Susan London

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE  – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn't come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE  – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn't come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE  – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians' prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children's, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn't come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Antibiotic-resistant infections are becoming more common in hospitalizations, and the profile of patients with these infections is changing, according to a retrospective study of about 370 million U.S. hospitalizations spanning a recent 10-year period.

During 1997-2006, the percentage of those having a diagnosis of antibiotic-resistant infection nearly quadrupled, researchers reported at the annual meeting of the North American Primary Care Research Group.

The mean age of the patients with resistant infections fell by 22 years, and the proportion with health insurance decreased by 7%. In addition, those who were uninsured had a shorter length of stay than did their insured counterparts.

"There has been a steady upward trend in antibiotic-resistant [infections in] hospitalizations," commented lead investigator Arch G. Mainous III, Ph.D. "Resistant infections now account for almost 2.5% of infection-related hospitalizations, and we have to assume that that [percentage] will only go up."

Better strategies to combat rising resistance are needed, both in the community (for example, a tighter control of physicians’ prescribing practices and the elimination of avenues by which people obtain antibiotics without a prescription) and in hospitals (such as the use of better infection control measures), he said.

The findings suggest that insurance status may influence the care of inpatients with resistant infections, according to Dr. Mainous. "Either people without insurance are being discharged prematurely, or people with insurance are [being kept] in the hospital longer than they need to be [so that hospitals can] make money," he said. "Either way, I think it has particular implications for quality of care."

Dr. Franklin Michota, however, did not think that the lack of insurance was leading to premature discharge. "One reason that [length of stay] for antibiotic-resistant infections is getting shorter may be that our ability to provide home therapies – such as IV antibiotics, which we typically end up giving when antibiotic resistance is found – was available in 2006, but not in 1997. In addition, the skilled inpatient facility was not available in 1997 to the extent that it is today, so many patients who simply need IV antibiotics to treat resistant infections may be discharged to receive care elsewhere. It is not as if their care is ending."

The criteria for discharge are the same between resistant and nonresistant infections, noted Dr. Michota, who is the director of academic affairs in the department of hospital medicine at the Cleveland Clinic. "Furthermore, there is nothing in this study to suggest that those patients who presented with resistant infections were more ill than those patients with infections involving antibiotic-susceptible organisms."

The researchers analyzed data from the National Hospital Discharge Survey for the years 1997-2006. Survey participants are a nationally representative sample of short-stay, children’s, and general hospitals.

The researchers evaluated hospitalizations, looking for diagnosis codes for infections and drug resistance. National estimates were based on a weighted 370.3 million hospitalizations.

Results showed that the annual number of infection-related hospitalizations with resistance rose by nearly 136,000 (or 327%) between 1997 and 2006, reported Dr. Mainous, a professor in the department of family medicine at the Medical University of South Carolina in Charleston.

Among all hospitalizations, the percentage having a diagnosis of resistant infection increased from 0.12% to 0.46%. And among just infection-related hospitalizations, the percentage having a diagnosis of resistance increased from 0.66% to 2.40%.

The mean age of patients having resistant infections fell sharply, from 65.7 years in 1997 to 44.2 years in 2006. The rise in these infections was greatest among patients younger than 18 years of age.

By far, the most common resistance found was to penicillin, with penicillin-resistant infections accounting for 94% of all resistant infections. Infections having isolated vancomycin resistance came in a distant second, at 3%.

In a finding that Dr. Mainous described as "definitely counterintuitive," the median length of stay for infection-related hospitalizations with resistance decreased by 40%, from 6.6 to 4.0 days. The stay for those without resistance remained essentially unchanged, at 4.8 and 4.3 days.

About 97% of patients with resistant infections had health insurance in 1997, but that figure fell to 90% in 2006. And uninsured patients had shorter stays than did their insured peers.

"What we are seeing is that as people get younger, they are less likely to have insurance and their length of stay goes down," Dr. Mainous commented. "We couldn’t come up with a specific mechanism by which insurance would make the infection less virulent."

Over the 10-year period, there were favorable trends in outcomes whereby infection-related hospitalizations that involved resistance were less likely to end in death or discharge to a care institution, and more likely to end in routine discharge.

Growing awareness of antibiotic resistance may have altered coding practices during the study period, Dr. Mainous acknowledged. Additionally, the study was limited by the inability to tell if infections arose in the hospital or in the community, and how severe they were.

Dr. Mainous did not report having any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

SEATTLE – Inadvertent freezing of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine while it is being stored in vaccine refrigerators may be contributing to the rise in pertussis in the community, new data suggest.

Using continuous data loggers, investigators at the Baylor College of Medicine in Houston found that one-quarter of 54 vaccine refrigerators in the city’s community health centers had temperatures that dipped into the freezing range, most commonly at night and on weekends.

There was a significant 76% correlation between the percentage of vaccine refrigerators in a health region experiencing prolonged freezing temperatures and that region’s rate of pertussis, the investigators reported at the annual meeting of the North American Primary Care Research Group.

