks per drinking day over time than the group with no SSO involvement,” Dr. Berger said. “Participants who did receive naltrexone experienced fluctuations of higher and lower average number of drinks per drinking day over time relative to those participants without SSO involvement. So it appears that there is some support for naltrexone in terms of helping those with SSO involvement reduce their average number of drinks per drinking day.”

The researchers also found that study participants with involvement of an SSO had more alcohol-related problems at baseline, compared with their counterparts who did not have involvement from an SSO. However, those with an SSO had fewer problems halfway through the 4-month combined treatment period and had fewer problems thereafter, compared with the participants without an SSO.

“The results suggest that SSO involvement alone and in combination with naltrexone may positively impact patient alcohol use and alcohol-related problems,” Dr. Berger said.

The SSO main effect on percentage of days abstinent “may have been in part due to the SSO's role in supporting abstinence,” she explained.

“In the present study, however, this is a tentative notion, because we do not know what was stated in [the behavioral intervention] session about abstinence and the role of the SSO. Nor do we know to what fidelity this may have even occurred.”

An ideal significant other supports the participant's sobriety and treatment.

Source DR. BERGER

Vitals

Major Finding: Participants with supportive significant others had a higher percentage of alcohol-abstinent days.

Data Source: COMBINE, a multisite, double-blind clinical trial of combinations of medications and behavioral therapies in treating alcohol dependence.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism sponsored the study. Dr. Berger had no conflicts to disclose.

SAN DIEGO – Alcohol-dependent patients with a supportive significant other have a greater reduction in drinking-related consequences over time, compared with those without such support, results from an exploratory analysis demonstrate.

The finding underscores the importance of social support in treatment and recovery from alcohol problems, Lisa Berger, Ph.D., said during the annual scientific conference of the Research Society on Alcoholism.

“There is a body of literature that positively supports the involvement of family members–in particular, spouses or cohabiting partners–in the treatment of individuals with alcoholism,” said Dr. Berger, a scientist in the University of Wisconsin, Milwaukee's Center for Addiction and Behavioral Health Research. “Yet to date, not as much work has been done on family member or supportive significant other involvement in combined behavioral and medication alcoholism treatments, especially in terms of the newer medications: naltrexone and acamprosate.”

She and her associates explored the effects of a supportive significant other (SSO) on drinking behavior in a cohort of patients from the Combined Pharmacotherapies and Behavioral Interventions study (COMBINE). For the current study, participants were treatment seeking, and the involvement of an SSO was a component of the combined behavioral intervention psychotherapy.

“A supportive significant other did not necessarily have to be a spouse or a partner, although we believe most were,” Dr. Berger said. “An ideal SSO candidate was an individual who supported a participant's sobriety and their treatment, an individual who the participant sees regularly, and an individual who is important to the participant.”

The mean age of the 619 study participants was 45 years, and 69% were men. Most (89%) had at least a high school education, 44% were married, 76% were white and 24% reported being black, Hispanic, or of another racial identity.

Alcohol outcome study measures included percentage of days abstinent and drinks per drinking day as derived from Form 90, a structured assessment interview for drinking and related behaviors. They used the Drinker Inventory of Consequences to measured alcohol-related problems.

Dr. Berger said that 161 study participants (26%) had an SSO involved in their treatment. Slightly more than half of SSOs (54%) attended one combined behavioral intervention session, 22% attended 2–3 sessions, and 24% attended 4 or more sessions.

Mixed-model repeated measures of variance revealed a significant main effect for time in the study and a significant three-way interaction effect for naltrexone, by SSO, and by time in the reduction of the number of drinks per drinking day.

“Participants who did not receive naltrexone but had SSO involvement had a higher average number of drinks per drinking day over time than the group with no SSO involvement,” Dr. Berger said. “Participants who did receive naltrexone experienced fluctuations of higher and lower average number of drinks per drinking day over time relative to those participants without SSO involvement. So it appears that there is some support for naltrexone in terms of helping those with SSO involvement reduce their average number of drinks per drinking day.”

The researchers also found that study participants with involvement of an SSO had more alcohol-related problems at baseline, compared with their counterparts who did not have involvement from an SSO. However, those with an SSO had fewer problems halfway through the 4-month combined treatment period and had fewer problems thereafter, compared with the participants without an SSO.

“The results suggest that SSO involvement alone and in combination with naltrexone may positively impact patient alcohol use and alcohol-related problems,” Dr. Berger said.

