Robert Finn

The Centers for Disease Control and Prevention has recommended that providers temporarily defer administration of the routine Haemophilus influenzae type b (Hib) vaccine booster dose at age 12–15 months except to children in specific groups at high risk.

These groups include children with asplenia, sickle cell disease, HIV infection and certain other immunodeficiency syndromes, and malignant neoplasms.

American Indian/Alaska Native children also are at special risk and should continue to receive the booster (MMWR Dispatch 2007;56:1–2).

The CDC made its decision in consultation with its Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Merck & Company announced a voluntary recall last month of 13 lots of Hib vaccine because of potential contamination at its Pennsylvania manufacturing plant.

Those lots include about 1 million doses of vaccine distributed beginning in April 2007 that are currently in doctors' offices.

In routine testing, the company identified the potential for microorganisms to survive a sterilization step during the manufacturing process.

No actual contamination has been found, and the Centers for Disease Control and Prevention and the Food and Drug Administration have seen no evidence of any adverse events.

The most likely type of adverse event would involve bumps or abscesses at the injection site appearing about 1 week following the immunization.

“This is not an immediate health threat,” Dr. Julie L. Gerberding, CDC director, said at a news conference.

“But we do need to do everything we can to restore effective vaccine coverage in the long run, because children are at risk for Haemophilus influenzae disease if we don't solve this problem over the next several months,” she said.

Two vaccine products are affected. Merck is recalling 11 lots of PedvaxHIB and 2 lots of COMVAX. COMVAX combines the Hib vaccine with a vaccine for hepatitis B.

The lot numbers that are being recalled can be located at www.cdc.gov/vaccines/recs/recalls/hib-recall-faqs-12-12-07.htm

Dr. Gerberding emphasized that the potency of the vaccine in the recalled lots was unaffected, so children who already have received doses from those lots will not need to be reimmunized.

Merck supplies about 50% of the 14 million doses of Hib vaccine used annually in the United States, with Sanofi Aventis providing the other 50%.

It's unknown how soon Merck will be able to resume full production, but Dr. Anne Schuchat, director of the CDC National Center for Immunization and Respiratory Diseases, said that she anticipates supply problems.

“This is not a health threat, but it's certainly an inconvenience,” Dr. Schuchat said.

“It certainly poses some challenges for parents and for doctors. We are working closely together with Merck and with Sanofi. … We're also working closely with public health and providers to decrease the interruptions in practice that might occur because of this recall.”

Prior to the introduction of the vaccine, there were 20,000 cases of H. influenzae disease in the United States annually, 1,000 of which ended in death. In recent years, however, there have been fewer than 100 documented cases annually.

“I think we have a nice cushion of protection in this country, because 94% of toddlers are up to date on their Hib vaccine, and there's very little of this bacteria spreading around in our community,” Dr. Schuchat said.

The CDC and the FDA have initiated discussions with Sanofi-Aventis to determine whether that company might be able to increase its supply of vaccine.

The CDC maintains a stockpile of approximately 750,000 doses of PediavaxHIB, and will be releasing some of those doses, but this will not fully address the shortage.

The CDC will be releasing these stockpiled doses to the private sector through Merck and to the public sector through the Vaccines for Children (VFC) program.

The Centers for Disease Control and Prevention has recommended that providers temporarily defer administration of the routine Haemophilus influenzae type b (Hib) vaccine booster dose at age 12–15 months except to children in specific groups at high risk.

These groups include children with asplenia, sickle cell disease, HIV infection and certain other immunodeficiency syndromes, and malignant neoplasms.

American Indian/Alaska Native children also are at special risk and should continue to receive the booster (MMWR Dispatch 2007;56:1–2).

The CDC made its decision in consultation with its Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Merck & Company announced a voluntary recall last month of 13 lots of Hib vaccine because of potential contamination at its Pennsylvania manufacturing plant.

Those lots include about 1 million doses of vaccine distributed beginning in April 2007 that are currently in doctors' offices.

In routine testing, the company identified the potential for microorganisms to survive a sterilization step during the manufacturing process.

No actual contamination has been found, and the Centers for Disease Control and Prevention and the Food and Drug Administration have seen no evidence of any adverse events.

The most likely type of adverse event would involve bumps or abscesses at the injection site appearing about 1 week following the immunization.

“This is not an immediate health threat,” Dr. Julie L. Gerberding, CDC director, said at a news conference.

“But we do need to do everything we can to restore effective vaccine coverage in the long run, because children are at risk for Haemophilus influenzae disease if we don't solve this problem over the next several months,” she said.

Two vaccine products are affected. Merck is recalling 11 lots of PedvaxHIB and 2 lots of COMVAX. COMVAX combines the Hib vaccine with a vaccine for hepatitis B.

The lot numbers that are being recalled can be located at www.cdc.gov/vaccines/recs/recalls/hib-recall-faqs-12-12-07.htm

Dr. Gerberding emphasized that the potency of the vaccine in the recalled lots was unaffected, so children who already have received doses from those lots will not need to be reimmunized.

Merck supplies about 50% of the 14 million doses of Hib vaccine used annually in the United States, with Sanofi Aventis providing the other 50%.

It's unknown how soon Merck will be able to resume full production, but Dr. Anne Schuchat, director of the CDC National Center for Immunization and Respiratory Diseases, said that she anticipates supply problems.

“This is not a health threat, but it's certainly an inconvenience,” Dr. Schuchat said.

“It certainly poses some challenges for parents and for doctors. We are working closely together with Merck and with Sanofi. … We're also working closely with public health and providers to decrease the interruptions in practice that might occur because of this recall.”

Prior to the introduction of the vaccine, there were 20,000 cases of H. influenzae disease in the United States annually, 1,000 of which ended in death. In recent years, however, there have been fewer than 100 documented cases annually.

“I think we have a nice cushion of protection in this country, because 94% of toddlers are up to date on their Hib vaccine, and there's very little of this bacteria spreading around in our community,” Dr. Schuchat said.

The CDC and the FDA have initiated discussions with Sanofi-Aventis to determine whether that company might be able to increase its supply of vaccine.

The CDC maintains a stockpile of approximately 750,000 doses of PediavaxHIB, and will be releasing some of those doses, but this will not fully address the shortage.

The CDC will be releasing these stockpiled doses to the private sector through Merck and to the public sector through the Vaccines for Children (VFC) program.

The Centers for Disease Control and Prevention has recommended that providers temporarily defer administration of the routine Haemophilus influenzae type b (Hib) vaccine booster dose at age 12–15 months except to children in specific groups at high risk.

These groups include children with asplenia, sickle cell disease, HIV infection and certain other immunodeficiency syndromes, and malignant neoplasms.

American Indian/Alaska Native children also are at special risk and should continue to receive the booster (MMWR Dispatch 2007;56:1–2).

The CDC made its decision in consultation with its Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics.

Merck & Company announced a voluntary recall last month of 13 lots of Hib vaccine because of potential contamination at its Pennsylvania manufacturing plant.

Those lots include about 1 million doses of vaccine distributed beginning in April 2007 that are currently in doctors' offices.

In routine testing, the company identified the potential for microorganisms to survive a sterilization step during the manufacturing process.

No actual contamination has been found, and the Centers for Disease Control and Prevention and the Food and Drug Administration have seen no evidence of any adverse events.

The most likely type of adverse event would involve bumps or abscesses at the injection site appearing about 1 week following the immunization.

“This is not an immediate health threat,” Dr. Julie L. Gerberding, CDC director, said at a news conference.

“But we do need to do everything we can to restore effective vaccine coverage in the long run, because children are at risk for Haemophilus influenzae disease if we don't solve this problem over the next several months,” she said.

Two vaccine products are affected. Merck is recalling 11 lots of PedvaxHIB and 2 lots of COMVAX. COMVAX combines the Hib vaccine with a vaccine for hepatitis B.

The lot numbers that are being recalled can be located at www.cdc.gov/vaccines/recs/recalls/hib-recall-faqs-12-12-07.htm

Dr. Gerberding emphasized that the potency of the vaccine in the recalled lots was unaffected, so children who already have received doses from those lots will not need to be reimmunized.