The study establishes only correlation, and there are many possible confounders and explanations, acknowledged lead investigator Dr. Patrick J. McColloster, an associate professor of family medicine at the college.

"But I think though that one thing that has been neglected in looking at the pertussis outbreaks in the United States is inadvertent freezing and the instability of DTaP – back to the cold chain again," he said, referring to the practice of ensuring that the vaccine is continuously kept at the recommended temperature.

In interviews, nursing staff at the centers were skeptical of the freezing because they more often noticed warm temperatures during the workday, he commented. "Whenever they would open and close the refrigerator doors, they always made sure [the temperature] was within normal range, and if it was a little too hot, they would just crank the refrigerator up a little bit more. So basically, they were freezing the vaccines like crazy."

Explaining the rationale for the study, Dr. McColloster noted that the incidence of pertussis fell in the 10 years after introduction of the DTP (diphtheria, tetanus, pertussis) vaccine, but it actually rose in the 9 years after subsequent introduction of the DTaP vaccine.

"Currently, all the studies that are out there are saying it’s due to seasonal variation, unvaccinated pediatric clusters, and declining adult immunity," he said. "Gee, it doesn’t have anything to do with DTaP, does it?"

The impact of failure of the vaccine cold chain on the occurrence of pertussis has not been studied in the United States. "DTaP uses aluminum as an adjuvant (just like DTP does), but it’s a little bit different in that it’s more sensitive to freezing," he explained. In fact, the manufacturer recommends discarding any vaccine exposed to freezing temperatures.

In the study, the investigators attached data loggers to 54 vaccine refrigerators in 13 Community Health Centers in the Harris County Hospital District of Houston. The centers provide approximately 580,000 outpatient visits each year to an indigent population.

The loggers sampled the refrigerator temperature every minute for at least 6 days. Data from the first hour were discarded to allow the logger’s temperature to equilibrate.

The centers’ own procedure for cold chain monitoring consisted of twice-daily readings from approved digital thermometers during weekday work hours, as mandated by the Centers for Disease Control and Prevention.

The investigators obtained data on the incidence of pertussis in the district for the years 2005-2009 from the City of Houston Health Department.

Results showed that 48% of refrigerators maintained temperature in the correct range (2?C to 8?C), Dr. McColloster reported. But 19% experienced cold temperatures (0.1?C to 1.9?C) and 24% experienced freezing ones (0?C or lower). The remaining 9% had temperatures rising into the warm range (greater than 8?C), but this usually was so transient that it was unlikely to alter temperature of the vaccine itself, he said.

Among the refrigerators with freezing temperatures, the average time spent at freezing was 2 hours per day. Freezing usually occurred on nights and over weekends.

Across the six health regions within the district, the percentage of refrigerators in the region having freezing temperatures for more than 2 hours daily ranged from 14% to 80%. And the average annual pertussis rate ranged from 2.9 to 6.3 cases per 100,000 population.

The higher the percentage of refrigerators in a region experiencing freezing temperatures for more than 2 hours daily, the higher the pertussis rate for that region (r = 0.76, P less than .05), Dr. McColloster reported.

Establishing causation will require freezing the vaccine and then testing its immunogenicity in animals, or assessing pertussis immune status in patients who have received vaccines from refrigerators experiencing freezing, he acknowledged.

To address the problem, there are several possible solutions, according to Dr. McColloster. DTaP vaccine vials could be affixed with temperature-sensitive labels that show immediately if they have been frozen. Also, clinics could use refrigerators that do not permit staff to manually adjust the temperature.

Dr. McColloster said he did not have any conflicts of interest related to the study.

LAS VEGAS - Travelers returning from international destinations may bring home with them a variety of rash-causing illnesses that range from the self-limited to the life-threatening, according to Dr. Rachel L. Chin.

The most common dermatologic conditions in ill returned travelers are arthropod-related ones (accounting for 31%), pyodermas (13%), soil-related ones (11%), and animal-related ones (9%) (Int. J. Infect. Dis. 2008;12:593-602), she told attendees of the annual meeting of the American College of Emergency Physicians.

In sorting out the many possible etiologies of a rash in the traveler returning home, "use the mnemonic TRIPS," recommended Dr. Chin, who is a professor of emergency medicine at the University of California, San Francisco.

It stands for time of travel (the time of year and itinerary), region visited (and associated risks and any specific exposures), incubation period (a range, calculated from the first day and last day of travel to symptom onset), prophylaxis taken (which helps rule out possibilities), and signs and symptoms.

In addition, she noted that the Geosentinel Surveillance Network (www.istm.org/geosentinel/main.html) can be an invaluable aid for staying aware of existing and emerging health threats in various parts of the world.

"It's the largest collaborative effort in travel medicine, [involving] the CDC and the International Society of Travel Medicine," she explained. "They monitor travel and tropical medicine clinics on six continents."

