Timothy F. Kirn

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of pregnant women who were screened at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women who were being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of the 353 women who were screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden.

Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. Specifically, they found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of pregnant women who were screened at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women who were being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of the 353 women who were screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden.

Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. Specifically, they found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of pregnant women who were screened at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women who were being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of the 353 women who were screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden.

Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. Specifically, they found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SEATTLE – Obesity costs the United States $49 billion for each group of 4 million children born, findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth show.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis, of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese–from ages 3 to 65–for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is made up of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide.

However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

SEATTLE – Obesity costs the United States $49 billion for each group of 4 million children born, findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth show.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis, of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese–from ages 3 to 65–for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is made up of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide.

However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

SEATTLE – Obesity costs the United States $49 billion for each group of 4 million children born, findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth show.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis, of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese–from ages 3 to 65–for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is made up of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide.

However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records. “Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted. Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

What they did see was that if doctors did not take to the technology right away, they never did. DR. SIMPSON

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records. “Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted. Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

What they did see was that if doctors did not take to the technology right away, they never did. DR. SIMPSON

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records. “Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted. Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians. What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

What they did see was that if doctors did not take to the technology right away, they never did. DR. SIMPSON

LAS VEGAS — Adolescents can be insulin resistant and have the risk factors of early heart disease, Dr. Alan Sinaiko said at the Fourth World Congress on the Insulin Resistance Syndrome.

Dr. Sinaiko has followed a cohort of about 400 Minnesota children from age 11 years to 23 years. In the study, he used an insulin clamp technique in which glucose and insulin are infused together to measure the glucose's uptake by muscle.

He has found that at 13 years, 2% of the patients have insulin resistance and the metabolic syndrome, and by 19 years, 9% do, according to adult standards. The percentage is higher (9% at age 15) if one uses the more lenient standards for children.

Insulin resistance in childhood predicts resistance as an adult, said Dr. Sinaiko, a professor of pediatrics at the University of Minnesota, Minneapolis. Weight makes a difference, worsening cardiovascular risk factors, but weight and insulin resistance seem independent of each other. An increase in body mass index seems worst.

Insulin resistance appears differently in children than in adults. In pediatrics, it is hard to judge resistance by fasting insulin, because the values vary greatly and children experience a reduction in insulin sensitivity as they progress though the Tanner stages. The sensitivity normalizes after puberty. Insulin sensitivity falls in males after puberty during their teens, but not in females. Males also have greater increases in blood pressure and triglycerides and a dip in HDL cholesterol, showing they accumulate heart disease risks at a young age.

LAS VEGAS — Adolescents can be insulin resistant and have the risk factors of early heart disease, Dr. Alan Sinaiko said at the Fourth World Congress on the Insulin Resistance Syndrome.

Dr. Sinaiko has followed a cohort of about 400 Minnesota children from age 11 years to 23 years. In the study, he used an insulin clamp technique in which glucose and insulin are infused together to measure the glucose's uptake by muscle.

He has found that at 13 years, 2% of the patients have insulin resistance and the metabolic syndrome, and by 19 years, 9% do, according to adult standards. The percentage is higher (9% at age 15) if one uses the more lenient standards for children.

Insulin resistance in childhood predicts resistance as an adult, said Dr. Sinaiko, a professor of pediatrics at the University of Minnesota, Minneapolis. Weight makes a difference, worsening cardiovascular risk factors, but weight and insulin resistance seem independent of each other. An increase in body mass index seems worst.

Insulin resistance appears differently in children than in adults. In pediatrics, it is hard to judge resistance by fasting insulin, because the values vary greatly and children experience a reduction in insulin sensitivity as they progress though the Tanner stages. The sensitivity normalizes after puberty. Insulin sensitivity falls in males after puberty during their teens, but not in females. Males also have greater increases in blood pressure and triglycerides and a dip in HDL cholesterol, showing they accumulate heart disease risks at a young age.

LAS VEGAS — Adolescents can be insulin resistant and have the risk factors of early heart disease, Dr. Alan Sinaiko said at the Fourth World Congress on the Insulin Resistance Syndrome.

Dr. Sinaiko has followed a cohort of about 400 Minnesota children from age 11 years to 23 years. In the study, he used an insulin clamp technique in which glucose and insulin are infused together to measure the glucose's uptake by muscle.