Merck supplies about 50% of the 14 million doses of Hib vaccine used annually in the United States, with Sanofi Aventis providing the other 50%.

It's unknown how soon Merck will be able to resume full production, but Dr. Anne Schuchat, director of the CDC National Center for Immunization and Respiratory Diseases, said that she anticipates supply problems.

“This is not a health threat, but it's certainly an inconvenience,” Dr. Schuchat said.

“It certainly poses some challenges for parents and for doctors. We are working closely together with Merck and with Sanofi. … We're also working closely with public health and providers to decrease the interruptions in practice that might occur because of this recall.”

Prior to the introduction of the vaccine, there were 20,000 cases of H. influenzae disease in the United States annually, 1,000 of which ended in death. In recent years, however, there have been fewer than 100 documented cases annually.

“I think we have a nice cushion of protection in this country, because 94% of toddlers are up to date on their Hib vaccine, and there's very little of this bacteria spreading around in our community,” Dr. Schuchat said.

The CDC and the FDA have initiated discussions with Sanofi-Aventis to determine whether that company might be able to increase its supply of vaccine.

The CDC maintains a stockpile of approximately 750,000 doses of PediavaxHIB, and will be releasing some of those doses, but this will not fully address the shortage.

The CDC will be releasing these stockpiled doses to the private sector through Merck and to the public sector through the Vaccines for Children (VFC) program.

The pace of research in cardiology is proceeding so rapidly that important changes have been issued to two guidelines initially promulgated in the not-so-distant past.

The “focused updates” involve the treatment of ST-elevation myocardial infarction (STEMI) and the technique of percutaneous coronary intervention (PCI). While the updates maintained many of the recommendations in the full guidelines, issued in 2004 for STEMI and 2005 for PCI, they each included significant recommendations for practice changes. (See boxes.)

The STEMI updates, for example, reiterate that the overarching goal of treatment remains rapid reperfusion. But they state that, with the exception of aspirin, NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately. And β-blockers should not be administered to patients in certain high-risk groups.

The PCI updates emphasized the importance of ensuring that patients will be able to comply with dual antiplatelet therapy for a full year after receiving a drug-eluting stent. Bare-metal stents should be substituted when that compliance can't be ensured. This dual antiplatelet therapy is so important that physicians should take into account the possibility that the patient may later need medical procedures that would require that antiplatelet therapy be discontinued. Bare-metal stents or balloon angioplasty with provisional stent implantation should be considered for those patients.

The STEMI update was a joint effort of the American College of Cardiology and the American Heart Association and appeared in Circulation and the Journal of the American College of Cardiology. The PCI update was a joint effort of the ACC, the AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) and appeared in Circulation, the Journal of the American College of Cardiology, and Catheterization and Cardiovascular Interventions. The updates are available online at www.americanheart.orgwww.acc.org

The focused update strategy was developed by the ACC/AHA Task Force on Practice Guidelines as a way to speed up the often years-long process of developing comprehensive new guidelines on the basis of full literature reviews. Twice a year or more experts are polled, and if there is a consensus that data from late-breaking clinical trials warrant an update, one can be prepared relatively quickly.

According to Dr. Elliott M. Antman, cochair of the STEMI update committee and chair of the 2004 writing committee, new research suggests several important changes in the management of this most critical type of heart attack. Among at least 15 guideline modifications or additions, he highlighted several in an interview.

“We indicate that physicians should not routinely administer intravenous β-blockers acutely to patients with heart failure or shock, or who are at risk for heart failure or shock,” said Dr. Antman of Harvard Medical School, Boston. “There is information about facilitated PCI indicating that a strategy of a full-dose fibrinolytic followed by immediate routine PCI is not recommended anymore.”

On the other hand, “It's not unreasonable to use a strategy of preparatory pharmacological regimen other than a full-dose fibrinolytic and routine immediate PCI in certain situations where the patient is at risk, PCI cannot be performed within 90 minutes, and bleeding risk is low.”

Dr. Antman said that he has not heard any significant criticisms of the new STEMI guidelines, and that most will not be difficult to implement. “Physicians understand the importance of responding to evidence,” he said. “These are strategies that are a matter of just organizing systems of care for patients with STEMI. We would hope that physicians would meet as a team in their local hospitals and local systems and consider how they are going to approach the STEMI patients in the future with this new information in mind.”

The recommendation for prehospital 12-lead ECG may be one of the most challenging to implement, since many emergency medical technicians are not trained in interpreting ECGs, and many ambulance systems don't have prehospital ECG capability, he added.

In the PCI update, “We are reaching a point where we really have to look across time and also understand the impact of adjunctive therapies, and how we combine all of this I think is a real challenge,” said Dr. Sidney C. Smith Jr., cochair of the focused update writing committee, in an interview posted on the ACC's Cardiosource Web site (www.cardiosource.com/guidelinefocus

“My personal opinion is that comprehensive therapy really has a place in the management of patients,” continued Dr. Smith of the University of North Carolina, Chapel Hill. “I still think that the high-risk patients, the patients that are symptomatic, benefit from revascularization, but we definitely are getting to a point where I personally will be urging and being certain that my patients not only have revascularization when they need it, but that they adhere to the comprehensive medical therapies that are so important in terms of reducing future events.”

Each of the focused updates includes detailed information about potential conflicts of interest among members of the writing committees. Individual members who appeared to have a conflict recused themselves from voting on certain sections.

Highlights of the Percutaneous Coronary Intervention Updates

1. After implantation of a drug-eluting stent (DES), dual antiplatelet therapy comprising clopidogrel and aspirin is required for at least 1 year or longer.

2. If the patient is likely to face additional surgery requiring interruption of dual antiplatelet therapy, a bare-metal stent (BMS) or balloon angioplasty with provisional stent implantation should be considered instead of a DES.

3. Between 24 hours and 28 days after a heart attack, PCI is not recommended in patients with one- or two-vessel disease and a totally occluded coronary artery if they are not hemodynamically and electrically stable and have no ongoing or easily provoked chest pain.

4. On the other hand, physicians might consider PCI for those patients or patients who respond favorably to initial fibrinolysis treatment if they don't continue to do well on drug therapy alone.

5. The balance of the evidence supports an early invasive strategy for PCI in patients with unstable angina or non-STEMI who are at moderate and higher risk.

6. In patients with STEMI, facilitated PCI with regimens other than full-dose fibrinolytic therapy may be considered in high-risk patients if PCI is not immediately available within 90 minutes and if the risk of bleeding is low.

7. In patients with STEMI, a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful.

8. A strategy of coronary angiography with the intent to perform rescue PCI is reasonable for those patients in whom fibrinolytic therapy has failed.

9. The update includes specific guidelines for ancillary therapy in patients undergoing PCI for STEMI who received prior treatment with unfractionated heparin, enoxaparin, or fondaparinux.

10. Serum LDL cholesterol should be maintained below 100 mg/dL after PCI, and further reduction to less than 70 mg/dL is reasonable.

Source: J. Am. Coll. Cardiol. 2008;51:172–209.

Highlights of the ST-Elevation Myocardial Infarction Updates

1. As in the 2004 guidelines, the overarching goal for treatment of ST elevation myocardial infarction is that reperfusion therapy should begin within 2 hours, and ideally within 1 hour of the event.

2. The emphasis on percutaneous coronary intervention should not obscure the importance of fibrinolytic therapy.

3. With the exception of aspirin, all NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately at the time of STEMI.

4. Early intravenous β-blocker therapy should not be given to STEMI patients who have signs of heart failure or other relative contraindications to β-blockade.

5. Long-term oral β-blockers should be used for secondary prevention in patients at high risk once they have stabilized.

6. The strategy of facilitated PCI (planned PCI immediately after administration of therapy to improve coronary patency) may be considered in subgroups of patients with a large MI or hemodynamic or electrical instability who are at low risk of bleeding.