Dr. Chin offered some tips for diagnosing and managing specific travel-related rashes that emergency physicians may encounter in their practice, although several of these rashes can also be acquired domestically.

Acute HIV Infection

Clinicians' vigilance for rashes due to sexually transmitted diseases should be especially high for travelers returning from sex tourism destinations, such as Pattaya, Thailand, and Angeles City, Philippines, she noted.

"If you have a patient who is back from any of these destinations with a new rash, ask for a detailed sexual history and send an HIV test," Dr. Chin recommended.

Importantly, the rapid test for HIV used in emergency departments is for antibodies, which are usually not detectable in acute infection, the time when the morbilliform or maculopapular rash often appears.

"Send the rapid test first," she advised. "If it's negative, send for an RNA test if you have a new rash [in a patient returning] from those destinations."

Dengue Fever

A mosquito-borne illness having an incubation period of up to 2 weeks, dengue produces fever, fatigue, myalgia, arthralgia, and severe headache (often described as retro-orbital pain), followed by a generalized maculopapular rash with scattered petechiae.

Photo (c) Elsevier Inc.

Laboratory testing often shows leukopenia, thrombocytopenia, and elevated transaminitis, according to Dr. Chin. Patients are typically not as ill as one would expect with meningococcemia, which may also be in the differential.

"Dengue is often a clinical diagnosis, and you confirm it with a rise in serum antibody titers and, of course, they have traveled in an endemic area," she said, such as certain parts of Central and South America and Africa.

"The treatment for dengue is supportive," Dr. Chin noted; once the rash appears, the fever begins to subside and patients begin to feel better.

"You want to avoid NSAIDs because of the thrombocytopenia that they have and the increased risk of bleeding," she cautioned. "You can use Tylenol."

African Tick Bite Fever

One of the spotted fevers, African tick bite fever is a rickettsial illness seen in travelers exposed to wild animals through camping, hiking, or safaris in grass or scrubby areas. After an incubation period of about 1 week, travelers develop a fever and papulovesicular rash beginning on the trunk, sometimes accompanied by leukopenia or thrombocytopenia.

"An important diagnostic clue with this is the eschar," Dr. Chin pointed out. "It's a painless, necrotic or crusted lesion at the site of the tick bite with surrounding erythema." African tick bite fever can be definitively diagnosed with serology during the convalescent period. Affected patients should be treated with doxycycline. "A fast recovery is often diagnostic with this rickettsial disease – we often will see recovery within 24-48 hours," she commented.

Chikungunya

A viral illness that shares some similarities with dengue, chikungunya produces a clinical triad of fever, often severe arthropathy, and generalized rash, according to Dr. Chin.

"It is transmitted by the same mosquito that transmits dengue, and it's often mistaken for dengue because the clinical symptoms are very similar, except that [patients with chikungunya] have more arthralgia and joint swelling, and less of the retro-orbital pain," she said. The diagnosis is typically a clinical one, although clinicians can get virus-specific antibody titers, Dr. Chin noted.

"Treatment is symptomatic, but in this case you can use NSAIDs because they have less of the thrombocytopenia that you see with dengue," she said. "There have been many case reports that chloroquine was effective, but there are no controlled studies of that."

Typhoid

Transmitted by ingestion of contaminated food or water, typhoid (enteric fever) has an incubation period of about 1-2 weeks. It produces fever, abdominal pain, and constipation more often than diarrhea. About 30% of cases will have a rash consisting of macular lesions called rose spots. Patients may also have leukopenia, mild thrombocytopenia, and moderately elevated alanine aminotransferase levels. Untreated patients may develop life-threatening complications such as gastrointestinal perforation, pneumonia, and myocarditis, typically in the third week of infection, Dr. Chin said.

"The diagnosis relies on isolation of Salmonella typhi from the patients, [using] either blood … or urine cultures," she said. "Stool is not often done, because they are constipated." Typhoid is typically treated with fluoroquinolones, but clinicians should be aware that multidrug resistance is now problematic in India (seen in 35% of isolates from there) and Vietnam (in 80%). "If your patient is coming back from a fluoroquinolone resistance area, you can consider ceftriaxone or azithromycin," she advised.

Cutaneous Larva Migrans

Travelers acquire cutaneous larva migrans, the infective (larval) stage of the dog or cat hookworm, through contact with contaminated soil or sand on tropical or subtropical beaches. Hence, this rash is more often seen on the feet or buttocks.

Photo (c) Elsevier Inc.

The infection begins with pruritic papules, which are followed by a serpiginous linear rash that migrates superficially several millimeters a day and hence is referred to as a creeping eruption. It usually lasts from weeks to months if not treated.

"Our [infectious disease] people think that these [organisms] die anyway, so they question treatment," Dr. Chin commented. If cutaneous larva migrans is treated, clinicians should use ivermectin or albendazole, she said.

Botfly Infestation

Travelers acquire botfly infestation (cutaneous myiasis) when they are bitten by insects carrying eggs of the human botfly, which is widely distributed in Central and South America, Dr. Chin said. They seek medical care for enlarging bumps on and possibly a crawling sensation beneath their skin, in the absence of any psychiatric illness.