He has found that at 13 years, 2% of the patients have insulin resistance and the metabolic syndrome, and by 19 years, 9% do, according to adult standards. The percentage is higher (9% at age 15) if one uses the more lenient standards for children.

Insulin resistance in childhood predicts resistance as an adult, said Dr. Sinaiko, a professor of pediatrics at the University of Minnesota, Minneapolis. Weight makes a difference, worsening cardiovascular risk factors, but weight and insulin resistance seem independent of each other. An increase in body mass index seems worst.

Insulin resistance appears differently in children than in adults. In pediatrics, it is hard to judge resistance by fasting insulin, because the values vary greatly and children experience a reduction in insulin sensitivity as they progress though the Tanner stages. The sensitivity normalizes after puberty. Insulin sensitivity falls in males after puberty during their teens, but not in females. Males also have greater increases in blood pressure and triglycerides and a dip in HDL cholesterol, showing they accumulate heart disease risks at a young age.

LAS VEGAS — Dieting and losing weight will help patients with insulin resistance, but it should be a moderately low-carbohydrate diet, Dr. Tracey McLaughlin emphasized at the Fourth World Congress on the Insulin Resistance Syndrome.

That recommendation runs counter to those made by the American Heart Association and the American Diabetes Association, which recommend a diet that has less than 30% of calories consumed from fat. But the evidence bears it out, said Dr. McLaughlin, of the division of endocrinology at Stanford (Calif.) University. A diet a little lower in carbohydrates than in fat can result in equal weight loss, a better lipid profile, and lower insulin levels.

The lipid profile of someone with insulin resistance tends to be one with high triglycerides and low HDL cholesterol. In fact, a ratio of those two parameters is a good easy screen for insulin resistance—it should be 3.0 (or 1.8 in SI units), according to one study (Ann. Intern. Med. 2003;139:802–9). A diet higher in fat will improve both those parameters, she said. And a number of studies have suggested that a high carbohydrate diet for persons with insulin resistance can worsen those parameters.

Dr. McLaughlin performed one of the recent studies. She and her colleagues randomly assigned 57 obese, insulin-resistant individuals to either a diet of 60% carbohydrate, 25% fat, and 15% protein, or one of 40% carbohydrate, 45% fat, and 15% protein, for 16 weeks (Am. J. Clin. Nutr. 2006;84:813–21). One aim of the study was to use diets that were not too extreme in their restrictions on carbohydrate or fat because such diets, often effective in the short run, are difficult for individuals to sustain.

Average weight loss over the 16 weeks was slightly better in the higher fat diet, though not significantly so (6.9 kg vs. 5.7 kg). But the study found daylong insulin levels dropped an average 32% in those on the higher fat diet, compared with 13% in those on the higher carbohydrate diet. Daylong triacylglycerol dropped an average 25% with the higher fat diet, compared with 7% with the higher carbohydrate diet.

LDL cholesterol went up 12% in the subjects on the higher fat diet, and was unchanged in the subjects on the higher carbohydrate diet. However, the ratio of total cholesterol to HDL did not change in the subjects on the higher fat diet, which suggests that the lipid profile was not harmed by this increase in LDL, Dr. McLaughlin said. The study also found the more weight lost, the greater the improvement in insulin sensitivity.

LAS VEGAS — Dieting and losing weight will help patients with insulin resistance, but it should be a moderately low-carbohydrate diet, Dr. Tracey McLaughlin emphasized at the Fourth World Congress on the Insulin Resistance Syndrome.

That recommendation runs counter to those made by the American Heart Association and the American Diabetes Association, which recommend a diet that has less than 30% of calories consumed from fat. But the evidence bears it out, said Dr. McLaughlin, of the division of endocrinology at Stanford (Calif.) University. A diet a little lower in carbohydrates than in fat can result in equal weight loss, a better lipid profile, and lower insulin levels.

The lipid profile of someone with insulin resistance tends to be one with high triglycerides and low HDL cholesterol. In fact, a ratio of those two parameters is a good easy screen for insulin resistance—it should be 3.0 (or 1.8 in SI units), according to one study (Ann. Intern. Med. 2003;139:802–9). A diet higher in fat will improve both those parameters, she said. And a number of studies have suggested that a high carbohydrate diet for persons with insulin resistance can worsen those parameters.

