Michele G. Sullivan

ST. LOUIS — Physician assistants are playing an increasingly large role in dermatology practices, providing both direct patient care and ancillary services that free the dermatologist to see more patients.

"Over the past 2 decades, we've seen substantial growth in the number of patients seeking dermatology care, but at the same time, the number of residents entering derm training programs has remained stagnant," Emily P. Tierney, M.D., said at the annual meeting of the Society of Investigational Dermatology. "PAs and [nurse-practitioners] have been well-poised to take advantage of these opportunities, as they are able to move into a dermatology practice and with a couple of months of on-the-job training, see patients with limited physician supervision."

Dermatologists have been struggling for several years with their workloads, Dr. Tierney said. A 2004 study noted that one-third of practices were seeking one or more new associates, and of that group, one-third were seeking two or more new associates.

A 2002 study noted the impact these vacancies have on patient care. "The patient waiting time [for an appointment] was 53 days for dermatology practices with vacancies, compared to 28 days for those without vacancies—and the mean time to filling those vacancies was about 16 months."

PAs have been particularly useful in easing these provider shortages, said Dr. Tierney of Brigham and Women's Hospital, Boston. "They are popular because they are highly cost effective and work with dermatologists in a cooperative environment, where they are not competitors." The number of PAs in dermatology has increased by 49% over the past 2 years, while the number of medical doctors in dermatology has increased by only 2%. In 1993, there were only 6 PAs in dermatology practices; in 2004, there were more than 1,600.

"In 2003, PAs saw 2.9 million dermatology patients each year. That is equivalent to 1 in every 32 visits." PAs are seeing an average of 22 patients per day, compared with 35–40 patients per day seen by dermatologists, she said.

The 2002 Dermatology Practice Profile Survey by the American Academy of Dermatology concluded that large and multispecialty practices are most likely to use a PA as a physician extender. More than 51% of dermatologists in these practices reported using PAs, while only about 35% of private solo practices or small groups employed them

These different practices also used PAs in different ways, Dr. Tierney said. "In larger practices, over 90% of the PAs are used to evaluate and treat medical dermatology patients. In the smaller practices, their primary function seems to be assisting with cosmetics, and ancillary and administrative duties, thus allowing the physician to see more patients."

The survey also contained information about another interesting trend, she said. Dermatologists are performing more and more cosmetic procedures in the office, and those who spend a lot of time on cosmetics are much more likely to hire a PA or NP.

"Among dermatologists who do 10 or more hours a week of cosmetics, 74% had a PA or NP, compared with only 26% of those who do less than 10 hours per week of cosmetics," Dr. Tierney said.

The number of noncosmetic procedures, like Mohs' surgery, wasn't affected by the presence of a physician extender, however.

"This implies that the physician extender is actually doing the cosmetic procedure, or that having one allows the dermatologist to leverage other treatments to the extender, so the physician can focus on the cosmetics," she said.

ST. LOUIS — Physician assistants are playing an increasingly large role in dermatology practices, providing both direct patient care and ancillary services that free the dermatologist to see more patients.

"Over the past 2 decades, we've seen substantial growth in the number of patients seeking dermatology care, but at the same time, the number of residents entering derm training programs has remained stagnant," Emily P. Tierney, M.D., said at the annual meeting of the Society of Investigational Dermatology. "PAs and [nurse-practitioners] have been well-poised to take advantage of these opportunities, as they are able to move into a dermatology practice and with a couple of months of on-the-job training, see patients with limited physician supervision."

Dermatologists have been struggling for several years with their workloads, Dr. Tierney said. A 2004 study noted that one-third of practices were seeking one or more new associates, and of that group, one-third were seeking two or more new associates.

A 2002 study noted the impact these vacancies have on patient care. "The patient waiting time [for an appointment] was 53 days for dermatology practices with vacancies, compared to 28 days for those without vacancies—and the mean time to filling those vacancies was about 16 months."

PAs have been particularly useful in easing these provider shortages, said Dr. Tierney of Brigham and Women's Hospital, Boston. "They are popular because they are highly cost effective and work with dermatologists in a cooperative environment, where they are not competitors." The number of PAs in dermatology has increased by 49% over the past 2 years, while the number of medical doctors in dermatology has increased by only 2%. In 1993, there were only 6 PAs in dermatology practices; in 2004, there were more than 1,600.

"In 2003, PAs saw 2.9 million dermatology patients each year. That is equivalent to 1 in every 32 visits." PAs are seeing an average of 22 patients per day, compared with 35–40 patients per day seen by dermatologists, she said.

The 2002 Dermatology Practice Profile Survey by the American Academy of Dermatology concluded that large and multispecialty practices are most likely to use a PA as a physician extender. More than 51% of dermatologists in these practices reported using PAs, while only about 35% of private solo practices or small groups employed them

These different practices also used PAs in different ways, Dr. Tierney said. "In larger practices, over 90% of the PAs are used to evaluate and treat medical dermatology patients. In the smaller practices, their primary function seems to be assisting with cosmetics, and ancillary and administrative duties, thus allowing the physician to see more patients."

The survey also contained information about another interesting trend, she said. Dermatologists are performing more and more cosmetic procedures in the office, and those who spend a lot of time on cosmetics are much more likely to hire a PA or NP.

"Among dermatologists who do 10 or more hours a week of cosmetics, 74% had a PA or NP, compared with only 26% of those who do less than 10 hours per week of cosmetics," Dr. Tierney said.

The number of noncosmetic procedures, like Mohs' surgery, wasn't affected by the presence of a physician extender, however.

"This implies that the physician extender is actually doing the cosmetic procedure, or that having one allows the dermatologist to leverage other treatments to the extender, so the physician can focus on the cosmetics," she said.

ST. LOUIS — Physician assistants are playing an increasingly large role in dermatology practices, providing both direct patient care and ancillary services that free the dermatologist to see more patients.

"Over the past 2 decades, we've seen substantial growth in the number of patients seeking dermatology care, but at the same time, the number of residents entering derm training programs has remained stagnant," Emily P. Tierney, M.D., said at the annual meeting of the Society of Investigational Dermatology. "PAs and [nurse-practitioners] have been well-poised to take advantage of these opportunities, as they are able to move into a dermatology practice and with a couple of months of on-the-job training, see patients with limited physician supervision."

Dermatologists have been struggling for several years with their workloads, Dr. Tierney said. A 2004 study noted that one-third of practices were seeking one or more new associates, and of that group, one-third were seeking two or more new associates.

A 2002 study noted the impact these vacancies have on patient care. "The patient waiting time [for an appointment] was 53 days for dermatology practices with vacancies, compared to 28 days for those without vacancies—and the mean time to filling those vacancies was about 16 months."