Photo (c) Elsevier Inc.

On examination, patients have raised papules resembling boils, with a central punctate air hole through which the growing botfly larva breathes. The larva can be surgically extracted, smothered with occlusive agents such as petroleum jelly to encourage emergence, removed with a venom extractor, or simply squeezed out of the lesion, she said.

Acute Schistosomiasis

The rash of acute schistosomiasis, also called Katayama fever, is pruritic and accompanied by flulike symptoms, lymphadenopathy, and eosinophilia, appearing after an incubation period of 2-8 weeks. Travelers acquire this parasitic infection through contact with fresh water harboring the organism's host, the snail, in endemic regions such as sub-Saharan Africa and parts of Southeast Asia, Dr. Chin said. It is treated with praziquantel. Some patients develop a schistosomal myelopathy that can lead to permanent neurologic damage, she noted.

Leptospirosis

The spirochete that causes leptospirosis is carried by and shed in the urine of livestock, dogs, rodents, and wild animals, and is thus found in water or soil, according to Dr. Chin. The incubation period is 7-12 days. "Patients may have a biphasic illness," she noted. "Fever, headaches, myalgias, sometimes with conjunctivitis and a rash," initially. "And some people may develop a secondary systemic infection of jaundice and renal failure," known as Weil syndrome.

This infection is diagnosed with serology and treated with doxycycline or penicillin, she said.

Dr. Chin reported no conflicts of interest.

LAS VEGAS - Travelers returning from international destinations may bring home with them a variety of rash-causing illnesses that range from the self-limited to the life-threatening, according to Dr. Rachel L. Chin.

The most common dermatologic conditions in ill returned travelers are arthropod-related ones (accounting for 31%), pyodermas (13%), soil-related ones (11%), and animal-related ones (9%) (Int. J. Infect. Dis. 2008;12:593-602), she told attendees of the annual meeting of the American College of Emergency Physicians.

In sorting out the many possible etiologies of a rash in the traveler returning home, "use the mnemonic TRIPS," recommended Dr. Chin, who is a professor of emergency medicine at the University of California, San Francisco.

It stands for time of travel (the time of year and itinerary), region visited (and associated risks and any specific exposures), incubation period (a range, calculated from the first day and last day of travel to symptom onset), prophylaxis taken (which helps rule out possibilities), and signs and symptoms.

In addition, she noted that the Geosentinel Surveillance Network (www.istm.org/geosentinel/main.html) can be an invaluable aid for staying aware of existing and emerging health threats in various parts of the world.

"It's the largest collaborative effort in travel medicine, [involving] the CDC and the International Society of Travel Medicine," she explained. "They monitor travel and tropical medicine clinics on six continents."

Dr. Chin offered some tips for diagnosing and managing specific travel-related rashes that emergency physicians may encounter in their practice, although several of these rashes can also be acquired domestically.

Acute HIV Infection

Clinicians' vigilance for rashes due to sexually transmitted diseases should be especially high for travelers returning from sex tourism destinations, such as Pattaya, Thailand, and Angeles City, Philippines, she noted.

"If you have a patient who is back from any of these destinations with a new rash, ask for a detailed sexual history and send an HIV test," Dr. Chin recommended.

Importantly, the rapid test for HIV used in emergency departments is for antibodies, which are usually not detectable in acute infection, the time when the morbilliform or maculopapular rash often appears.

"Send the rapid test first," she advised. "If it's negative, send for an RNA test if you have a new rash [in a patient returning] from those destinations."

Dengue Fever

A mosquito-borne illness having an incubation period of up to 2 weeks, dengue produces fever, fatigue, myalgia, arthralgia, and severe headache (often described as retro-orbital pain), followed by a generalized maculopapular rash with scattered petechiae.

Photo (c) Elsevier Inc.

Laboratory testing often shows leukopenia, thrombocytopenia, and elevated transaminitis, according to Dr. Chin. Patients are typically not as ill as one would expect with meningococcemia, which may also be in the differential.

"Dengue is often a clinical diagnosis, and you confirm it with a rise in serum antibody titers and, of course, they have traveled in an endemic area," she said, such as certain parts of Central and South America and Africa.

"The treatment for dengue is supportive," Dr. Chin noted; once the rash appears, the fever begins to subside and patients begin to feel better.

"You want to avoid NSAIDs because of the thrombocytopenia that they have and the increased risk of bleeding," she cautioned. "You can use Tylenol."

African Tick Bite Fever

One of the spotted fevers, African tick bite fever is a rickettsial illness seen in travelers exposed to wild animals through camping, hiking, or safaris in grass or scrubby areas. After an incubation period of about 1 week, travelers develop a fever and papulovesicular rash beginning on the trunk, sometimes accompanied by leukopenia or thrombocytopenia.