7. Rescue PCI is suitable for patients who have received fibrinolytic therapy and who have cardiogenic shock, ventricular arrhythmia, or severe heart failure and/or pulmonary edema.

8. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for at least 48 hours and preferably for the duration of the initial hospital stay up to 8 days.

9. Clopidogrel should be added to aspirin in patients with STEMI whether or not they receive reperfusion therapy, and the clopidogrel should be continued for at least 14 days.

10. Emergency medical systems that provide advanced life support should increase the use of prehospital 12-lead electrocardiography.

Sources: J. Am. Coll. Cardiol. 2008;51:210–47

The pace of research in cardiology is proceeding so rapidly that important changes have been issued to two guidelines initially promulgated in the not-so-distant past.

The “focused updates” involve the treatment of ST-elevation myocardial infarction (STEMI) and the technique of percutaneous coronary intervention (PCI). While the updates maintained many of the recommendations in the full guidelines, issued in 2004 for STEMI and 2005 for PCI, they each included significant recommendations for practice changes. (See boxes.)

The STEMI updates, for example, reiterate that the overarching goal of treatment remains rapid reperfusion. But they state that, with the exception of aspirin, NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately. And β-blockers should not be administered to patients in certain high-risk groups.

The PCI updates emphasized the importance of ensuring that patients will be able to comply with dual antiplatelet therapy for a full year after receiving a drug-eluting stent. Bare-metal stents should be substituted when that compliance can't be ensured. This dual antiplatelet therapy is so important that physicians should take into account the possibility that the patient may later need medical procedures that would require that antiplatelet therapy be discontinued. Bare-metal stents or balloon angioplasty with provisional stent implantation should be considered for those patients.

The STEMI update was a joint effort of the American College of Cardiology and the American Heart Association and appeared in Circulation and the Journal of the American College of Cardiology. The PCI update was a joint effort of the ACC, the AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) and appeared in Circulation, the Journal of the American College of Cardiology, and Catheterization and Cardiovascular Interventions. The updates are available online at www.americanheart.orgwww.acc.org

The focused update strategy was developed by the ACC/AHA Task Force on Practice Guidelines as a way to speed up the often years-long process of developing comprehensive new guidelines on the basis of full literature reviews. Twice a year or more experts are polled, and if there is a consensus that data from late-breaking clinical trials warrant an update, one can be prepared relatively quickly.

According to Dr. Elliott M. Antman, cochair of the STEMI update committee and chair of the 2004 writing committee, new research suggests several important changes in the management of this most critical type of heart attack. Among at least 15 guideline modifications or additions, he highlighted several in an interview.

“We indicate that physicians should not routinely administer intravenous β-blockers acutely to patients with heart failure or shock, or who are at risk for heart failure or shock,” said Dr. Antman of Harvard Medical School, Boston. “There is information about facilitated PCI indicating that a strategy of a full-dose fibrinolytic followed by immediate routine PCI is not recommended anymore.”

On the other hand, “It's not unreasonable to use a strategy of preparatory pharmacological regimen other than a full-dose fibrinolytic and routine immediate PCI in certain situations where the patient is at risk, PCI cannot be performed within 90 minutes, and bleeding risk is low.”

Dr. Antman said that he has not heard any significant criticisms of the new STEMI guidelines, and that most will not be difficult to implement. “Physicians understand the importance of responding to evidence,” he said. “These are strategies that are a matter of just organizing systems of care for patients with STEMI. We would hope that physicians would meet as a team in their local hospitals and local systems and consider how they are going to approach the STEMI patients in the future with this new information in mind.”

The recommendation for prehospital 12-lead ECG may be one of the most challenging to implement, since many emergency medical technicians are not trained in interpreting ECGs, and many ambulance systems don't have prehospital ECG capability, he added.

In the PCI update, “We are reaching a point where we really have to look across time and also understand the impact of adjunctive therapies, and how we combine all of this I think is a real challenge,” said Dr. Sidney C. Smith Jr., cochair of the focused update writing committee, in an interview posted on the ACC's Cardiosource Web site (www.cardiosource.com/guidelinefocus

“My personal opinion is that comprehensive therapy really has a place in the management of patients,” continued Dr. Smith of the University of North Carolina, Chapel Hill. “I still think that the high-risk patients, the patients that are symptomatic, benefit from revascularization, but we definitely are getting to a point where I personally will be urging and being certain that my patients not only have revascularization when they need it, but that they adhere to the comprehensive medical therapies that are so important in terms of reducing future events.”

Each of the focused updates includes detailed information about potential conflicts of interest among members of the writing committees. Individual members who appeared to have a conflict recused themselves from voting on certain sections.

Highlights of the Percutaneous Coronary Intervention Updates

1. After implantation of a drug-eluting stent (DES), dual antiplatelet therapy comprising clopidogrel and aspirin is required for at least 1 year or longer.

2. If the patient is likely to face additional surgery requiring interruption of dual antiplatelet therapy, a bare-metal stent (BMS) or balloon angioplasty with provisional stent implantation should be considered instead of a DES.

3. Between 24 hours and 28 days after a heart attack, PCI is not recommended in patients with one- or two-vessel disease and a totally occluded coronary artery if they are not hemodynamically and electrically stable and have no ongoing or easily provoked chest pain.

4. On the other hand, physicians might consider PCI for those patients or patients who respond favorably to initial fibrinolysis treatment if they don't continue to do well on drug therapy alone.

5. The balance of the evidence supports an early invasive strategy for PCI in patients with unstable angina or non-STEMI who are at moderate and higher risk.

6. In patients with STEMI, facilitated PCI with regimens other than full-dose fibrinolytic therapy may be considered in high-risk patients if PCI is not immediately available within 90 minutes and if the risk of bleeding is low.

7. In patients with STEMI, a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful.

8. A strategy of coronary angiography with the intent to perform rescue PCI is reasonable for those patients in whom fibrinolytic therapy has failed.

9. The update includes specific guidelines for ancillary therapy in patients undergoing PCI for STEMI who received prior treatment with unfractionated heparin, enoxaparin, or fondaparinux.

10. Serum LDL cholesterol should be maintained below 100 mg/dL after PCI, and further reduction to less than 70 mg/dL is reasonable.

Source: J. Am. Coll. Cardiol. 2008;51:172–209.

Highlights of the ST-Elevation Myocardial Infarction Updates

1. As in the 2004 guidelines, the overarching goal for treatment of ST elevation myocardial infarction is that reperfusion therapy should begin within 2 hours, and ideally within 1 hour of the event.

2. The emphasis on percutaneous coronary intervention should not obscure the importance of fibrinolytic therapy.

3. With the exception of aspirin, all NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately at the time of STEMI.

4. Early intravenous β-blocker therapy should not be given to STEMI patients who have signs of heart failure or other relative contraindications to β-blockade.

5. Long-term oral β-blockers should be used for secondary prevention in patients at high risk once they have stabilized.

6. The strategy of facilitated PCI (planned PCI immediately after administration of therapy to improve coronary patency) may be considered in subgroups of patients with a large MI or hemodynamic or electrical instability who are at low risk of bleeding.

7. Rescue PCI is suitable for patients who have received fibrinolytic therapy and who have cardiogenic shock, ventricular arrhythmia, or severe heart failure and/or pulmonary edema.

8. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for at least 48 hours and preferably for the duration of the initial hospital stay up to 8 days.

9. Clopidogrel should be added to aspirin in patients with STEMI whether or not they receive reperfusion therapy, and the clopidogrel should be continued for at least 14 days.

10. Emergency medical systems that provide advanced life support should increase the use of prehospital 12-lead electrocardiography.

Sources: J. Am. Coll. Cardiol. 2008;51:210–47

The pace of research in cardiology is proceeding so rapidly that important changes have been issued to two guidelines initially promulgated in the not-so-distant past.

The “focused updates” involve the treatment of ST-elevation myocardial infarction (STEMI) and the technique of percutaneous coronary intervention (PCI). While the updates maintained many of the recommendations in the full guidelines, issued in 2004 for STEMI and 2005 for PCI, they each included significant recommendations for practice changes. (See boxes.)