Dr. McLaughlin performed one of the recent studies. She and her colleagues randomly assigned 57 obese, insulin-resistant individuals to either a diet of 60% carbohydrate, 25% fat, and 15% protein, or one of 40% carbohydrate, 45% fat, and 15% protein, for 16 weeks (Am. J. Clin. Nutr. 2006;84:813–21). One aim of the study was to use diets that were not too extreme in their restrictions on carbohydrate or fat because such diets, often effective in the short run, are difficult for individuals to sustain.

Average weight loss over the 16 weeks was slightly better in the higher fat diet, though not significantly so (6.9 kg vs. 5.7 kg). But the study found daylong insulin levels dropped an average 32% in those on the higher fat diet, compared with 13% in those on the higher carbohydrate diet. Daylong triacylglycerol dropped an average 25% with the higher fat diet, compared with 7% with the higher carbohydrate diet.

LDL cholesterol went up 12% in the subjects on the higher fat diet, and was unchanged in the subjects on the higher carbohydrate diet. However, the ratio of total cholesterol to HDL did not change in the subjects on the higher fat diet, which suggests that the lipid profile was not harmed by this increase in LDL, Dr. McLaughlin said. The study also found the more weight lost, the greater the improvement in insulin sensitivity.

LAS VEGAS — Dieting and losing weight will help patients with insulin resistance, but it should be a moderately low-carbohydrate diet, Dr. Tracey McLaughlin emphasized at the Fourth World Congress on the Insulin Resistance Syndrome.

That recommendation runs counter to those made by the American Heart Association and the American Diabetes Association, which recommend a diet that has less than 30% of calories consumed from fat. But the evidence bears it out, said Dr. McLaughlin, of the division of endocrinology at Stanford (Calif.) University. A diet a little lower in carbohydrates than in fat can result in equal weight loss, a better lipid profile, and lower insulin levels.

The lipid profile of someone with insulin resistance tends to be one with high triglycerides and low HDL cholesterol. In fact, a ratio of those two parameters is a good easy screen for insulin resistance—it should be 3.0 (or 1.8 in SI units), according to one study (Ann. Intern. Med. 2003;139:802–9). A diet higher in fat will improve both those parameters, she said. And a number of studies have suggested that a high carbohydrate diet for persons with insulin resistance can worsen those parameters.

Dr. McLaughlin performed one of the recent studies. She and her colleagues randomly assigned 57 obese, insulin-resistant individuals to either a diet of 60% carbohydrate, 25% fat, and 15% protein, or one of 40% carbohydrate, 45% fat, and 15% protein, for 16 weeks (Am. J. Clin. Nutr. 2006;84:813–21). One aim of the study was to use diets that were not too extreme in their restrictions on carbohydrate or fat because such diets, often effective in the short run, are difficult for individuals to sustain.

Average weight loss over the 16 weeks was slightly better in the higher fat diet, though not significantly so (6.9 kg vs. 5.7 kg). But the study found daylong insulin levels dropped an average 32% in those on the higher fat diet, compared with 13% in those on the higher carbohydrate diet. Daylong triacylglycerol dropped an average 25% with the higher fat diet, compared with 7% with the higher carbohydrate diet.

LDL cholesterol went up 12% in the subjects on the higher fat diet, and was unchanged in the subjects on the higher carbohydrate diet. However, the ratio of total cholesterol to HDL did not change in the subjects on the higher fat diet, which suggests that the lipid profile was not harmed by this increase in LDL, Dr. McLaughlin said. The study also found the more weight lost, the greater the improvement in insulin sensitivity.

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of screened pregnant women at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of 353 women screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden. Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. They found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of screened pregnant women at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of 353 women screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden. Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. They found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SAN FRANCISCO — Staphylococcus aureus was carried in the vaginal-rectal area in 11% of screened pregnant women at a Camden, N.J., hospital, according to a study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The investigators took vaginal-rectal specimens collected from pregnant women being screened for group B streptococcus from June 2005 until March 2006 and cultured them for S. aureus.