"An important diagnostic clue with this is the eschar," Dr. Chin pointed out. "It's a painless, necrotic or crusted lesion at the site of the tick bite with surrounding erythema." African tick bite fever can be definitively diagnosed with serology during the convalescent period. Affected patients should be treated with doxycycline. "A fast recovery is often diagnostic with this rickettsial disease – we often will see recovery within 24-48 hours," she commented.

Chikungunya

A viral illness that shares some similarities with dengue, chikungunya produces a clinical triad of fever, often severe arthropathy, and generalized rash, according to Dr. Chin.

"It is transmitted by the same mosquito that transmits dengue, and it's often mistaken for dengue because the clinical symptoms are very similar, except that [patients with chikungunya] have more arthralgia and joint swelling, and less of the retro-orbital pain," she said. The diagnosis is typically a clinical one, although clinicians can get virus-specific antibody titers, Dr. Chin noted.

"Treatment is symptomatic, but in this case you can use NSAIDs because they have less of the thrombocytopenia that you see with dengue," she said. "There have been many case reports that chloroquine was effective, but there are no controlled studies of that."

Typhoid

Transmitted by ingestion of contaminated food or water, typhoid (enteric fever) has an incubation period of about 1-2 weeks. It produces fever, abdominal pain, and constipation more often than diarrhea. About 30% of cases will have a rash consisting of macular lesions called rose spots. Patients may also have leukopenia, mild thrombocytopenia, and moderately elevated alanine aminotransferase levels. Untreated patients may develop life-threatening complications such as gastrointestinal perforation, pneumonia, and myocarditis, typically in the third week of infection, Dr. Chin said.

"The diagnosis relies on isolation of Salmonella typhi from the patients, [using] either blood … or urine cultures," she said. "Stool is not often done, because they are constipated." Typhoid is typically treated with fluoroquinolones, but clinicians should be aware that multidrug resistance is now problematic in India (seen in 35% of isolates from there) and Vietnam (in 80%). "If your patient is coming back from a fluoroquinolone resistance area, you can consider ceftriaxone or azithromycin," she advised.

Cutaneous Larva Migrans

Travelers acquire cutaneous larva migrans, the infective (larval) stage of the dog or cat hookworm, through contact with contaminated soil or sand on tropical or subtropical beaches. Hence, this rash is more often seen on the feet or buttocks.

Photo (c) Elsevier Inc.

The infection begins with pruritic papules, which are followed by a serpiginous linear rash that migrates superficially several millimeters a day and hence is referred to as a creeping eruption. It usually lasts from weeks to months if not treated.

"Our [infectious disease] people think that these [organisms] die anyway, so they question treatment," Dr. Chin commented. If cutaneous larva migrans is treated, clinicians should use ivermectin or albendazole, she said.

Botfly Infestation

Travelers acquire botfly infestation (cutaneous myiasis) when they are bitten by insects carrying eggs of the human botfly, which is widely distributed in Central and South America, Dr. Chin said. They seek medical care for enlarging bumps on and possibly a crawling sensation beneath their skin, in the absence of any psychiatric illness.

Photo (c) Elsevier Inc.

On examination, patients have raised papules resembling boils, with a central punctate air hole through which the growing botfly larva breathes. The larva can be surgically extracted, smothered with occlusive agents such as petroleum jelly to encourage emergence, removed with a venom extractor, or simply squeezed out of the lesion, she said.

Acute Schistosomiasis

The rash of acute schistosomiasis, also called Katayama fever, is pruritic and accompanied by flulike symptoms, lymphadenopathy, and eosinophilia, appearing after an incubation period of 2-8 weeks. Travelers acquire this parasitic infection through contact with fresh water harboring the organism's host, the snail, in endemic regions such as sub-Saharan Africa and parts of Southeast Asia, Dr. Chin said. It is treated with praziquantel. Some patients develop a schistosomal myelopathy that can lead to permanent neurologic damage, she noted.

Leptospirosis

The spirochete that causes leptospirosis is carried by and shed in the urine of livestock, dogs, rodents, and wild animals, and is thus found in water or soil, according to Dr. Chin. The incubation period is 7-12 days. "Patients may have a biphasic illness," she noted. "Fever, headaches, myalgias, sometimes with conjunctivitis and a rash," initially. "And some people may develop a secondary systemic infection of jaundice and renal failure," known as Weil syndrome.

This infection is diagnosed with serology and treated with doxycycline or penicillin, she said.

Dr. Chin reported no conflicts of interest.

LAS VEGAS - Travelers returning from international destinations may bring home with them a variety of rash-causing illnesses that range from the self-limited to the life-threatening, according to Dr. Rachel L. Chin.

The most common dermatologic conditions in ill returned travelers are arthropod-related ones (accounting for 31%), pyodermas (13%), soil-related ones (11%), and animal-related ones (9%) (Int. J. Infect. Dis. 2008;12:593-602), she told attendees of the annual meeting of the American College of Emergency Physicians.