The STEMI updates, for example, reiterate that the overarching goal of treatment remains rapid reperfusion. But they state that, with the exception of aspirin, NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately. And β-blockers should not be administered to patients in certain high-risk groups.

The PCI updates emphasized the importance of ensuring that patients will be able to comply with dual antiplatelet therapy for a full year after receiving a drug-eluting stent. Bare-metal stents should be substituted when that compliance can't be ensured. This dual antiplatelet therapy is so important that physicians should take into account the possibility that the patient may later need medical procedures that would require that antiplatelet therapy be discontinued. Bare-metal stents or balloon angioplasty with provisional stent implantation should be considered for those patients.

The STEMI update was a joint effort of the American College of Cardiology and the American Heart Association and appeared in Circulation and the Journal of the American College of Cardiology. The PCI update was a joint effort of the ACC, the AHA, and the Society for Cardiovascular Angiography and Interventions (SCAI) and appeared in Circulation, the Journal of the American College of Cardiology, and Catheterization and Cardiovascular Interventions. The updates are available online at www.americanheart.orgwww.acc.org

The focused update strategy was developed by the ACC/AHA Task Force on Practice Guidelines as a way to speed up the often years-long process of developing comprehensive new guidelines on the basis of full literature reviews. Twice a year or more experts are polled, and if there is a consensus that data from late-breaking clinical trials warrant an update, one can be prepared relatively quickly.

According to Dr. Elliott M. Antman, cochair of the STEMI update committee and chair of the 2004 writing committee, new research suggests several important changes in the management of this most critical type of heart attack. Among at least 15 guideline modifications or additions, he highlighted several in an interview.

“We indicate that physicians should not routinely administer intravenous β-blockers acutely to patients with heart failure or shock, or who are at risk for heart failure or shock,” said Dr. Antman of Harvard Medical School, Boston. “There is information about facilitated PCI indicating that a strategy of a full-dose fibrinolytic followed by immediate routine PCI is not recommended anymore.”

On the other hand, “It's not unreasonable to use a strategy of preparatory pharmacological regimen other than a full-dose fibrinolytic and routine immediate PCI in certain situations where the patient is at risk, PCI cannot be performed within 90 minutes, and bleeding risk is low.”

Dr. Antman said that he has not heard any significant criticisms of the new STEMI guidelines, and that most will not be difficult to implement. “Physicians understand the importance of responding to evidence,” he said. “These are strategies that are a matter of just organizing systems of care for patients with STEMI. We would hope that physicians would meet as a team in their local hospitals and local systems and consider how they are going to approach the STEMI patients in the future with this new information in mind.”

The recommendation for prehospital 12-lead ECG may be one of the most challenging to implement, since many emergency medical technicians are not trained in interpreting ECGs, and many ambulance systems don't have prehospital ECG capability, he added.

In the PCI update, “We are reaching a point where we really have to look across time and also understand the impact of adjunctive therapies, and how we combine all of this I think is a real challenge,” said Dr. Sidney C. Smith Jr., cochair of the focused update writing committee, in an interview posted on the ACC's Cardiosource Web site (www.cardiosource.com/guidelinefocus

“My personal opinion is that comprehensive therapy really has a place in the management of patients,” continued Dr. Smith of the University of North Carolina, Chapel Hill. “I still think that the high-risk patients, the patients that are symptomatic, benefit from revascularization, but we definitely are getting to a point where I personally will be urging and being certain that my patients not only have revascularization when they need it, but that they adhere to the comprehensive medical therapies that are so important in terms of reducing future events.”

Each of the focused updates includes detailed information about potential conflicts of interest among members of the writing committees. Individual members who appeared to have a conflict recused themselves from voting on certain sections.

Highlights of the Percutaneous Coronary Intervention Updates

1. After implantation of a drug-eluting stent (DES), dual antiplatelet therapy comprising clopidogrel and aspirin is required for at least 1 year or longer.

2. If the patient is likely to face additional surgery requiring interruption of dual antiplatelet therapy, a bare-metal stent (BMS) or balloon angioplasty with provisional stent implantation should be considered instead of a DES.

3. Between 24 hours and 28 days after a heart attack, PCI is not recommended in patients with one- or two-vessel disease and a totally occluded coronary artery if they are not hemodynamically and electrically stable and have no ongoing or easily provoked chest pain.

4. On the other hand, physicians might consider PCI for those patients or patients who respond favorably to initial fibrinolysis treatment if they don't continue to do well on drug therapy alone.

5. The balance of the evidence supports an early invasive strategy for PCI in patients with unstable angina or non-STEMI who are at moderate and higher risk.

6. In patients with STEMI, facilitated PCI with regimens other than full-dose fibrinolytic therapy may be considered in high-risk patients if PCI is not immediately available within 90 minutes and if the risk of bleeding is low.

7. In patients with STEMI, a planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI may be harmful.

8. A strategy of coronary angiography with the intent to perform rescue PCI is reasonable for those patients in whom fibrinolytic therapy has failed.

9. The update includes specific guidelines for ancillary therapy in patients undergoing PCI for STEMI who received prior treatment with unfractionated heparin, enoxaparin, or fondaparinux.

10. Serum LDL cholesterol should be maintained below 100 mg/dL after PCI, and further reduction to less than 70 mg/dL is reasonable.

Source: J. Am. Coll. Cardiol. 2008;51:172–209.

Highlights of the ST-Elevation Myocardial Infarction Updates

1. As in the 2004 guidelines, the overarching goal for treatment of ST elevation myocardial infarction is that reperfusion therapy should begin within 2 hours, and ideally within 1 hour of the event.

2. The emphasis on percutaneous coronary intervention should not obscure the importance of fibrinolytic therapy.

3. With the exception of aspirin, all NSAIDs and cyclooxygenase-2 inhibitors should be discontinued immediately at the time of STEMI.

4. Early intravenous β-blocker therapy should not be given to STEMI patients who have signs of heart failure or other relative contraindications to β-blockade.

5. Long-term oral β-blockers should be used for secondary prevention in patients at high risk once they have stabilized.

6. The strategy of facilitated PCI (planned PCI immediately after administration of therapy to improve coronary patency) may be considered in subgroups of patients with a large MI or hemodynamic or electrical instability who are at low risk of bleeding.

7. Rescue PCI is suitable for patients who have received fibrinolytic therapy and who have cardiogenic shock, ventricular arrhythmia, or severe heart failure and/or pulmonary edema.

8. Patients undergoing reperfusion with fibrinolytics should receive anticoagulant therapy for at least 48 hours and preferably for the duration of the initial hospital stay up to 8 days.

9. Clopidogrel should be added to aspirin in patients with STEMI whether or not they receive reperfusion therapy, and the clopidogrel should be continued for at least 14 days.

10. Emergency medical systems that provide advanced life support should increase the use of prehospital 12-lead electrocardiography.

Sources: J. Am. Coll. Cardiol. 2008;51:210–47

A scoring method that combines bilirubin and lactate values with the specific etiology of acute liver failure better predicts death or the need for transplant than do existing methods, Dr. Johannes Hadem and his colleagues reported.

The new scoring method, known as the bilirubin-lactate-etiology (BiLE) measure, has a sensitivity of 79% and a specificity of 84% for predicting death or the need for transplant if the patient's score is above 6.9. These sensitivity and specificity values are significantly better than are other measures including the Model for End-Stage Liver Disease (MELD) and the Simplified Acute Physiology Score III (SAPS-III), according to Dr. Hadem of Hannover (Germany) Medical School, and his colleagues (Clin. Gastroenterol. Hepatol. 2008;6:339–45).

The BiLE score is simple to calculate and is especially suited to bedside use immediately after ICU admission, the investigators wrote. But because of the diversity of acute liver failure etiologies in different regions of the world, the BiLE score will need to be validated in other centers and with other patient cohorts.