Of 353 women screened, 39 (11%) were colonized with staphylococcus; 7 of the 39 (2%) were methicillin-resistant strains, said Dr. Henry Fraimow of Cooper University Hospital in Camden. Five of the seven MRSA isolates contained the Panton-Valentine leukocidin virulence gene.

All seven were susceptible to clindamycin and levofloxacin.

The study could help to explain why in Camden generally half of S. aureus abscesses occur below the waist, and why Camden nurseries have had outbreaks of neonatal S. aureus infections, Dr. Fraimow said at the conference, which was sponsored by the American Society for Microbiology.

“This is higher than reported rates of vaginal colonization with staph aureus, most [studies] of which were done in the 1980s during some of the toxic shock syndrome outbreaks,” he said. “There hasn't been a lot of good recent data.”

One other recent study that looked at vaginal colonization found a higher rate of carriage, 18%, but a lower rate of methicillin resistance, 0.5%, he added.

Dr. Fraimow and his colleagues also found much more carriage in the summer months than during the rest of the year. They found that 14% of the specimens collected between June and September were colonized, compared with only 7% of those collected between October and March.

“We also conclude that all reservoirs for this organism must be considered when looking at strategies such as decolonization to prevent recurrent infections,” Dr. Fraimow said.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

E-prescribing eliminates physician handwriting, which is a common source of error, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow e-prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said at the conference.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If physicians did not take to the technology right away, they never did, she added. The study was sponsored by a grant from the Ohio Medical Quality Foundation.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

E-prescribing eliminates physician handwriting, which is a common source of error, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow e-prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said at the conference.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If physicians did not take to the technology right away, they never did, she added. The study was sponsored by a grant from the Ohio Medical Quality Foundation.

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

E-prescribing eliminates physician handwriting, which is a common source of error, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow e-prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

“Until all these systems are integrated, we are not going to have widespread adoption of this,” Dr. Simpson said at the conference.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. If physicians did not take to the technology right away, they never did, she added. The study was sponsored by a grant from the Ohio Medical Quality Foundation.

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates among those serotypes of the bacteria included in the vaccine, there is already some evidence that “replacement” serotypes are appearing.

And among those replacement serotypes, penicillin resistance may be on the increase, Dr. Sheldon Kaplan said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

This is a situation that deserves watching, said Dr. Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Two serotypes that seem to be emerging as the more common ones contained in the vaccine decline are serotypes 15 and 33, Dr. Kaplan reported.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean five cases of invasive disease caused by serotype 15 in 1994–2000.

In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period.

In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected by the project have been found to have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time.

That suggests the different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates appear to be the same clone.

Serotype 19A also appears to be on the increase, and 19A appears specifically to be a serotype that is replacing 19F, a serotype in the vaccine.

According to one report, the annual incidence rate of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95).

There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan commented. “CDC is actually reporting increases in these serotypes as well.”

Moreover, as is well known, a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine.

That was true, but it may not be anymore, Dr. Kaplan said. The rate of penicillin nonsusceptible infections may actually be increasing again.

Although the number of cases caused by serotypes in the vaccine has declined precipitously, the number of cases caused by serotypes not in the vaccine has increased, and those serotypes appear to be acquiring more resistance.

The incidence rate of invasive disease caused by penicillin nonsusceptible pneumococci among children younger than 2 years has increased overall since 2002. And, considering just isolates not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

In addition, a group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be those not in the vaccine—serotypes 1, 3, and 19A.

The Salt Lake City group reported that for the 4 years prior to the vaccine, their medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after the vaccine's introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years prior to the vaccine, but 32% of the cases after the vaccine (Pediatr. Infect. Dis. J. 2006;25:250–4).

Serotype 1 was the most common serotype associated with the empyema both prior to the vaccine (46%) and afterward (34%). Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are clearly seeing more cases, with more nonvaccine types,” Dr. Kaplan said.

He noted that the vaccine may have to be updated with at least some of these emerging strains.

“We do see these emerging serotypes. How we will address that down the road will have to be seen,” Dr. Kaplan added. “It is an expensive vaccine.”

'We're not the only people who are seeing this. CDC is actually reporting increases.' DR. KAPLAN

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates among those serotypes of the bacteria included in the vaccine, there is already some evidence that “replacement” serotypes are appearing.