In sorting out the many possible etiologies of a rash in the traveler returning home, "use the mnemonic TRIPS," recommended Dr. Chin, who is a professor of emergency medicine at the University of California, San Francisco.

It stands for time of travel (the time of year and itinerary), region visited (and associated risks and any specific exposures), incubation period (a range, calculated from the first day and last day of travel to symptom onset), prophylaxis taken (which helps rule out possibilities), and signs and symptoms.

In addition, she noted that the Geosentinel Surveillance Network (www.istm.org/geosentinel/main.html) can be an invaluable aid for staying aware of existing and emerging health threats in various parts of the world.

"It's the largest collaborative effort in travel medicine, [involving] the CDC and the International Society of Travel Medicine," she explained. "They monitor travel and tropical medicine clinics on six continents."

Dr. Chin offered some tips for diagnosing and managing specific travel-related rashes that emergency physicians may encounter in their practice, although several of these rashes can also be acquired domestically.

Acute HIV Infection

Clinicians' vigilance for rashes due to sexually transmitted diseases should be especially high for travelers returning from sex tourism destinations, such as Pattaya, Thailand, and Angeles City, Philippines, she noted.

"If you have a patient who is back from any of these destinations with a new rash, ask for a detailed sexual history and send an HIV test," Dr. Chin recommended.

Importantly, the rapid test for HIV used in emergency departments is for antibodies, which are usually not detectable in acute infection, the time when the morbilliform or maculopapular rash often appears.

"Send the rapid test first," she advised. "If it's negative, send for an RNA test if you have a new rash [in a patient returning] from those destinations."

Dengue Fever

A mosquito-borne illness having an incubation period of up to 2 weeks, dengue produces fever, fatigue, myalgia, arthralgia, and severe headache (often described as retro-orbital pain), followed by a generalized maculopapular rash with scattered petechiae.

Photo (c) Elsevier Inc.

Laboratory testing often shows leukopenia, thrombocytopenia, and elevated transaminitis, according to Dr. Chin. Patients are typically not as ill as one would expect with meningococcemia, which may also be in the differential.

"Dengue is often a clinical diagnosis, and you confirm it with a rise in serum antibody titers and, of course, they have traveled in an endemic area," she said, such as certain parts of Central and South America and Africa.

"The treatment for dengue is supportive," Dr. Chin noted; once the rash appears, the fever begins to subside and patients begin to feel better.

"You want to avoid NSAIDs because of the thrombocytopenia that they have and the increased risk of bleeding," she cautioned. "You can use Tylenol."

African Tick Bite Fever

One of the spotted fevers, African tick bite fever is a rickettsial illness seen in travelers exposed to wild animals through camping, hiking, or safaris in grass or scrubby areas. After an incubation period of about 1 week, travelers develop a fever and papulovesicular rash beginning on the trunk, sometimes accompanied by leukopenia or thrombocytopenia.

"An important diagnostic clue with this is the eschar," Dr. Chin pointed out. "It's a painless, necrotic or crusted lesion at the site of the tick bite with surrounding erythema." African tick bite fever can be definitively diagnosed with serology during the convalescent period. Affected patients should be treated with doxycycline. "A fast recovery is often diagnostic with this rickettsial disease – we often will see recovery within 24-48 hours," she commented.

Chikungunya

A viral illness that shares some similarities with dengue, chikungunya produces a clinical triad of fever, often severe arthropathy, and generalized rash, according to Dr. Chin.

"It is transmitted by the same mosquito that transmits dengue, and it's often mistaken for dengue because the clinical symptoms are very similar, except that [patients with chikungunya] have more arthralgia and joint swelling, and less of the retro-orbital pain," she said. The diagnosis is typically a clinical one, although clinicians can get virus-specific antibody titers, Dr. Chin noted.

"Treatment is symptomatic, but in this case you can use NSAIDs because they have less of the thrombocytopenia that you see with dengue," she said. "There have been many case reports that chloroquine was effective, but there are no controlled studies of that."

Typhoid

Transmitted by ingestion of contaminated food or water, typhoid (enteric fever) has an incubation period of about 1-2 weeks. It produces fever, abdominal pain, and constipation more often than diarrhea. About 30% of cases will have a rash consisting of macular lesions called rose spots. Patients may also have leukopenia, mild thrombocytopenia, and moderately elevated alanine aminotransferase levels. Untreated patients may develop life-threatening complications such as gastrointestinal perforation, pneumonia, and myocarditis, typically in the third week of infection, Dr. Chin said.

"The diagnosis relies on isolation of Salmonella typhi from the patients, [using] either blood … or urine cultures," she said. "Stool is not often done, because they are constipated." Typhoid is typically treated with fluoroquinolones, but clinicians should be aware that multidrug resistance is now problematic in India (seen in 35% of isolates from there) and Vietnam (in 80%). "If your patient is coming back from a fluoroquinolone resistance area, you can consider ceftriaxone or azithromycin," she advised.