To develop the BiLE score, the investigators conducted a retrospective analysis of 102 ICU patients from a single institution who fulfilled the diagnostic criteria for acute liver failure. Of those, 39 survived for at least 8 weeks without the need for orthotopic liver transplant (OLT), 18 died without OLT, 5 died following OLT, and 40 survived following OLT. In all, 79 of the patients (77%) survived to week 8.

For the purposes of the study, patients with hepatic dysfunction were diagnosed with acute liver failure if they had hepatic encephalopathy, acute-onset increase of the International Normalized Ratio (INR) above 1.5, and the absence of signs of chronic liver disease during the clinical and ultrasound examinations.

There was no predominant etiology for acute liver failure among the patients in the study. Cryptogenic acute liver failure was the etiology in 21 patients, acute hepatitis B in 18, acetaminophen ingestion in 16, Budd-Chiari syndrome in 9, phenprocoumon toxicity in 7, idiosyncratic drug reactions in 5, Amanita phalloides ingestion in 5, Wilson's disease in 5, hepatitis A in 4, ischemic hepatitis in 4, and halothane reaction in 3. The remaining 5 patients had etiologies classified as “other.”

In comparing patients who survived with those who died or required OLT, the investigators found that 15 different laboratory values and other characteristics showed statistically significant differences. Multivariate linear regression revealed that bilirubin and lactate levels were the most predictive of survival.

Patients who survived without transplantation had a mean bilirubin level of 103 micromol/L, vs. 263 micromol/L in the liver transplantation or death group. Similarly, patients who survived without transplantation had a mean lactate level of 2.9 mmol/L, vs. 4.7 mmol/L in the liver transplantation or death group.

Patients with cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity were more likely to die or require transplant, while those with acetaminophen toxicity were more likely to survive without the need for transplant.

The investigators designed the BiLE score empirically. To bring bilirubin and lactate into the same range of values, the equation calls for dividing bilirubin concentrations in micromol/L by 100. To this figure, one adds the lactate concentration in mmol/L and then adds or subtracts a value depending on the etiology. (See box.)

Using a cutoff value of 6.9 to predict death or the need for transplant, the BiLE score achieved a sensitivity of 79%, a specificity of 84%, a positive predictive value of 89%, and a negative predictive value of 71%. Sensitivity was 100% in patients with cryptogenic acute liver failure.

In contrast, lactate alone with a cutoff of 3.5 mmol/L achieved a sensitivity and specificity of 59% and 66%, respectively. The MELD score with a cutoff of 32 achieved a sensitivity and specificity of 65% and 69%, respectively, and the King's College Criteria achieved a sensitivity and specificity of 58% and 82%, respectively.

The investigators stated that they had no conflicts of interest to report.

Calculation of the BiLE Score

The calculation method for the BiLE score is as follows:

Bilirubin (micromol/L)/100 + lactate (mmol/L)

+ 4 (in the case of cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity)

− 2 (in the case of acetaminophen toxicity)

+ 0 (in the case of other etiologies)

BiLE scores above 6.9 are predictive of death or liver transplantation.

A scoring method that combines bilirubin and lactate values with the specific etiology of acute liver failure better predicts death or the need for transplant than do existing methods, Dr. Johannes Hadem and his colleagues reported.

The new scoring method, known as the bilirubin-lactate-etiology (BiLE) measure, has a sensitivity of 79% and a specificity of 84% for predicting death or the need for transplant if the patient's score is above 6.9. These sensitivity and specificity values are significantly better than are other measures including the Model for End-Stage Liver Disease (MELD) and the Simplified Acute Physiology Score III (SAPS-III), according to Dr. Hadem of Hannover (Germany) Medical School, and his colleagues (Clin. Gastroenterol. Hepatol. 2008;6:339–45).

The BiLE score is simple to calculate and is especially suited to bedside use immediately after ICU admission, the investigators wrote. But because of the diversity of acute liver failure etiologies in different regions of the world, the BiLE score will need to be validated in other centers and with other patient cohorts.

To develop the BiLE score, the investigators conducted a retrospective analysis of 102 ICU patients from a single institution who fulfilled the diagnostic criteria for acute liver failure. Of those, 39 survived for at least 8 weeks without the need for orthotopic liver transplant (OLT), 18 died without OLT, 5 died following OLT, and 40 survived following OLT. In all, 79 of the patients (77%) survived to week 8.

For the purposes of the study, patients with hepatic dysfunction were diagnosed with acute liver failure if they had hepatic encephalopathy, acute-onset increase of the International Normalized Ratio (INR) above 1.5, and the absence of signs of chronic liver disease during the clinical and ultrasound examinations.

There was no predominant etiology for acute liver failure among the patients in the study. Cryptogenic acute liver failure was the etiology in 21 patients, acute hepatitis B in 18, acetaminophen ingestion in 16, Budd-Chiari syndrome in 9, phenprocoumon toxicity in 7, idiosyncratic drug reactions in 5, Amanita phalloides ingestion in 5, Wilson's disease in 5, hepatitis A in 4, ischemic hepatitis in 4, and halothane reaction in 3. The remaining 5 patients had etiologies classified as “other.”

In comparing patients who survived with those who died or required OLT, the investigators found that 15 different laboratory values and other characteristics showed statistically significant differences. Multivariate linear regression revealed that bilirubin and lactate levels were the most predictive of survival.

Patients who survived without transplantation had a mean bilirubin level of 103 micromol/L, vs. 263 micromol/L in the liver transplantation or death group. Similarly, patients who survived without transplantation had a mean lactate level of 2.9 mmol/L, vs. 4.7 mmol/L in the liver transplantation or death group.

Patients with cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity were more likely to die or require transplant, while those with acetaminophen toxicity were more likely to survive without the need for transplant.

The investigators designed the BiLE score empirically. To bring bilirubin and lactate into the same range of values, the equation calls for dividing bilirubin concentrations in micromol/L by 100. To this figure, one adds the lactate concentration in mmol/L and then adds or subtracts a value depending on the etiology. (See box.)

Using a cutoff value of 6.9 to predict death or the need for transplant, the BiLE score achieved a sensitivity of 79%, a specificity of 84%, a positive predictive value of 89%, and a negative predictive value of 71%. Sensitivity was 100% in patients with cryptogenic acute liver failure.

In contrast, lactate alone with a cutoff of 3.5 mmol/L achieved a sensitivity and specificity of 59% and 66%, respectively. The MELD score with a cutoff of 32 achieved a sensitivity and specificity of 65% and 69%, respectively, and the King's College Criteria achieved a sensitivity and specificity of 58% and 82%, respectively.

The investigators stated that they had no conflicts of interest to report.

Calculation of the BiLE Score

The calculation method for the BiLE score is as follows:

Bilirubin (micromol/L)/100 + lactate (mmol/L)

+ 4 (in the case of cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity)

− 2 (in the case of acetaminophen toxicity)

+ 0 (in the case of other etiologies)

BiLE scores above 6.9 are predictive of death or liver transplantation.

A scoring method that combines bilirubin and lactate values with the specific etiology of acute liver failure better predicts death or the need for transplant than do existing methods, Dr. Johannes Hadem and his colleagues reported.

The new scoring method, known as the bilirubin-lactate-etiology (BiLE) measure, has a sensitivity of 79% and a specificity of 84% for predicting death or the need for transplant if the patient's score is above 6.9. These sensitivity and specificity values are significantly better than are other measures including the Model for End-Stage Liver Disease (MELD) and the Simplified Acute Physiology Score III (SAPS-III), according to Dr. Hadem of Hannover (Germany) Medical School, and his colleagues (Clin. Gastroenterol. Hepatol. 2008;6:339–45).

The BiLE score is simple to calculate and is especially suited to bedside use immediately after ICU admission, the investigators wrote. But because of the diversity of acute liver failure etiologies in different regions of the world, the BiLE score will need to be validated in other centers and with other patient cohorts.

To develop the BiLE score, the investigators conducted a retrospective analysis of 102 ICU patients from a single institution who fulfilled the diagnostic criteria for acute liver failure. Of those, 39 survived for at least 8 weeks without the need for orthotopic liver transplant (OLT), 18 died without OLT, 5 died following OLT, and 40 survived following OLT. In all, 79 of the patients (77%) survived to week 8.