PAs have been particularly useful in easing these provider shortages, said Dr. Tierney of Brigham and Women's Hospital, Boston. "They are popular because they are highly cost effective and work with dermatologists in a cooperative environment, where they are not competitors." The number of PAs in dermatology has increased by 49% over the past 2 years, while the number of medical doctors in dermatology has increased by only 2%. In 1993, there were only 6 PAs in dermatology practices; in 2004, there were more than 1,600.

"In 2003, PAs saw 2.9 million dermatology patients each year. That is equivalent to 1 in every 32 visits." PAs are seeing an average of 22 patients per day, compared with 35–40 patients per day seen by dermatologists, she said.

The 2002 Dermatology Practice Profile Survey by the American Academy of Dermatology concluded that large and multispecialty practices are most likely to use a PA as a physician extender. More than 51% of dermatologists in these practices reported using PAs, while only about 35% of private solo practices or small groups employed them

These different practices also used PAs in different ways, Dr. Tierney said. "In larger practices, over 90% of the PAs are used to evaluate and treat medical dermatology patients. In the smaller practices, their primary function seems to be assisting with cosmetics, and ancillary and administrative duties, thus allowing the physician to see more patients."

The survey also contained information about another interesting trend, she said. Dermatologists are performing more and more cosmetic procedures in the office, and those who spend a lot of time on cosmetics are much more likely to hire a PA or NP.

"Among dermatologists who do 10 or more hours a week of cosmetics, 74% had a PA or NP, compared with only 26% of those who do less than 10 hours per week of cosmetics," Dr. Tierney said.

The number of noncosmetic procedures, like Mohs' surgery, wasn't affected by the presence of a physician extender, however.

"This implies that the physician extender is actually doing the cosmetic procedure, or that having one allows the dermatologist to leverage other treatments to the extender, so the physician can focus on the cosmetics," she said.

Women who exercise moderately after a diagnosis of breast cancer experience a 20%–50% reduction in their risk of breast cancer death or breast cancer recurrence, data from the Nurses' Health Study suggest.

The survival advantage is particularly strong for women who have estrogen or progesterone receptor-positive tumors. These women experienced a 50% decrease in the risk of breast cancer death, reported Michelle D. Holmes, M.D., of Harvard Medical School, Boston, and her colleagues.

“Our results suggest a possible hormonal mechanism for improved survival among women who are physically active,” the researchers said. Physical activity might also increase survival through short- and long-term improvements in insulin resistance and reduction in hyperinsulinemia (JAMA 2005;293:2479–86).

Since the maximum benefit occurred with moderate levels of exercise (walking 3–5 hr/wk at a moderate pace), the researchers concluded that women with breast cancer should follow the exercise recommendations set forth by the Centers for Disease Control and Prevention: exercise at moderate intensity for 30 or more minutes per day, at least 5 days per week.

It has been estimated that women decrease their physical activity levels by 2 hr/wk after a diagnosis of breast cancer, and that less than one-third of survivors exercise at the recommended level.

The investigators used data from the national Nurses' Health Study for their retrospective analysis, which followed 2,987 women with stages I, II, or III breast cancer who were diagnosed between 1984 and 1998. The women were followed until June 2002 or death, whichever came first.

Activity was determined by self-report and analyzed by metabolic equivalent task (MET)-hours. Three MET-hours are equivalent to walking 2–2.9 mph for 1 hour.

After adjusting for variables such as age, smoking status, and hormone therapy use, women who engaged in 3–8.9 MET-hr/wk had a 20% decreased risk of death from breast cancer, compared with those who exercised less.

Those women who were engaged in 9–14.9 MET-hr/wk had a 50% decreased risk. There was no additional benefit for more exercise: women who engaged in 15–23.9 MET-hr/wk had a 44% decreased risk, and women who exercised more than that had a 40% decreased risk.

Risk of recurrence also was lowest for women who engaged in 9–14.9 MET-hr/wk. These women had a 43% decreased risk, compared with women who accrued less than 3 MET-hr/wk.

Exercise also improved 10-year breast cancer survival rates, the researchers said. The survival rate was 86% for less than 3 MET-hr/wk; 89% for 3–8.9 MET-hr/wk; and 92% for at least 9 MET-hr/wk.

The protective benefit was similar among overweight women and those of normal weight, and greater for women with hormone receptor-positive tumors. Those with hormone receptor-positive tumors who exercised moderately had a 50% decreased risk, compared with a 9% decreased risk for those whose tumors lacked hormone receptors.

Exercise also was particularly beneficial for women with more advanced cancer. Women with stage III cancer who engaged in at least 9 MET-hr/wk had a 63% decreased risk of breast cancer death, compared with women with stage III cancer who exercised less. However, the researchers noted, these results were based on only 76 women and 15 breast cancer deaths.

When they analyzed risk by type of exercise, the researchers found that both walking and vigorous exercise contributed to lowering the risks.

Women who exercise moderately after a diagnosis of breast cancer experience a 20%–50% reduction in their risk of breast cancer death or breast cancer recurrence, data from the Nurses' Health Study suggest.

The survival advantage is particularly strong for women who have estrogen or progesterone receptor-positive tumors. These women experienced a 50% decrease in the risk of breast cancer death, reported Michelle D. Holmes, M.D., of Harvard Medical School, Boston, and her colleagues.

“Our results suggest a possible hormonal mechanism for improved survival among women who are physically active,” the researchers said. Physical activity might also increase survival through short- and long-term improvements in insulin resistance and reduction in hyperinsulinemia (JAMA 2005;293:2479–86).

Since the maximum benefit occurred with moderate levels of exercise (walking 3–5 hr/wk at a moderate pace), the researchers concluded that women with breast cancer should follow the exercise recommendations set forth by the Centers for Disease Control and Prevention: exercise at moderate intensity for 30 or more minutes per day, at least 5 days per week.

It has been estimated that women decrease their physical activity levels by 2 hr/wk after a diagnosis of breast cancer, and that less than one-third of survivors exercise at the recommended level.

The investigators used data from the national Nurses' Health Study for their retrospective analysis, which followed 2,987 women with stages I, II, or III breast cancer who were diagnosed between 1984 and 1998. The women were followed until June 2002 or death, whichever came first.

Activity was determined by self-report and analyzed by metabolic equivalent task (MET)-hours. Three MET-hours are equivalent to walking 2–2.9 mph for 1 hour.

After adjusting for variables such as age, smoking status, and hormone therapy use, women who engaged in 3–8.9 MET-hr/wk had a 20% decreased risk of death from breast cancer, compared with those who exercised less.