Cutaneous Larva Migrans

Travelers acquire cutaneous larva migrans, the infective (larval) stage of the dog or cat hookworm, through contact with contaminated soil or sand on tropical or subtropical beaches. Hence, this rash is more often seen on the feet or buttocks.

Photo (c) Elsevier Inc.

The infection begins with pruritic papules, which are followed by a serpiginous linear rash that migrates superficially several millimeters a day and hence is referred to as a creeping eruption. It usually lasts from weeks to months if not treated.

"Our [infectious disease] people think that these [organisms] die anyway, so they question treatment," Dr. Chin commented. If cutaneous larva migrans is treated, clinicians should use ivermectin or albendazole, she said.

Botfly Infestation

Travelers acquire botfly infestation (cutaneous myiasis) when they are bitten by insects carrying eggs of the human botfly, which is widely distributed in Central and South America, Dr. Chin said. They seek medical care for enlarging bumps on and possibly a crawling sensation beneath their skin, in the absence of any psychiatric illness.

Photo (c) Elsevier Inc.

On examination, patients have raised papules resembling boils, with a central punctate air hole through which the growing botfly larva breathes. The larva can be surgically extracted, smothered with occlusive agents such as petroleum jelly to encourage emergence, removed with a venom extractor, or simply squeezed out of the lesion, she said.

Acute Schistosomiasis

The rash of acute schistosomiasis, also called Katayama fever, is pruritic and accompanied by flulike symptoms, lymphadenopathy, and eosinophilia, appearing after an incubation period of 2-8 weeks. Travelers acquire this parasitic infection through contact with fresh water harboring the organism's host, the snail, in endemic regions such as sub-Saharan Africa and parts of Southeast Asia, Dr. Chin said. It is treated with praziquantel. Some patients develop a schistosomal myelopathy that can lead to permanent neurologic damage, she noted.

Leptospirosis

The spirochete that causes leptospirosis is carried by and shed in the urine of livestock, dogs, rodents, and wild animals, and is thus found in water or soil, according to Dr. Chin. The incubation period is 7-12 days. "Patients may have a biphasic illness," she noted. "Fever, headaches, myalgias, sometimes with conjunctivitis and a rash," initially. "And some people may develop a secondary systemic infection of jaundice and renal failure," known as Weil syndrome.

This infection is diagnosed with serology and treated with doxycycline or penicillin, she said.

Dr. Chin reported no conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C.– A live, interactive, cased-based educational initiative improved primary care physicians’ knowledge of chronic obstructive pulmonary disease, according to study results reported at the annual meeting of the American College of Chest Physicians.

In a cross-sectional study of 50 primary care physicians who participated in the initiative and 50 similar nonparticipants, the former were more likely to know that alveolar destruction is a pathophysiologic feature of COPD (94% vs. 74%) and that women have greater susceptibility to the harmful effects of smoking (90% vs. 54%), according to Dr. Nicola A. Hanania and his coinvestigators.

Additionally, when presented with case vignettes, the participants were more likely to recognize the presence of COPD in dyspnea patients (90% vs. 74%).

"Even though this was sort of a one-time ... cross-sectional survey, we believe that educational initiatives such as this one may at least improve the knowledge about COPD – both diagnosis and management," commented Dr. Hanania, an associate professor of medicine at Baylor College of Medicine, Houston.

Explaining the need for primary care–focused efforts, he noted that "the majority of COPD patients are [seen] in the primary care arena."

But statistics show that "COPD remains under-recognized and underdiagnosed in about 50% of the population out there, not only in the United States but in other countries as well. It also remains undertreated," even though the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines now stress that it is a treatable disease.

The initiative studied – called Improving COPD Patient Outcomes: Breaking Down the Barriers to Optimal Care – was designed to improve primary care providers’ knowledge and competency in the guideline-based diagnosis, staging, and management of COPD, Dr. Hanania said.

It consisted of a series of live half-day meetings conducted over a 3-month period that included short lectures, a video on correct use of inhaler devices, and small-group workshops that incorporated detailed case discussions and hands-on demonstrations and practice in the use of spirometry.

A total of 769 physicians attended the meetings. The investigators assessed the initiative’s effectiveness with a case vignette–based survey, given to a randomly selected subset of 50 participants and 50 nonparticipants with similar demographics and practice characteristics.

The number of patients with COPD seen weekly was 11 for participants and 15 for nonparticipants. The mean number of years in practice was 28 and 24, respectively. And both groups were about equally divided between family physicians and internal medicine physicians. Participants were somewhat more likely to be in solo practice (45% vs. 38%) or work in a government facility (25% vs. 0%), and less likely to be in group practice (31% vs. 58%).

Survey results showed that in the area of diagnosis, the participants were more likely than the nonparticipants to recognize COPD in case vignettes of patients with dyspnea (90% vs. 74%, P = .007) and to be aware of the greater susceptibility of women compared with men to the harmful effects of smoking (90% vs. 54%, P less than .001).