For the purposes of the study, patients with hepatic dysfunction were diagnosed with acute liver failure if they had hepatic encephalopathy, acute-onset increase of the International Normalized Ratio (INR) above 1.5, and the absence of signs of chronic liver disease during the clinical and ultrasound examinations.

There was no predominant etiology for acute liver failure among the patients in the study. Cryptogenic acute liver failure was the etiology in 21 patients, acute hepatitis B in 18, acetaminophen ingestion in 16, Budd-Chiari syndrome in 9, phenprocoumon toxicity in 7, idiosyncratic drug reactions in 5, Amanita phalloides ingestion in 5, Wilson's disease in 5, hepatitis A in 4, ischemic hepatitis in 4, and halothane reaction in 3. The remaining 5 patients had etiologies classified as “other.”

In comparing patients who survived with those who died or required OLT, the investigators found that 15 different laboratory values and other characteristics showed statistically significant differences. Multivariate linear regression revealed that bilirubin and lactate levels were the most predictive of survival.

Patients who survived without transplantation had a mean bilirubin level of 103 micromol/L, vs. 263 micromol/L in the liver transplantation or death group. Similarly, patients who survived without transplantation had a mean lactate level of 2.9 mmol/L, vs. 4.7 mmol/L in the liver transplantation or death group.

Patients with cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity were more likely to die or require transplant, while those with acetaminophen toxicity were more likely to survive without the need for transplant.

The investigators designed the BiLE score empirically. To bring bilirubin and lactate into the same range of values, the equation calls for dividing bilirubin concentrations in micromol/L by 100. To this figure, one adds the lactate concentration in mmol/L and then adds or subtracts a value depending on the etiology. (See box.)

Using a cutoff value of 6.9 to predict death or the need for transplant, the BiLE score achieved a sensitivity of 79%, a specificity of 84%, a positive predictive value of 89%, and a negative predictive value of 71%. Sensitivity was 100% in patients with cryptogenic acute liver failure.

In contrast, lactate alone with a cutoff of 3.5 mmol/L achieved a sensitivity and specificity of 59% and 66%, respectively. The MELD score with a cutoff of 32 achieved a sensitivity and specificity of 65% and 69%, respectively, and the King's College Criteria achieved a sensitivity and specificity of 58% and 82%, respectively.

The investigators stated that they had no conflicts of interest to report.

Calculation of the BiLE Score

The calculation method for the BiLE score is as follows:

Bilirubin (micromol/L)/100 + lactate (mmol/L)

+ 4 (in the case of cryptogenic acute liver failure, Budd-Chiari syndrome, or phenprocoumon toxicity)

− 2 (in the case of acetaminophen toxicity)

+ 0 (in the case of other etiologies)

BiLE scores above 6.9 are predictive of death or liver transplantation.

SAN FRANCISCO — Patients with community-acquired pneumonia who were admitted to the intensive care unit 2 or more days after diagnosis were more than twice as likely to die within 30 days as were those who were admitted in 24 hours or less, according to a poster presentation at the International Conference of the American Thoracic Society.

The retrospective, observational study involved 161 patients seen over a 3-year period at two tertiary care hospitals in San Antonio. All patients were 18 years old or older, all had received a chest x-ray within 24 hours of admission, and all had a diagnosis consistent with community-acquired pneumonia, wrote Dr. Marcos I. Restrepo and his colleagues at the University of Texas at San Antonio.

There were no significant differences in demographic or clinical characteristics between the 142 patients admitted to the ICU early and the 19 admitted late. There were also no significant differences between the two groups in whether they received antibiotics within 4 hours, whether their blood was cultured appropriately, or whether they received guideline-concordant antibiotic therapy.

After 30 days, 47% of the patients who had been admitted late had died, compared with 23% of the patients who had been admitted early, a significant difference.

The investigators wrote that further research is needed to isolate the factors underlying the association between late ICU admission and increased mortality.

SAN FRANCISCO — Patients with community-acquired pneumonia who were admitted to the intensive care unit 2 or more days after diagnosis were more than twice as likely to die within 30 days as were those who were admitted in 24 hours or less, according to a poster presentation at the International Conference of the American Thoracic Society.

The retrospective, observational study involved 161 patients seen over a 3-year period at two tertiary care hospitals in San Antonio. All patients were 18 years old or older, all had received a chest x-ray within 24 hours of admission, and all had a diagnosis consistent with community-acquired pneumonia, wrote Dr. Marcos I. Restrepo and his colleagues at the University of Texas at San Antonio.

There were no significant differences in demographic or clinical characteristics between the 142 patients admitted to the ICU early and the 19 admitted late. There were also no significant differences between the two groups in whether they received antibiotics within 4 hours, whether their blood was cultured appropriately, or whether they received guideline-concordant antibiotic therapy.

After 30 days, 47% of the patients who had been admitted late had died, compared with 23% of the patients who had been admitted early, a significant difference.

The investigators wrote that further research is needed to isolate the factors underlying the association between late ICU admission and increased mortality.

SAN FRANCISCO — Patients with community-acquired pneumonia who were admitted to the intensive care unit 2 or more days after diagnosis were more than twice as likely to die within 30 days as were those who were admitted in 24 hours or less, according to a poster presentation at the International Conference of the American Thoracic Society.

The retrospective, observational study involved 161 patients seen over a 3-year period at two tertiary care hospitals in San Antonio. All patients were 18 years old or older, all had received a chest x-ray within 24 hours of admission, and all had a diagnosis consistent with community-acquired pneumonia, wrote Dr. Marcos I. Restrepo and his colleagues at the University of Texas at San Antonio.

There were no significant differences in demographic or clinical characteristics between the 142 patients admitted to the ICU early and the 19 admitted late. There were also no significant differences between the two groups in whether they received antibiotics within 4 hours, whether their blood was cultured appropriately, or whether they received guideline-concordant antibiotic therapy.

After 30 days, 47% of the patients who had been admitted late had died, compared with 23% of the patients who had been admitted early, a significant difference.

The investigators wrote that further research is needed to isolate the factors underlying the association between late ICU admission and increased mortality.

SAN FRANCISCO — “The future of ablation has very little to do with ablation,” Dr. Jaime Landman said at the annual meeting of the Society of Laparoendoscopic Surgeons. “Ablation is about targeting, and targeting is clearly about imaging.”

Dr. Landman, of Columbia University, New York, described a number of technical developments that may improve the utility of ablation technology in surgery.

Although cryoablation, radiofrequency ablation, and brachytherapy have been the most frequently used modalities, there's a new kid on the block, he said. High-intensity focused ultrasound (HIFU) involves ultrasonic radiation focused by a lens, a curved array, or a phased array to target extremely small areas of tissue—on the order of a few millimeters—for heating and destruction.

This very precision, however, is both HIFU's beauty and its Achilles' heel, Dr. Landman said. The small focal zone makes it difficult to target a large area such as a tumor or a benign growth.

“I still think [HIFU] has a long way to go,” Dr. Landman said. “This is a beautiful technology. It is less invasive. It's not percutaneous; it's transcutaneous. And theoretically it can become a wonderful ablative modality.”

HIFU may prove especially useful when coupled with robotic targeting. An early example of this kind of robotic technology, called PAKY (Percutaneous Access of the KidneY), was designed for fluoroscopic-guided percutaneous needle insertion into the renal collecting system. Several groups are working on computer technologies that will combine stored CT images with real-time ultrasound images to target robotic probes to precise locations for biopsy or ablation.

Even more exciting is the “stealth robot,” so-called because it is compatible with real-time MRI imaging, he said. Propelled with a pneumatic motor and constructed exclusively of materials such as plastics, ceramics, crystals, and rubber, stealth robots are also electricity free, using light signals internally. All electrical components can be located outside the imaging room (Minim. Invasive Ther. Allied Technol. 2007;16:241–8). The stealth robot could potentially allow the surgeon to target a precise location for ablation while the patient is inside the MRI tube being actively scanned.