Those women who were engaged in 9–14.9 MET-hr/wk had a 50% decreased risk. There was no additional benefit for more exercise: women who engaged in 15–23.9 MET-hr/wk had a 44% decreased risk, and women who exercised more than that had a 40% decreased risk.

Risk of recurrence also was lowest for women who engaged in 9–14.9 MET-hr/wk. These women had a 43% decreased risk, compared with women who accrued less than 3 MET-hr/wk.

Exercise also improved 10-year breast cancer survival rates, the researchers said. The survival rate was 86% for less than 3 MET-hr/wk; 89% for 3–8.9 MET-hr/wk; and 92% for at least 9 MET-hr/wk.

The protective benefit was similar among overweight women and those of normal weight, and greater for women with hormone receptor-positive tumors. Those with hormone receptor-positive tumors who exercised moderately had a 50% decreased risk, compared with a 9% decreased risk for those whose tumors lacked hormone receptors.

Exercise also was particularly beneficial for women with more advanced cancer. Women with stage III cancer who engaged in at least 9 MET-hr/wk had a 63% decreased risk of breast cancer death, compared with women with stage III cancer who exercised less. However, the researchers noted, these results were based on only 76 women and 15 breast cancer deaths.

When they analyzed risk by type of exercise, the researchers found that both walking and vigorous exercise contributed to lowering the risks.

Women who exercise moderately after a diagnosis of breast cancer experience a 20%–50% reduction in their risk of breast cancer death or breast cancer recurrence, data from the Nurses' Health Study suggest.

The survival advantage is particularly strong for women who have estrogen or progesterone receptor-positive tumors. These women experienced a 50% decrease in the risk of breast cancer death, reported Michelle D. Holmes, M.D., of Harvard Medical School, Boston, and her colleagues.

“Our results suggest a possible hormonal mechanism for improved survival among women who are physically active,” the researchers said. Physical activity might also increase survival through short- and long-term improvements in insulin resistance and reduction in hyperinsulinemia (JAMA 2005;293:2479–86).

Since the maximum benefit occurred with moderate levels of exercise (walking 3–5 hr/wk at a moderate pace), the researchers concluded that women with breast cancer should follow the exercise recommendations set forth by the Centers for Disease Control and Prevention: exercise at moderate intensity for 30 or more minutes per day, at least 5 days per week.

It has been estimated that women decrease their physical activity levels by 2 hr/wk after a diagnosis of breast cancer, and that less than one-third of survivors exercise at the recommended level.

The investigators used data from the national Nurses' Health Study for their retrospective analysis, which followed 2,987 women with stages I, II, or III breast cancer who were diagnosed between 1984 and 1998. The women were followed until June 2002 or death, whichever came first.

Activity was determined by self-report and analyzed by metabolic equivalent task (MET)-hours. Three MET-hours are equivalent to walking 2–2.9 mph for 1 hour.

After adjusting for variables such as age, smoking status, and hormone therapy use, women who engaged in 3–8.9 MET-hr/wk had a 20% decreased risk of death from breast cancer, compared with those who exercised less.

Those women who were engaged in 9–14.9 MET-hr/wk had a 50% decreased risk. There was no additional benefit for more exercise: women who engaged in 15–23.9 MET-hr/wk had a 44% decreased risk, and women who exercised more than that had a 40% decreased risk.

Risk of recurrence also was lowest for women who engaged in 9–14.9 MET-hr/wk. These women had a 43% decreased risk, compared with women who accrued less than 3 MET-hr/wk.

Exercise also improved 10-year breast cancer survival rates, the researchers said. The survival rate was 86% for less than 3 MET-hr/wk; 89% for 3–8.9 MET-hr/wk; and 92% for at least 9 MET-hr/wk.

The protective benefit was similar among overweight women and those of normal weight, and greater for women with hormone receptor-positive tumors. Those with hormone receptor-positive tumors who exercised moderately had a 50% decreased risk, compared with a 9% decreased risk for those whose tumors lacked hormone receptors.

Exercise also was particularly beneficial for women with more advanced cancer. Women with stage III cancer who engaged in at least 9 MET-hr/wk had a 63% decreased risk of breast cancer death, compared with women with stage III cancer who exercised less. However, the researchers noted, these results were based on only 76 women and 15 breast cancer deaths.

When they analyzed risk by type of exercise, the researchers found that both walking and vigorous exercise contributed to lowering the risks.

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen therapy for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

“These recommendations expand the evidence base physicians depend on to deliver good quality medical care that meets the needs of individual patients,” Carolyn M. Clancy, M.D., who is director of the Agency for Healthcare Research and Quality, said in a statement. “The evidence can also help women become better-informed patients and decide with their clinicians what alternatives are available to prevent these chronic diseases.”

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles the risk of invasive breast cancer.

▸ Doubles the risk of endometrial cancer.

▸ Doubles the risk of venous thromboembolism.

▸ Increases the risk of stroke by up to 41%.

▸ Increases the risk of heart disease by 29%.

▸ Increases the risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force.

“A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen therapy for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

“These recommendations expand the evidence base physicians depend on to deliver good quality medical care that meets the needs of individual patients,” Carolyn M. Clancy, M.D., who is director of the Agency for Healthcare Research and Quality, said in a statement. “The evidence can also help women become better-informed patients and decide with their clinicians what alternatives are available to prevent these chronic diseases.”

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles the risk of invasive breast cancer.

▸ Doubles the risk of endometrial cancer.

▸ Doubles the risk of venous thromboembolism.

▸ Increases the risk of stroke by up to 41%.

▸ Increases the risk of heart disease by 29%.

▸ Increases the risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force.

“A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen therapy for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

“These recommendations expand the evidence base physicians depend on to deliver good quality medical care that meets the needs of individual patients,” Carolyn M. Clancy, M.D., who is director of the Agency for Healthcare Research and Quality, said in a statement. “The evidence can also help women become better-informed patients and decide with their clinicians what alternatives are available to prevent these chronic diseases.”

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles the risk of invasive breast cancer.

▸ Doubles the risk of endometrial cancer.

▸ Doubles the risk of venous thromboembolism.

▸ Increases the risk of stroke by up to 41%.

▸ Increases the risk of heart disease by 29%.

▸ Increases the risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force.

“A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

Meningococcal disease is almost 12 times more likely to occur in a child whose mother is pregnant, possibly due to hormonal alterations in the mucosal barriers of pregnant women that predispose them to carry the bacteria.

Elske van Gils and her colleagues at the University of Amsterdam examined family composition in 176 hospitalized children (mean age about 4 years); 88 were admitted with confirmed meningococcal disease and 88 for other reasons, mostly surgery.