Also, when asked which of several pathophysiologic features was one of COPD, participants were more likely to correctly answer alveolar destruction (94% vs. 74%, P = .007). (The other options were muscular deconditioning, synovial inflammation, and increased ventricular filling pressure.)

While the groups did not differ significantly in terms of how likely they were to use spirometry for diagnosis and staging of COPD, participants were more likely than nonparticipants to indicate that difficulty in obtaining spirometry results in the office setting was a very significant barrier to COPD management (27% vs. 12%). "Maybe they acknowledged that it is an important tool, but they cannot do it," he commented.

The groups were statistically indistinguishable with respect to their approaches to caring for patients with repeated exacerbations and improving adherence, and their selection of appropriate maintenance therapy.

The survey also asked about barriers to managing COPD, which may help in designing future initiatives, Dr. Hanania said.

In addition to difficulty with spirometry, the groups were similarly likely to rate as very significant a patient’s nonadherence to a recommendation to stop smoking, the complexity of the medical regimen, and a lack of clarity about the staging of COPD severity.

A calculation of the initiative’s quality of education index showed that participants were 50% more likely than nonparticipants to provide evidence-based, guideline-driven COPD care, Dr. Hanania reported. "We estimate that participation in this half-day program can potentially improve the care of many patients per week, but this needs to be further tested," he commented.

"We did not attempt to look at long-term [outcomes] – retention of knowledge or practice change – which are very important," Dr. Hanania acknowledged. But a similar, ongoing initiative, being conducted by the ACCP, is currently assessing impact on real-life practice.

That initiative is including not only physicians but also physician assistants and nurse practitioners, Dr. Hanania noted. "In our primary care setting in the U.S., nonphysician extenders – PAs, nurse practitioners – play a major role in encountering COPD, and those are people we like to target," he explained. Furthermore, their role will likely increase if health care reform proceeds and primary care physicians are overwhelmed by demand.

The initiative meetings were supported by an educational grant from Novartis Pharmaceuticals. Dr. Hanania had no relevant conflicts of interest.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.

VANCOUVER, B.C. – Small cell lung cancer presentation varies by sex and race, according to a retrospective analysis of U.S. national data spanning a 32-year period.

Women were more likely than men to have limited disease at diagnosis and had better survival, Dr. Shagun Arora reported at the annual meeting of the American College of Chest Physicians. African Americans were younger than whites at diagnosis, and the small cell type made up a smaller proportion of all lung cancers in African American patients than in white patients.

Possible explanations include differences in patterns of smoking and susceptibility to the deleterious effects of tobacco smoke, as well as hormonal factors, according to Dr. Arora, an internist at McLaren Regional Medical Center in Flint, Mich.

Using histologic codes, the investigators identified all cases of small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database among white and African American patients between the years 1973 and 2005.

Analyses were based on 70,886 patients with small cell lung cancer. About 91% were white and 55% were male.

During the study period, the male-to-female ratio in the proportion of all lung cancers that were of small cell type fell from 2.6 to 0.9, which mainly reflected a rise among women, Dr. Aurora said.

Age at presentation did not differ by sex. But women were more likely to have disease that was limited in stage (that is, confined to one hemithorax) at diagnosis than were men (35% vs. 30%).

And although cancer-specific survival improved for both sexes over time, it was consistently longer for women than for men. At the end of the study period, 2-year survival was approximately 20% among women, vs. 15% among men.

"We all know that small cell lung cancer is very closely related to smoking," Dr. Arora commented. Hence, differences between the sexes in smoking patterns may explain some of these findings.

"Females began smoking 20 years after males," she noted, and their smoking rates have been slower to decline. In addition, "females are more prone to tobacco effects: They are 1.5 times more likely to develop lung cancer than males with the same smoking habits."

The study did not use multivariate or stage-stratified analysis, Dr. Arora said; hence, the less-extensive disease of women at presentation may have contributed to their better survival. Nonetheless, this finding "begs the question of a possible hormonal factor."

Study results for race showed that the proportion of all lung cancers that were of small cell type was consistently lower among African American patients than among white patients throughout the study period. As of 2005, the value was 9% compared with 12% for white patients.

Age at presentation was younger among African American patients than among white patients. For example, roughly 50% of African American patients received their cancer diagnosis before age 64, compared with 40% of white patients. But the two racial groups did not differ with respect to the stage at diagnosis or cancer-specific survival.

Here, again, smoking patterns and susceptibility may explain some of the observed differences, according to Dr. Arora.

On the one hand, African American smokers smoke fewer cigarettes daily than do their white peers and start smoking later in life, she said. But "because of their lower quit rates, their prevalence of smoking is higher." Also, they smoke more menthol cigarettes, which have higher levels of tar than the nonmentholated kind.

"On top of that, there is a race effect," Dr. Arora noted. "African Americans are 1.8 times more susceptible than whites to developing small cell lung cancer with the same amount of smoking."

Dr. Arora reported that she did not have any relevant financial conflicts.