On the subject of ultrasound, a technology in frequent use today, Dr. Landman said, “Ultrasound is incredibly useful. … We all use it, it's commonly available, and it's relatively inexpensive. But it's been hampered in ablation in that we need to know what's viable. This is the most important part of ablation—making tissue that we don't want viable dead. Unfortunately we have not been able to do that in ultrasound because of the lack of contrast material.”

Enter contrast-enhanced ultrasound. The contrast agent contains large numbers of gas-filled microbubbles. Injected into the circulatory system, these microbubbles have a high degree of echogenicity and can be used to image blood perfusion.

Dr. Landman himself has been working on computer-assisted ultrasound targeting. It consists of a familiar ultrasound probe with a slight modification—the addition of a needle guide that's connected by computer to a targeting mechanism. In in vitro demonstrations, the operator can easily hit a 1-mm target with the needle.

“Now this doesn't look particularly remarkable until I tell you that the person who did this is a first-year medical student who never touched an ultrasound before in his life,” Dr. Landman said. “And he was able to go 10 cm deep and hit 1-mm targets. This means to me than in the very near future I'm going to be able to take this device and take a kidney tumor and treat it in my office with cryoablation.”

Dr. Landman urged the surgeons in the audience to become proficient in ablative technologies including associated imaging and targeting modalities, implying that if surgeons don't enter this arena, others will fill the void. “Our training as surgeons has been very limited regarding imaging,” he said. “And it's very clear that imaging specialists, interventional radiologists, have been very aggressive and very pleased to proceed with ablative procedures.”

Dr. Landman disclosed receiving grant support from and serving as a consultant to a number of companies involved in imaging and ablative technology.

SAN FRANCISCO — “The future of ablation has very little to do with ablation,” Dr. Jaime Landman said at the annual meeting of the Society of Laparoendoscopic Surgeons. “Ablation is about targeting, and targeting is clearly about imaging.”

Dr. Landman, of Columbia University, New York, described a number of technical developments that may improve the utility of ablation technology in surgery.

Although cryoablation, radiofrequency ablation, and brachytherapy have been the most frequently used modalities, there's a new kid on the block, he said. High-intensity focused ultrasound (HIFU) involves ultrasonic radiation focused by a lens, a curved array, or a phased array to target extremely small areas of tissue—on the order of a few millimeters—for heating and destruction.

This very precision, however, is both HIFU's beauty and its Achilles' heel, Dr. Landman said. The small focal zone makes it difficult to target a large area such as a tumor or a benign growth.

“I still think [HIFU] has a long way to go,” Dr. Landman said. “This is a beautiful technology. It is less invasive. It's not percutaneous; it's transcutaneous. And theoretically it can become a wonderful ablative modality.”

HIFU may prove especially useful when coupled with robotic targeting. An early example of this kind of robotic technology, called PAKY (Percutaneous Access of the KidneY), was designed for fluoroscopic-guided percutaneous needle insertion into the renal collecting system. Several groups are working on computer technologies that will combine stored CT images with real-time ultrasound images to target robotic probes to precise locations for biopsy or ablation.

Even more exciting is the “stealth robot,” so-called because it is compatible with real-time MRI imaging, he said. Propelled with a pneumatic motor and constructed exclusively of materials such as plastics, ceramics, crystals, and rubber, stealth robots are also electricity free, using light signals internally. All electrical components can be located outside the imaging room (Minim. Invasive Ther. Allied Technol. 2007;16:241–8). The stealth robot could potentially allow the surgeon to target a precise location for ablation while the patient is inside the MRI tube being actively scanned.

On the subject of ultrasound, a technology in frequent use today, Dr. Landman said, “Ultrasound is incredibly useful. … We all use it, it's commonly available, and it's relatively inexpensive. But it's been hampered in ablation in that we need to know what's viable. This is the most important part of ablation—making tissue that we don't want viable dead. Unfortunately we have not been able to do that in ultrasound because of the lack of contrast material.”

Enter contrast-enhanced ultrasound. The contrast agent contains large numbers of gas-filled microbubbles. Injected into the circulatory system, these microbubbles have a high degree of echogenicity and can be used to image blood perfusion.

Dr. Landman himself has been working on computer-assisted ultrasound targeting. It consists of a familiar ultrasound probe with a slight modification—the addition of a needle guide that's connected by computer to a targeting mechanism. In in vitro demonstrations, the operator can easily hit a 1-mm target with the needle.

“Now this doesn't look particularly remarkable until I tell you that the person who did this is a first-year medical student who never touched an ultrasound before in his life,” Dr. Landman said. “And he was able to go 10 cm deep and hit 1-mm targets. This means to me than in the very near future I'm going to be able to take this device and take a kidney tumor and treat it in my office with cryoablation.”

Dr. Landman urged the surgeons in the audience to become proficient in ablative technologies including associated imaging and targeting modalities, implying that if surgeons don't enter this arena, others will fill the void. “Our training as surgeons has been very limited regarding imaging,” he said. “And it's very clear that imaging specialists, interventional radiologists, have been very aggressive and very pleased to proceed with ablative procedures.”

Dr. Landman disclosed receiving grant support from and serving as a consultant to a number of companies involved in imaging and ablative technology.

SAN FRANCISCO — “The future of ablation has very little to do with ablation,” Dr. Jaime Landman said at the annual meeting of the Society of Laparoendoscopic Surgeons. “Ablation is about targeting, and targeting is clearly about imaging.”

Dr. Landman, of Columbia University, New York, described a number of technical developments that may improve the utility of ablation technology in surgery.

Although cryoablation, radiofrequency ablation, and brachytherapy have been the most frequently used modalities, there's a new kid on the block, he said. High-intensity focused ultrasound (HIFU) involves ultrasonic radiation focused by a lens, a curved array, or a phased array to target extremely small areas of tissue—on the order of a few millimeters—for heating and destruction.

This very precision, however, is both HIFU's beauty and its Achilles' heel, Dr. Landman said. The small focal zone makes it difficult to target a large area such as a tumor or a benign growth.

“I still think [HIFU] has a long way to go,” Dr. Landman said. “This is a beautiful technology. It is less invasive. It's not percutaneous; it's transcutaneous. And theoretically it can become a wonderful ablative modality.”

HIFU may prove especially useful when coupled with robotic targeting. An early example of this kind of robotic technology, called PAKY (Percutaneous Access of the KidneY), was designed for fluoroscopic-guided percutaneous needle insertion into the renal collecting system. Several groups are working on computer technologies that will combine stored CT images with real-time ultrasound images to target robotic probes to precise locations for biopsy or ablation.

Even more exciting is the “stealth robot,” so-called because it is compatible with real-time MRI imaging, he said. Propelled with a pneumatic motor and constructed exclusively of materials such as plastics, ceramics, crystals, and rubber, stealth robots are also electricity free, using light signals internally. All electrical components can be located outside the imaging room (Minim. Invasive Ther. Allied Technol. 2007;16:241–8). The stealth robot could potentially allow the surgeon to target a precise location for ablation while the patient is inside the MRI tube being actively scanned.

On the subject of ultrasound, a technology in frequent use today, Dr. Landman said, “Ultrasound is incredibly useful. … We all use it, it's commonly available, and it's relatively inexpensive. But it's been hampered in ablation in that we need to know what's viable. This is the most important part of ablation—making tissue that we don't want viable dead. Unfortunately we have not been able to do that in ultrasound because of the lack of contrast material.”

Enter contrast-enhanced ultrasound. The contrast agent contains large numbers of gas-filled microbubbles. Injected into the circulatory system, these microbubbles have a high degree of echogenicity and can be used to image blood perfusion.

Dr. Landman himself has been working on computer-assisted ultrasound targeting. It consists of a familiar ultrasound probe with a slight modification—the addition of a needle guide that's connected by computer to a targeting mechanism. In in vitro demonstrations, the operator can easily hit a 1-mm target with the needle.