Among the meningococcal cases, 17 (19%) of mothers were pregnant during the hospitalization, 6 were in their first or second trimester, and the rest were in their third trimester (Pediatrics 2005;115:590–3).

Among the controls, only 2 (2%) of mothers were pregnant. Pregnancy was associated with an increased odds ratio of 11.7, multivariate analysis showed.

Other studies have found that meningococcal infections in children are related to maternal carriage. The authors hypothesized that pregnant women may have increased or prolonged carriage rates.

Meningococcal disease is almost 12 times more likely to occur in a child whose mother is pregnant, possibly due to hormonal alterations in the mucosal barriers of pregnant women that predispose them to carry the bacteria.

Elske van Gils and her colleagues at the University of Amsterdam examined family composition in 176 hospitalized children (mean age about 4 years); 88 were admitted with confirmed meningococcal disease and 88 for other reasons, mostly surgery.

Among the meningococcal cases, 17 (19%) of mothers were pregnant during the hospitalization, 6 were in their first or second trimester, and the rest were in their third trimester (Pediatrics 2005;115:590–3).

Among the controls, only 2 (2%) of mothers were pregnant. Pregnancy was associated with an increased odds ratio of 11.7, multivariate analysis showed.

Other studies have found that meningococcal infections in children are related to maternal carriage. The authors hypothesized that pregnant women may have increased or prolonged carriage rates.

Meningococcal disease is almost 12 times more likely to occur in a child whose mother is pregnant, possibly due to hormonal alterations in the mucosal barriers of pregnant women that predispose them to carry the bacteria.

Elske van Gils and her colleagues at the University of Amsterdam examined family composition in 176 hospitalized children (mean age about 4 years); 88 were admitted with confirmed meningococcal disease and 88 for other reasons, mostly surgery.

Among the meningococcal cases, 17 (19%) of mothers were pregnant during the hospitalization, 6 were in their first or second trimester, and the rest were in their third trimester (Pediatrics 2005;115:590–3).

Among the controls, only 2 (2%) of mothers were pregnant. Pregnancy was associated with an increased odds ratio of 11.7, multivariate analysis showed.

Other studies have found that meningococcal infections in children are related to maternal carriage. The authors hypothesized that pregnant women may have increased or prolonged carriage rates.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles risk of invasive breast cancer.

▸ Doubles risk of endometrial cancer.

▸ Doubles risk of venous thromboembolism.

▸ Increases risk of stroke by up to 41%.

▸ Increases risk of heart disease by 29%.

▸ Increases risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force. “A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles risk of invasive breast cancer.

▸ Doubles risk of endometrial cancer.

▸ Doubles risk of venous thromboembolism.

▸ Increases risk of stroke by up to 41%.

▸ Increases risk of heart disease by 29%.

▸ Increases risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force. “A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

Postmenopausal women should not receive unopposed estrogen or combination hormone therapy for the prevention of chronic disease, including heart disease, stroke, and osteoporosis, according to a new recommendation by the U.S. Preventive Services Task Force.

The task force also recommended against using unopposed estrogen for disease prevention in postmenopausal women who have undergone hysterectomy.

In 2002, the task force found insufficient evidence to recommend for or against such preventive therapy. The task force noted that HT has beneficial effects on bone and reduces the risk of colorectal cancer. But after reviewing findings from the Women's Health Initiative study, the task force concluded that the risks of both unopposed estrogen and combined HT probably exceed their benefits.

In addition to data from the WHI, the task force based its recommendations on the conclusions of the U.K. Million Women Study and many metaanalyses of other studies. Based on these studies, the force concluded that HT:

▸ Doubles risk of invasive breast cancer.

▸ Doubles risk of endometrial cancer.

▸ Doubles risk of venous thromboembolism.

▸ Increases risk of stroke by up to 41%.

▸ Increases risk of heart disease by 29%.

▸ Increases risk of dementia by about 40%.

The task force acknowledged that the additional risks conferred by HT are small (eight more strokes, eight more pulmonary embolisms, eight more invasive breast cancers, and seven more coronary heart disease events/10,000 women per year), but said patients and physicians should take them into account.

“The balance of benefits and harms for a woman will be influenced by her personal preferences, her risk for specific chronic diseases, and the presence of menopausal symptoms,” according to the task force. “A shared decision-making approach to preventing chronic disease in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences in selecting effective interventions for reducing the risks for fracture, heart disease, and cancer.”

The new recommendations are available at www.preventiveservices.ahrq.gov

MIAMI BEACH — Seaside visitors are at risk for deadly vacation mementos: neurotoxic poisoning from contaminated seafood.

“The reality of the world is that someone can be in the Caribbean one day and in an emergency room in Minnesota with ciguatera the next,” Elijah W. Stommel, M.D., said at the annual meeting of the American Academy of Neurology. “We all need to be prepared to deal with these illnesses.”

Most of the world's vacation hot spots boast their own unique seafood toxins, said Dr. Stommel, a neurologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Caribbean reef fish carry ciguatera, and shellfish from picturesque islands of eastern Canada can pack an algal toxin wallop.

Scombroid poisoning can be found wherever fresh tuna and other game fish are consumed.

A trip to Japan (or an expensive sushi bar) can increase the risk of puffer fish poisoning, which kills about 80 people a year in Japan.

Even the quiet coasts of New England can be dangerous for shellfish lovers; saxitoxin—which occurs in contaminated oysters, clams, and scallops—is 1,000 times more potent than sarin.

Ciguatera is the most common nonbacterial seafood poisoning. “This is a very interesting toxin, and it's commonly seen in emergency and neurology departments all over the world,” Dr. Stommel said. The toxin originates in a dinoflagellate that lives in bottom algae in tropical areas. Bottom feeders—barracudas, snappers, jacks, and groupers—ingest the algae with their meal, and the toxin concentrates in flesh as it moves up the food chain to humans.

Ciguatera opens the sodium channels, thereby changing the cells' electrical potential and permeability and increasing neuronal excitability. The toxin also affects coagulation, can alter acetylcholine receptors, and has serotoninergic effects.

Initial symptoms are gastrointestinal pain, nausea, vomiting, and diarrhea. Other symptoms follow, including dysesthesias of the extremities, itching (especially after drinking alcohol), headaches, vertigo, circumoral tingling, muscle pain, and fasciculations. “Patients may also complain of a sense that their teeth are loose,” Dr. Stommel said.

Inverted sensory perception is another classic symptom. “Patients walking on cold tile will complain of burning feet. This is considered by some to be pathognomonic of marine toxin poisoning.”