And among those replacement serotypes, penicillin resistance may be on the increase, Dr. Sheldon Kaplan said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

This is a situation that deserves watching, said Dr. Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Two serotypes that seem to be emerging as the more common ones contained in the vaccine decline are serotypes 15 and 33, Dr. Kaplan reported.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean five cases of invasive disease caused by serotype 15 in 1994–2000.

In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period.

In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected by the project have been found to have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time.

That suggests the different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates appear to be the same clone.

Serotype 19A also appears to be on the increase, and 19A appears specifically to be a serotype that is replacing 19F, a serotype in the vaccine.

According to one report, the annual incidence rate of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95).

There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan commented. “CDC is actually reporting increases in these serotypes as well.”

Moreover, as is well known, a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine.

That was true, but it may not be anymore, Dr. Kaplan said. The rate of penicillin nonsusceptible infections may actually be increasing again.

Although the number of cases caused by serotypes in the vaccine has declined precipitously, the number of cases caused by serotypes not in the vaccine has increased, and those serotypes appear to be acquiring more resistance.

The incidence rate of invasive disease caused by penicillin nonsusceptible pneumococci among children younger than 2 years has increased overall since 2002. And, considering just isolates not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

In addition, a group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be those not in the vaccine—serotypes 1, 3, and 19A.

The Salt Lake City group reported that for the 4 years prior to the vaccine, their medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after the vaccine's introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years prior to the vaccine, but 32% of the cases after the vaccine (Pediatr. Infect. Dis. J. 2006;25:250–4).

Serotype 1 was the most common serotype associated with the empyema both prior to the vaccine (46%) and afterward (34%). Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are clearly seeing more cases, with more nonvaccine types,” Dr. Kaplan said.

He noted that the vaccine may have to be updated with at least some of these emerging strains.

“We do see these emerging serotypes. How we will address that down the road will have to be seen,” Dr. Kaplan added. “It is an expensive vaccine.”

'We're not the only people who are seeing this. CDC is actually reporting increases.' DR. KAPLAN

ASPEN, COLO. — Although the conjugate heptavalent pneumococcal vaccine has decreased penicillin resistance rates among those serotypes of the bacteria included in the vaccine, there is already some evidence that “replacement” serotypes are appearing.

And among those replacement serotypes, penicillin resistance may be on the increase, Dr. Sheldon Kaplan said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

This is a situation that deserves watching, said Dr. Kaplan, chief of the infectious disease service at Texas Children's Hospital, Houston.

Two serotypes that seem to be emerging as the more common ones contained in the vaccine decline are serotypes 15 and 33, Dr. Kaplan reported.

According to a pneumococci surveillance project of eight children's hospitals, there was a mean five cases of invasive disease caused by serotype 15 in 1994–2000.

In 2002, there were 14 cases.

For serotype 33, the mean number of cases was less than one during the 1994–2000 period.

In 2002, there were nine cases, said Dr. Kaplan, whose hospital is part of the surveillance project (Pediatrics 2004;113:443–9).

Specific isolates of serotype 15 collected by the project have been found to have the same blot pattern on a pulse-field electrophoresis gel about 60% of the time.

That suggests the different isolates taken from various children are the same clone of the bacteria.

About 80% of the serotype 33 isolates appear to be the same clone.

Serotype 19A also appears to be on the increase, and 19A appears specifically to be a serotype that is replacing 19F, a serotype in the vaccine.

According to one report, the annual incidence rate of invasive disease in children less than 2 years of age caused by serotype 19A has increased from 1 case per 100,000 population in 2001 to more than 6 cases per 100,000 in 2004 (J. Infect. Dis. 2005;192:1988–95).

There also has been a 2.5-fold increase in cases in children older than 5 years of age.

“We're not the only people who are seeing this,” Dr. Kaplan commented. “CDC is actually reporting increases in these serotypes as well.”

Moreover, as is well known, a number of surveys have suggested there has been a decrease in antibiotic resistance since the introduction of the conjugate vaccine.

That was true, but it may not be anymore, Dr. Kaplan said. The rate of penicillin nonsusceptible infections may actually be increasing again.

Although the number of cases caused by serotypes in the vaccine has declined precipitously, the number of cases caused by serotypes not in the vaccine has increased, and those serotypes appear to be acquiring more resistance.