The SSO main effect on percentage of days abstinent “may have been in part due to the SSO's role in supporting abstinence,” she explained.

“In the present study, however, this is a tentative notion, because we do not know what was stated in [the behavioral intervention] session about abstinence and the role of the SSO. Nor do we know to what fidelity this may have even occurred.”

An ideal significant other supports the participant's sobriety and treatment.

Source DR. BERGER

Vitals

Major Finding: Participants with supportive significant others had a higher percentage of alcohol-abstinent days.

Data Source: COMBINE, a multisite, double-blind clinical trial of combinations of medications and behavioral therapies in treating alcohol dependence.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism sponsored the study. Dr. Berger had no conflicts to disclose.

SAN DIEGO – Alcohol-dependent patients with a supportive significant other have a greater reduction in drinking-related consequences over time, compared with those without such support, results from an exploratory analysis demonstrate.

The finding underscores the importance of social support in treatment and recovery from alcohol problems, Lisa Berger, Ph.D., said during the annual scientific conference of the Research Society on Alcoholism.

“There is a body of literature that positively supports the involvement of family members–in particular, spouses or cohabiting partners–in the treatment of individuals with alcoholism,” said Dr. Berger, a scientist in the University of Wisconsin, Milwaukee's Center for Addiction and Behavioral Health Research. “Yet to date, not as much work has been done on family member or supportive significant other involvement in combined behavioral and medication alcoholism treatments, especially in terms of the newer medications: naltrexone and acamprosate.”

She and her associates explored the effects of a supportive significant other (SSO) on drinking behavior in a cohort of patients from the Combined Pharmacotherapies and Behavioral Interventions study (COMBINE). For the current study, participants were treatment seeking, and the involvement of an SSO was a component of the combined behavioral intervention psychotherapy.

“A supportive significant other did not necessarily have to be a spouse or a partner, although we believe most were,” Dr. Berger said. “An ideal SSO candidate was an individual who supported a participant's sobriety and their treatment, an individual who the participant sees regularly, and an individual who is important to the participant.”

The mean age of the 619 study participants was 45 years, and 69% were men. Most (89%) had at least a high school education, 44% were married, 76% were white and 24% reported being black, Hispanic, or of another racial identity.

Alcohol outcome study measures included percentage of days abstinent and drinks per drinking day as derived from Form 90, a structured assessment interview for drinking and related behaviors. They used the Drinker Inventory of Consequences to measured alcohol-related problems.

Dr. Berger said that 161 study participants (26%) had an SSO involved in their treatment. Slightly more than half of SSOs (54%) attended one combined behavioral intervention session, 22% attended 2–3 sessions, and 24% attended 4 or more sessions.

Mixed-model repeated measures of variance revealed a significant main effect for time in the study and a significant three-way interaction effect for naltrexone, by SSO, and by time in the reduction of the number of drinks per drinking day.

“Participants who did not receive naltrexone but had SSO involvement had a higher average number of drinks per drinking day over time than the group with no SSO involvement,” Dr. Berger said. “Participants who did receive naltrexone experienced fluctuations of higher and lower average number of drinks per drinking day over time relative to those participants without SSO involvement. So it appears that there is some support for naltrexone in terms of helping those with SSO involvement reduce their average number of drinks per drinking day.”

The researchers also found that study participants with involvement of an SSO had more alcohol-related problems at baseline, compared with their counterparts who did not have involvement from an SSO. However, those with an SSO had fewer problems halfway through the 4-month combined treatment period and had fewer problems thereafter, compared with the participants without an SSO.

“The results suggest that SSO involvement alone and in combination with naltrexone may positively impact patient alcohol use and alcohol-related problems,” Dr. Berger said.

The SSO main effect on percentage of days abstinent “may have been in part due to the SSO's role in supporting abstinence,” she explained.

“In the present study, however, this is a tentative notion, because we do not know what was stated in [the behavioral intervention] session about abstinence and the role of the SSO. Nor do we know to what fidelity this may have even occurred.”

An ideal significant other supports the participant's sobriety and treatment.

Source DR. BERGER

Vitals

Major Finding: Participants with supportive significant others had a higher percentage of alcohol-abstinent days.

Data Source: COMBINE, a multisite, double-blind clinical trial of combinations of medications and behavioral therapies in treating alcohol dependence.

Disclosures: The National Institute on Alcohol Abuse and Alcoholism sponsored the study. Dr. Berger had no conflicts to disclose.