Ciguatera is probably underdiagnosed, because the diagnosis must be made solely on the basis of symptoms and history. There is no known antidote, so treatment must be supportive. High doses of intravenous mannitol (1 g/kg of a 20% solution) have been used for years for symptom relief, but a 2002 report suggests that saline infusion is just as effective. Atropine can be useful for bradycardia. In serious cases, calcium gluconate, which acts as a substrate against competitive inhibition of calcium by the ciguatoxin, is recommended.

Most patients recover in 3–6 weeks, but symptoms can recur when patients consume chicken (chicken feed contains fish meal) or alcohol. A serotonin-sparing diet is important during the acute phase and for 3–6 months afterward. This diet includes eliminating fish and shellfish, nuts, coconuts, seeds, seed products (including oils), alcohol, mayonnaise, chocolate, and mushrooms.

Amnestic shellfish poisoning has been reported in southern Canada, California, Washington, Oregon, and coastal Europe. An algae-dwelling diatom produces the toxin domoic acid, a glutamate agonist. This toxin can cause extensive hippocampal damage, as well as less severe damage to the thalamus and forebrain.

Within 24 hours of eating contaminated shellfish, patients will have GI symptoms followed by memory loss, seizures, hemiparesis, ophthalmoplegia, and coma. Poisoned patients may grimace and make chewing motions. Blood pressure lability may develop along with cardiac dysrhythmias.

There is no antidote. Benzodiazepines or glutamate antagonists such as valproic or kynurenic acid may suppress the excitotoxic effects. The disease can be fatal, and memory loss can be permanent.

Paralytic shellfish poisoning causes severe, almost immediate symptoms, including tingling, numbness, vertigo, dysarthria, dysphagia, weakness, ataxia, and even blindness. There are no GI symptoms. The lack of diarrhea and vomiting may contribute to the high rate of mortality because more of the toxin is absorbed rather than expelled from the body. Death is usually the result of respiratory failure.

The cause is saxitoxin, produced by several microorganisms and 1,000 times more potent than sarin gas. Saxitoxin blocks sodium channels in nerve and muscle, which arrests impulse conduction and can suppress atrioventricular node conduction.

There is no antidote; treatment is supportive. The toxin binds well to charcoal. Acidity enhances the toxin's effects, so serum alkalinization might be helpful.

Tetrodotoxin occurs in the organs of the puffer fish (Fugu rubripes), a delicacy in Japan, where fugu poisoning affects about 150 people yearly with 50% mortality. Symptoms develop within 20 minutes to 3 hours of consumption, and include oral and extremity paresthesias, GI disturbance, hypersalivation, diaphoresis, cranial nerve dysfunction, refractory hypotension, and cardiovascular collapse. Partial or complete paralysis may occur, although the patient can remain lucid. Death usually occurs within 4–6 hours.

“Again, there is no known antidote,” Dr. Stommel said. Gastric lavage and activated charcoal can be useful early in the course of the poisoning. Anticholinesterase agents, atropine, and α-agonists have been effective for cardiovascular instabilities.

Scombroid, the world's most common seafood poisoning, results from toxins that build up in improperly stored fish. It's most common in members of the tuna family but can occur in other game fish. Scombroid isn't fatal; the symptoms of headache, nausea, vomiting, diarrhea, abdominal cramps, and burning of the mouth and oropharynx usually subside within 12 hours.

Treatment usually consists of charcoal and histamine blockers (cimetidine or famotidine). It's advisable to block both H₁ and H₂ receptors.

MIAMI BEACH — Seaside visitors are at risk for deadly vacation mementos: neurotoxic poisoning from contaminated seafood.

“The reality of the world is that someone can be in the Caribbean one day and in an emergency room in Minnesota with ciguatera the next,” Elijah W. Stommel, M.D., said at the annual meeting of the American Academy of Neurology. “We all need to be prepared to deal with these illnesses.”

Most of the world's vacation hot spots boast their own unique seafood toxins, said Dr. Stommel, a neurologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Caribbean reef fish carry ciguatera, and shellfish from picturesque islands of eastern Canada can pack an algal toxin wallop.

Scombroid poisoning can be found wherever fresh tuna and other game fish are consumed.

A trip to Japan (or an expensive sushi bar) can increase the risk of puffer fish poisoning, which kills about 80 people a year in Japan.

Even the quiet coasts of New England can be dangerous for shellfish lovers; saxitoxin—which occurs in contaminated oysters, clams, and scallops—is 1,000 times more potent than sarin.

Ciguatera is the most common nonbacterial seafood poisoning. “This is a very interesting toxin, and it's commonly seen in emergency and neurology departments all over the world,” Dr. Stommel said. The toxin originates in a dinoflagellate that lives in bottom algae in tropical areas. Bottom feeders—barracudas, snappers, jacks, and groupers—ingest the algae with their meal, and the toxin concentrates in flesh as it moves up the food chain to humans.

Ciguatera opens the sodium channels, thereby changing the cells' electrical potential and permeability and increasing neuronal excitability. The toxin also affects coagulation, can alter acetylcholine receptors, and has serotoninergic effects.

Initial symptoms are gastrointestinal pain, nausea, vomiting, and diarrhea. Other symptoms follow, including dysesthesias of the extremities, itching (especially after drinking alcohol), headaches, vertigo, circumoral tingling, muscle pain, and fasciculations. “Patients may also complain of a sense that their teeth are loose,” Dr. Stommel said.

Inverted sensory perception is another classic symptom. “Patients walking on cold tile will complain of burning feet. This is considered by some to be pathognomonic of marine toxin poisoning.”

Ciguatera is probably underdiagnosed, because the diagnosis must be made solely on the basis of symptoms and history. There is no known antidote, so treatment must be supportive. High doses of intravenous mannitol (1 g/kg of a 20% solution) have been used for years for symptom relief, but a 2002 report suggests that saline infusion is just as effective. Atropine can be useful for bradycardia. In serious cases, calcium gluconate, which acts as a substrate against competitive inhibition of calcium by the ciguatoxin, is recommended.

Most patients recover in 3–6 weeks, but symptoms can recur when patients consume chicken (chicken feed contains fish meal) or alcohol. A serotonin-sparing diet is important during the acute phase and for 3–6 months afterward. This diet includes eliminating fish and shellfish, nuts, coconuts, seeds, seed products (including oils), alcohol, mayonnaise, chocolate, and mushrooms.

Amnestic shellfish poisoning has been reported in southern Canada, California, Washington, Oregon, and coastal Europe. An algae-dwelling diatom produces the toxin domoic acid, a glutamate agonist. This toxin can cause extensive hippocampal damage, as well as less severe damage to the thalamus and forebrain.