The incidence rate of invasive disease caused by penicillin nonsusceptible pneumococci among children younger than 2 years has increased overall since 2002. And, considering just isolates not in the vaccine, it has increased from 51% in 1999 to 68% in 2004, Dr. Kaplan said.

“It looks like these nonvaccine serotypes are more likely to be penicillin nonsusceptible today than they were 5 years ago,” he said.

In addition, a group from Salt Lake City has seen an increase in pediatric cases of pneumococcal pneumonia complicated with empyema since the introduction of the vaccine. Moreover, the serotypes associated with these cases tend to be those not in the vaccine—serotypes 1, 3, and 19A.

The Salt Lake City group reported that for the 4 years prior to the vaccine, their medical center saw an average of 38 cases of empyema, compared with an average of 72 cases in the first 4 years after the vaccine's introduction.

Also, pneumococcal parapneumonic empyema represented only 17% of the cases of identified invasive pneumococcal disease seen at that center in the years prior to the vaccine, but 32% of the cases after the vaccine (Pediatr. Infect. Dis. J. 2006;25:250–4).

Serotype 1 was the most common serotype associated with the empyema both prior to the vaccine (46%) and afterward (34%). Serotypes 3 and 19A became common after the vaccine (20% and 14%, respectively).

“I can't explain this, but they are clearly seeing more cases, with more nonvaccine types,” Dr. Kaplan said.

He noted that the vaccine may have to be updated with at least some of these emerging strains.

“We do see these emerging serotypes. How we will address that down the road will have to be seen,” Dr. Kaplan added. “It is an expensive vaccine.”

'We're not the only people who are seeing this. CDC is actually reporting increases.' DR. KAPLAN

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians.

What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

If doctors do not take to electronic prescribing technology right away, they never do. DR. SIMPSON

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians.

What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

If doctors do not take to electronic prescribing technology right away, they never do. DR. SIMPSON

SEATTLE — Electronic prescribing may be a way to significantly reduce medication errors, according to a study that reviewed records involving 749 private-practice patients and more than 1,000 prescriptions.

The study found an error rate of 3.9% when physicians used electronic prescribing, Martha Simpson, D.O., said at a conference on rural health sponsored by the WONCA, the World Organization of Family Doctors. That compares with medication error rates from hospital studies that range from 3% to 6%, and error rates from studies in the community that have reached as high as 10%.

“This is significantly lower than other reported rates have been,” said Dr. Simpson of the department of family medicine at Ohio University College of Osteopathic Medicine, Athens.

The study involved four group practices in Ohio, which were given equipment (Rcopia, DrFirst Inc., Rockville, Md.) and training for electronic prescribing to five local pharmacies. The prescriptions were written over a 14-month period. Medical records were then reviewed by a pharmacist, and the patients were telephoned 3 months after their final prescription for an interview to find out if they if they had any adverse events or problems.

The study's results are not particularly surprising, because one of the most common reasons for prescription error is physician handwriting, Dr. Simpson said.

However, once electronic prescribing becomes more common, it will bring with it errors and challenges that are unique to the process, she said. For example, physicians can easily point their cursors to the wrong box and click, thereby inadvertently canceling a prescription or ordering the wrong one. And, of course, computers sometimes go down temporarily.

Some states do not allow electronic prescribing, and most do not allow prescribing of scheduled drugs. Moreover, electronic prescribing technologies are not automatically entered into electronic medical records.

Another advantage of electronic prescribing will be that pharmacists will know when patients fail to pick up their prescribed medications, and will be able to notify the doctor, she noted.

Dr. Simpson said her study also looked at how the physicians accepted and used the technology they were given. Contrary to her expectations, there were no strong, enlightening patterns, she said.

Of the nine physicians and one nurse practitioner in the practices, four adopted it immediately, three used it about half of the time, and three did not use it at all. Some of those who used the system were the older physicians, and some of those who did not use the system were the younger physicians.

What they did see, however, was that if doctors did not take to the technology right away, they never did, she added.

The study was sponsored by a grant from the Ohio Medical Quality Foundation.

If doctors do not take to electronic prescribing technology right away, they never do. DR. SIMPSON