Within 24 hours of eating contaminated shellfish, patients will have GI symptoms followed by memory loss, seizures, hemiparesis, ophthalmoplegia, and coma. Poisoned patients may grimace and make chewing motions. Blood pressure lability may develop along with cardiac dysrhythmias.

There is no antidote. Benzodiazepines or glutamate antagonists such as valproic or kynurenic acid may suppress the excitotoxic effects. The disease can be fatal, and memory loss can be permanent.

Paralytic shellfish poisoning causes severe, almost immediate symptoms, including tingling, numbness, vertigo, dysarthria, dysphagia, weakness, ataxia, and even blindness. There are no GI symptoms. The lack of diarrhea and vomiting may contribute to the high rate of mortality because more of the toxin is absorbed rather than expelled from the body. Death is usually the result of respiratory failure.

The cause is saxitoxin, produced by several microorganisms and 1,000 times more potent than sarin gas. Saxitoxin blocks sodium channels in nerve and muscle, which arrests impulse conduction and can suppress atrioventricular node conduction.

There is no antidote; treatment is supportive. The toxin binds well to charcoal. Acidity enhances the toxin's effects, so serum alkalinization might be helpful.

Tetrodotoxin occurs in the organs of the puffer fish (Fugu rubripes), a delicacy in Japan, where fugu poisoning affects about 150 people yearly with 50% mortality. Symptoms develop within 20 minutes to 3 hours of consumption, and include oral and extremity paresthesias, GI disturbance, hypersalivation, diaphoresis, cranial nerve dysfunction, refractory hypotension, and cardiovascular collapse. Partial or complete paralysis may occur, although the patient can remain lucid. Death usually occurs within 4–6 hours.

“Again, there is no known antidote,” Dr. Stommel said. Gastric lavage and activated charcoal can be useful early in the course of the poisoning. Anticholinesterase agents, atropine, and α-agonists have been effective for cardiovascular instabilities.

Scombroid, the world's most common seafood poisoning, results from toxins that build up in improperly stored fish. It's most common in members of the tuna family but can occur in other game fish. Scombroid isn't fatal; the symptoms of headache, nausea, vomiting, diarrhea, abdominal cramps, and burning of the mouth and oropharynx usually subside within 12 hours.

Treatment usually consists of charcoal and histamine blockers (cimetidine or famotidine). It's advisable to block both H₁ and H₂ receptors.

MIAMI BEACH — Seaside visitors are at risk for deadly vacation mementos: neurotoxic poisoning from contaminated seafood.

“The reality of the world is that someone can be in the Caribbean one day and in an emergency room in Minnesota with ciguatera the next,” Elijah W. Stommel, M.D., said at the annual meeting of the American Academy of Neurology. “We all need to be prepared to deal with these illnesses.”

Most of the world's vacation hot spots boast their own unique seafood toxins, said Dr. Stommel, a neurologist at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

Caribbean reef fish carry ciguatera, and shellfish from picturesque islands of eastern Canada can pack an algal toxin wallop.

Scombroid poisoning can be found wherever fresh tuna and other game fish are consumed.

A trip to Japan (or an expensive sushi bar) can increase the risk of puffer fish poisoning, which kills about 80 people a year in Japan.

Even the quiet coasts of New England can be dangerous for shellfish lovers; saxitoxin—which occurs in contaminated oysters, clams, and scallops—is 1,000 times more potent than sarin.

Ciguatera is the most common nonbacterial seafood poisoning. “This is a very interesting toxin, and it's commonly seen in emergency and neurology departments all over the world,” Dr. Stommel said. The toxin originates in a dinoflagellate that lives in bottom algae in tropical areas. Bottom feeders—barracudas, snappers, jacks, and groupers—ingest the algae with their meal, and the toxin concentrates in flesh as it moves up the food chain to humans.

Ciguatera opens the sodium channels, thereby changing the cells' electrical potential and permeability and increasing neuronal excitability. The toxin also affects coagulation, can alter acetylcholine receptors, and has serotoninergic effects.

Initial symptoms are gastrointestinal pain, nausea, vomiting, and diarrhea. Other symptoms follow, including dysesthesias of the extremities, itching (especially after drinking alcohol), headaches, vertigo, circumoral tingling, muscle pain, and fasciculations. “Patients may also complain of a sense that their teeth are loose,” Dr. Stommel said.

Inverted sensory perception is another classic symptom. “Patients walking on cold tile will complain of burning feet. This is considered by some to be pathognomonic of marine toxin poisoning.”

Ciguatera is probably underdiagnosed, because the diagnosis must be made solely on the basis of symptoms and history. There is no known antidote, so treatment must be supportive. High doses of intravenous mannitol (1 g/kg of a 20% solution) have been used for years for symptom relief, but a 2002 report suggests that saline infusion is just as effective. Atropine can be useful for bradycardia. In serious cases, calcium gluconate, which acts as a substrate against competitive inhibition of calcium by the ciguatoxin, is recommended.

Most patients recover in 3–6 weeks, but symptoms can recur when patients consume chicken (chicken feed contains fish meal) or alcohol. A serotonin-sparing diet is important during the acute phase and for 3–6 months afterward. This diet includes eliminating fish and shellfish, nuts, coconuts, seeds, seed products (including oils), alcohol, mayonnaise, chocolate, and mushrooms.

Amnestic shellfish poisoning has been reported in southern Canada, California, Washington, Oregon, and coastal Europe. An algae-dwelling diatom produces the toxin domoic acid, a glutamate agonist. This toxin can cause extensive hippocampal damage, as well as less severe damage to the thalamus and forebrain.

Within 24 hours of eating contaminated shellfish, patients will have GI symptoms followed by memory loss, seizures, hemiparesis, ophthalmoplegia, and coma. Poisoned patients may grimace and make chewing motions. Blood pressure lability may develop along with cardiac dysrhythmias.

There is no antidote. Benzodiazepines or glutamate antagonists such as valproic or kynurenic acid may suppress the excitotoxic effects. The disease can be fatal, and memory loss can be permanent.

Paralytic shellfish poisoning causes severe, almost immediate symptoms, including tingling, numbness, vertigo, dysarthria, dysphagia, weakness, ataxia, and even blindness. There are no GI symptoms. The lack of diarrhea and vomiting may contribute to the high rate of mortality because more of the toxin is absorbed rather than expelled from the body. Death is usually the result of respiratory failure.

The cause is saxitoxin, produced by several microorganisms and 1,000 times more potent than sarin gas. Saxitoxin blocks sodium channels in nerve and muscle, which arrests impulse conduction and can suppress atrioventricular node conduction.

There is no antidote; treatment is supportive. The toxin binds well to charcoal. Acidity enhances the toxin's effects, so serum alkalinization might be helpful.

Tetrodotoxin occurs in the organs of the puffer fish (Fugu rubripes), a delicacy in Japan, where fugu poisoning affects about 150 people yearly with 50% mortality. Symptoms develop within 20 minutes to 3 hours of consumption, and include oral and extremity paresthesias, GI disturbance, hypersalivation, diaphoresis, cranial nerve dysfunction, refractory hypotension, and cardiovascular collapse. Partial or complete paralysis may occur, although the patient can remain lucid. Death usually occurs within 4–6 hours.

“Again, there is no known antidote,” Dr. Stommel said. Gastric lavage and activated charcoal can be useful early in the course of the poisoning. Anticholinesterase agents, atropine, and α-agonists have been effective for cardiovascular instabilities.

Scombroid, the world's most common seafood poisoning, results from toxins that build up in improperly stored fish. It's most common in members of the tuna family but can occur in other game fish. Scombroid isn't fatal; the symptoms of headache, nausea, vomiting, diarrhea, abdominal cramps, and burning of the mouth and oropharynx usually subside within 12 hours.

Treatment usually consists of charcoal and histamine blockers (cimetidine or famotidine). It's advisable to block both H₁ and H₂ receptors.

MIAMI BEACH — The risk of Alzheimer's disease declines by almost half among postmenopausal nonsmokers who use estrogen therapy, but nearly doubles among those who both smoke and use estrogen therapy, Rosebud O. Roberts, M.B., said in a poster presented at the annual meeting of the American Academy of Neurology.

Dr. Roberts, an epidemiologist at the Mayo Clinic, Rochester, Minn., also found that early estrogen therapy might be a predictor for Alzheimer's in postmenopausal women; in contrast, estrogen therapy taken later in life appears to be more protective. But these conclusions may have more to do with premenopausal estrogen levels than postmenopausal estrogen therapy, she said in an interview.

“What I suspect is that smoking may lead to lower estrogen levels premenopausally, which could lead to brain neurons that are less viable and more likely to die early. Those who initiate therapy earlier probably have less [endogenous] estrogen, and more symptoms, while those who initiate therapy at a later age—because they had fewer symptoms or less severe symptoms—probably had more premenopausal estrogen.”

She and her associates conducted a case-control study that included 216 women with natural menopause who developed Alzheimer's disease during 1985–1989. They were compared with 210 cognitively intact controls who had similar ages at menarche and menopause.

A similar percentage of women in both groups used estrogen therapy for at least 6 months (11.6% of cases, 14% of controls). Of the 54 women on estrogen, the 25 with Alzheimer's started estrogen therapy earlier than the 29 controls (50 years vs. 53 years), and had a shorter lag time between menopause and the initiation of estrogen therapy (1 year vs. 4 years). Estrogen users had a 20% reduced risk of Alzheimer's disease, but this was not statistically significant.

The investigators did see significant differences in estrogen therapy and the risk of Alzheimer's disease between smokers and nonsmokers, however. The odds ratio of Alzheimer's was 1.93 in smokers who used estrogen therapy and only 0.54 in nonsmokers who used estrogen therapy. In nonsmokers, estrogen therapy of more than 3 years' duration showed a significant protective effect, reducing the risk of Alzheimer's by almost 70%.

“It is in women who don't smoke where we see the beneficial effects of [estrogen therapy],” she said.

MIAMI BEACH — The risk of Alzheimer's disease declines by almost half among postmenopausal nonsmokers who use estrogen therapy, but nearly doubles among those who both smoke and use estrogen therapy, Rosebud O. Roberts, M.B., said in a poster presented at the annual meeting of the American Academy of Neurology.

Dr. Roberts, an epidemiologist at the Mayo Clinic, Rochester, Minn., also found that early estrogen therapy might be a predictor for Alzheimer's in postmenopausal women; in contrast, estrogen therapy taken later in life appears to be more protective. But these conclusions may have more to do with premenopausal estrogen levels than postmenopausal estrogen therapy, she said in an interview.

“What I suspect is that smoking may lead to lower estrogen levels premenopausally, which could lead to brain neurons that are less viable and more likely to die early. Those who initiate therapy earlier probably have less [endogenous] estrogen, and more symptoms, while those who initiate therapy at a later age—because they had fewer symptoms or less severe symptoms—probably had more premenopausal estrogen.”

She and her associates conducted a case-control study that included 216 women with natural menopause who developed Alzheimer's disease during 1985–1989. They were compared with 210 cognitively intact controls who had similar ages at menarche and menopause.

A similar percentage of women in both groups used estrogen therapy for at least 6 months (11.6% of cases, 14% of controls). Of the 54 women on estrogen, the 25 with Alzheimer's started estrogen therapy earlier than the 29 controls (50 years vs. 53 years), and had a shorter lag time between menopause and the initiation of estrogen therapy (1 year vs. 4 years). Estrogen users had a 20% reduced risk of Alzheimer's disease, but this was not statistically significant.

The investigators did see significant differences in estrogen therapy and the risk of Alzheimer's disease between smokers and nonsmokers, however. The odds ratio of Alzheimer's was 1.93 in smokers who used estrogen therapy and only 0.54 in nonsmokers who used estrogen therapy. In nonsmokers, estrogen therapy of more than 3 years' duration showed a significant protective effect, reducing the risk of Alzheimer's by almost 70%.

“It is in women who don't smoke where we see the beneficial effects of [estrogen therapy],” she said.

MIAMI BEACH — The risk of Alzheimer's disease declines by almost half among postmenopausal nonsmokers who use estrogen therapy, but nearly doubles among those who both smoke and use estrogen therapy, Rosebud O. Roberts, M.B., said in a poster presented at the annual meeting of the American Academy of Neurology.

Dr. Roberts, an epidemiologist at the Mayo Clinic, Rochester, Minn., also found that early estrogen therapy might be a predictor for Alzheimer's in postmenopausal women; in contrast, estrogen therapy taken later in life appears to be more protective. But these conclusions may have more to do with premenopausal estrogen levels than postmenopausal estrogen therapy, she said in an interview.

“What I suspect is that smoking may lead to lower estrogen levels premenopausally, which could lead to brain neurons that are less viable and more likely to die early. Those who initiate therapy earlier probably have less [endogenous] estrogen, and more symptoms, while those who initiate therapy at a later age—because they had fewer symptoms or less severe symptoms—probably had more premenopausal estrogen.”

She and her associates conducted a case-control study that included 216 women with natural menopause who developed Alzheimer's disease during 1985–1989. They were compared with 210 cognitively intact controls who had similar ages at menarche and menopause.

A similar percentage of women in both groups used estrogen therapy for at least 6 months (11.6% of cases, 14% of controls). Of the 54 women on estrogen, the 25 with Alzheimer's started estrogen therapy earlier than the 29 controls (50 years vs. 53 years), and had a shorter lag time between menopause and the initiation of estrogen therapy (1 year vs. 4 years). Estrogen users had a 20% reduced risk of Alzheimer's disease, but this was not statistically significant.

The investigators did see significant differences in estrogen therapy and the risk of Alzheimer's disease between smokers and nonsmokers, however. The odds ratio of Alzheimer's was 1.93 in smokers who used estrogen therapy and only 0.54 in nonsmokers who used estrogen therapy. In nonsmokers, estrogen therapy of more than 3 years' duration showed a significant protective effect, reducing the risk of Alzheimer's by almost 70%.

“It is in women who don't smoke where we see the beneficial effects of [estrogen therapy],” she said.

During just 1 year, Colorado's statewide after-hours call-in system handled almost 142,000 night and weekend calls from parents and other caregivers seeking medical advice for children, Shira Belman, M.D., and colleagues reported.

Although 88% of the calls were for clinical illness, almost half of those were not medically urgent and resulted in advice on in-home care of the child.

About 5% of the total number of night and weekend calls were for information only, said Dr. Belman of the University of Colorado and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:145–9).

A large number of these calls might be averted “if more anticipatory information was provided in the physician's office or [if] parents were directed to other sources of information available after hours,” the researchers wrote. “Investing in such alternatives should be especially appealing to physicians who answer their own after-hours calls or who pay out-of-pocket per call for a call center's services.”

The investigators analyzed all calls that had been placed to the After Hours Telephone Care Program in Denver for the period from June 1999 to July 2000. The center provides after-hours telephone triage to 90% of all Colorado pediatricians and is staffed by registered nurses who follow computerized triage algorithms. Calls result in advice to call 911, to seek urgent care, to contact the physician within 24 hours, to contact the physician within 72 hours, or to care for the child at home.

The 10 most common algorithms used by the program staff were for vomiting (8.4% of all calls), colds (6%), cough (6%), earache (6%), fever (4%), sore throat (4%), diarrhea (3.4%), croup (3%), head trauma (2.6%), and eye infection (2.5%).

Only 21% of the callers were directed to seek urgent care, with only 1% of those told to call 911. Forty-five percent of the callers were advised how to care for the child at home; 30% were told to call their physician the next day.

A small percentage of calls (5%) were for information only, including requests for the correct dose of over-the-counter medications, medication refill requests, questions about whether a condition was contagious, and calls to inquire whether certain medications could be administered to children simultaneously.

The highest volume of calls (29%) occurred during the winter and the lowest (20%) during the summer. Spring and fall had roughly equal volume (about 25% each).

During just 1 year, Colorado's statewide after-hours call-in system handled almost 142,000 night and weekend calls from parents and other caregivers seeking medical advice for children, Shira Belman, M.D., and colleagues reported.

Although 88% of the calls were for clinical illness, almost half of those were not medically urgent and resulted in advice on in-home care of the child.

About 5% of the total number of night and weekend calls were for information only, said Dr. Belman of the University of Colorado and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:145–9).

A large number of these calls might be averted “if more anticipatory information was provided in the physician's office or [if] parents were directed to other sources of information available after hours,” the researchers wrote. “Investing in such alternatives should be especially appealing to physicians who answer their own after-hours calls or who pay out-of-pocket per call for a call center's services.”

The investigators analyzed all calls that had been placed to the After Hours Telephone Care Program in Denver for the period from June 1999 to July 2000. The center provides after-hours telephone triage to 90% of all Colorado pediatricians and is staffed by registered nurses who follow computerized triage algorithms. Calls result in advice to call 911, to seek urgent care, to contact the physician within 24 hours, to contact the physician within 72 hours, or to care for the child at home.

The 10 most common algorithms used by the program staff were for vomiting (8.4% of all calls), colds (6%), cough (6%), earache (6%), fever (4%), sore throat (4%), diarrhea (3.4%), croup (3%), head trauma (2.6%), and eye infection (2.5%).

Only 21% of the callers were directed to seek urgent care, with only 1% of those told to call 911. Forty-five percent of the callers were advised how to care for the child at home; 30% were told to call their physician the next day.

A small percentage of calls (5%) were for information only, including requests for the correct dose of over-the-counter medications, medication refill requests, questions about whether a condition was contagious, and calls to inquire whether certain medications could be administered to children simultaneously.

The highest volume of calls (29%) occurred during the winter and the lowest (20%) during the summer. Spring and fall had roughly equal volume (about 25% each).

During just 1 year, Colorado's statewide after-hours call-in system handled almost 142,000 night and weekend calls from parents and other caregivers seeking medical advice for children, Shira Belman, M.D., and colleagues reported.

Although 88% of the calls were for clinical illness, almost half of those were not medically urgent and resulted in advice on in-home care of the child.

About 5% of the total number of night and weekend calls were for information only, said Dr. Belman of the University of Colorado and her associates (Arch. Pediatr. Adolesc. Med. 2005;159:145–9).

A large number of these calls might be averted “if more anticipatory information was provided in the physician's office or [if] parents were directed to other sources of information available after hours,” the researchers wrote. “Investing in such alternatives should be especially appealing to physicians who answer their own after-hours calls or who pay out-of-pocket per call for a call center's services.”

The investigators analyzed all calls that had been placed to the After Hours Telephone Care Program in Denver for the period from June 1999 to July 2000. The center provides after-hours telephone triage to 90% of all Colorado pediatricians and is staffed by registered nurses who follow computerized triage algorithms. Calls result in advice to call 911, to seek urgent care, to contact the physician within 24 hours, to contact the physician within 72 hours, or to care for the child at home.

The 10 most common algorithms used by the program staff were for vomiting (8.4% of all calls), colds (6%), cough (6%), earache (6%), fever (4%), sore throat (4%), diarrhea (3.4%), croup (3%), head trauma (2.6%), and eye infection (2.5%).

Only 21% of the callers were directed to seek urgent care, with only 1% of those told to call 911. Forty-five percent of the callers were advised how to care for the child at home; 30% were told to call their physician the next day.

A small percentage of calls (5%) were for information only, including requests for the correct dose of over-the-counter medications, medication refill requests, questions about whether a condition was contagious, and calls to inquire whether certain medications could be administered to children simultaneously.

The highest volume of calls (29%) occurred during the winter and the lowest (20%) during the summer. Spring and fall had roughly equal volume (about 25% each).