“Now this doesn't look particularly remarkable until I tell you that the person who did this is a first-year medical student who never touched an ultrasound before in his life,” Dr. Landman said. “And he was able to go 10 cm deep and hit 1-mm targets. This means to me than in the very near future I'm going to be able to take this device and take a kidney tumor and treat it in my office with cryoablation.”

Dr. Landman urged the surgeons in the audience to become proficient in ablative technologies including associated imaging and targeting modalities, implying that if surgeons don't enter this arena, others will fill the void. “Our training as surgeons has been very limited regarding imaging,” he said. “And it's very clear that imaging specialists, interventional radiologists, have been very aggressive and very pleased to proceed with ablative procedures.”

Dr. Landman disclosed receiving grant support from and serving as a consultant to a number of companies involved in imaging and ablative technology.

Patients taking anti-tumor necrosis factor-α medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer.

A study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-α (anti-TNF-α) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls. All three groups achieved about an 80% rate of protection to each of the three components of the influenza vaccine (Ann. Rheum. Dis. 2007;doi:10.1136/ard.2007.077552).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those treated with anti-TNF-α agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study. Their average age was 49 years, with a range of 18–85. Patients in the anti-TNF group had been using the agents for an average of 24 months with a range of 0.5–78 months.

All of the patients in the study were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-α agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with the patients not taking an anti-TNF-α agent and with the healthy controls.

Patients taking anti-tumor necrosis factor-α medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer.

A study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-α (anti-TNF-α) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls. All three groups achieved about an 80% rate of protection to each of the three components of the influenza vaccine (Ann. Rheum. Dis. 2007;doi:10.1136/ard.2007.077552).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those treated with anti-TNF-α agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study. Their average age was 49 years, with a range of 18–85. Patients in the anti-TNF group had been using the agents for an average of 24 months with a range of 0.5–78 months.

All of the patients in the study were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-α agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with the patients not taking an anti-TNF-α agent and with the healthy controls.

Patients taking anti-tumor necrosis factor-α medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer.

A study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-α (anti-TNF-α) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls. All three groups achieved about an 80% rate of protection to each of the three components of the influenza vaccine (Ann. Rheum. Dis. 2007;doi:10.1136/ard.2007.077552).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those treated with anti-TNF-α agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study. Their average age was 49 years, with a range of 18–85. Patients in the anti-TNF group had been using the agents for an average of 24 months with a range of 0.5–78 months.

All of the patients in the study were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-α agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with the patients not taking an anti-TNF-α agent and with the healthy controls.

The findings in a survey of medical students indicated that few received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the overwhelming majority failed to realize that civilian physicians are subject to being drafted.

Dr. J. Wesley Boyd and his colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail and invited them to participate in the survey.

Overall, 1,756 students (35%) completed the survey, and of those, a little more than 5% reported having served in the military or having an obligation to serve in the future (Int. J. Health Services 2007;37:643–50).

Of the total, 94% had received less than 1 hour of instruction during medical school about the ethical obligations of the physicians serving in the military, 4.3% received 1–5 hours of instruction, and 1.5% received more than 5 hours of training.

About 6% of the students reported being “very familiar” with the Geneva Conventions, whereas 66% reported being “somewhat familiar” with them. However, despite this high level of stated familiarity, only 37% of the students correctly answered that the conventions apply regardless of whether or not one's country has formally declared war.

About two-thirds of students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated that they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior: “when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered,” “when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection,” “when ordered to inject a lethal drug into a prisoner,” “all of the above,” or “none of the above.” Although 66% correctly answered “all of the above,” 27% thought that they were only required to disobey when actually injecting a lethal drug, and 6% said “none of the above.”

Congress approved the Health Care Personnel Delivery System in 1987, thereby establishing a specific process for drafting physicians that Congress and the president could activate within a matter of weeks. Only 3.5% of the students were aware of this system, and only 23.8% thought that a medical draft was more likely than a general draft. Less than 50% of the students would willingly serve in such a draft, with 34% saying that they would use all legal means to avoid service, about 7 % saying they would consider emigration, and just under 14% saying that they would refuse military induction as an act of civil disobedience.

“The fact is that most physicians–let alone medical students–are not familiar with the code of medical ethics,” Dr. Abraham L. Halpern said in an interview. “I feel that any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions.”

Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that when he has instructed medical students in ethics, he noticed that many of the seats in the lecture hall were empty, which he thinks shows that the students knew that they would never be tested on the material.

All medical ethics courses should include 'worldwide acceptance ofthe Geneva Conventions.' DR. HALPERN

The findings in a survey of medical students indicated that few received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the overwhelming majority failed to realize that civilian physicians are subject to being drafted.

Dr. J. Wesley Boyd and his colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail and invited them to participate in the survey.

Overall, 1,756 students (35%) completed the survey, and of those, a little more than 5% reported having served in the military or having an obligation to serve in the future (Int. J. Health Services 2007;37:643–50).

Of the total, 94% had received less than 1 hour of instruction during medical school about the ethical obligations of the physicians serving in the military, 4.3% received 1–5 hours of instruction, and 1.5% received more than 5 hours of training.

About 6% of the students reported being “very familiar” with the Geneva Conventions, whereas 66% reported being “somewhat familiar” with them. However, despite this high level of stated familiarity, only 37% of the students correctly answered that the conventions apply regardless of whether or not one's country has formally declared war.

About two-thirds of students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated that they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior: “when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered,” “when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection,” “when ordered to inject a lethal drug into a prisoner,” “all of the above,” or “none of the above.” Although 66% correctly answered “all of the above,” 27% thought that they were only required to disobey when actually injecting a lethal drug, and 6% said “none of the above.”

Congress approved the Health Care Personnel Delivery System in 1987, thereby establishing a specific process for drafting physicians that Congress and the president could activate within a matter of weeks. Only 3.5% of the students were aware of this system, and only 23.8% thought that a medical draft was more likely than a general draft. Less than 50% of the students would willingly serve in such a draft, with 34% saying that they would use all legal means to avoid service, about 7 % saying they would consider emigration, and just under 14% saying that they would refuse military induction as an act of civil disobedience.

“The fact is that most physicians–let alone medical students–are not familiar with the code of medical ethics,” Dr. Abraham L. Halpern said in an interview. “I feel that any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions.”

Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that when he has instructed medical students in ethics, he noticed that many of the seats in the lecture hall were empty, which he thinks shows that the students knew that they would never be tested on the material.

All medical ethics courses should include 'worldwide acceptance ofthe Geneva Conventions.' DR. HALPERN

The findings in a survey of medical students indicated that few received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the overwhelming majority failed to realize that civilian physicians are subject to being drafted.

Dr. J. Wesley Boyd and his colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail and invited them to participate in the survey.

Overall, 1,756 students (35%) completed the survey, and of those, a little more than 5% reported having served in the military or having an obligation to serve in the future (Int. J. Health Services 2007;37:643–50).

Of the total, 94% had received less than 1 hour of instruction during medical school about the ethical obligations of the physicians serving in the military, 4.3% received 1–5 hours of instruction, and 1.5% received more than 5 hours of training.

About 6% of the students reported being “very familiar” with the Geneva Conventions, whereas 66% reported being “somewhat familiar” with them. However, despite this high level of stated familiarity, only 37% of the students correctly answered that the conventions apply regardless of whether or not one's country has formally declared war.

About two-thirds of students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated that they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior: “when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered,” “when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection,” “when ordered to inject a lethal drug into a prisoner,” “all of the above,” or “none of the above.” Although 66% correctly answered “all of the above,” 27% thought that they were only required to disobey when actually injecting a lethal drug, and 6% said “none of the above.”

Congress approved the Health Care Personnel Delivery System in 1987, thereby establishing a specific process for drafting physicians that Congress and the president could activate within a matter of weeks. Only 3.5% of the students were aware of this system, and only 23.8% thought that a medical draft was more likely than a general draft. Less than 50% of the students would willingly serve in such a draft, with 34% saying that they would use all legal means to avoid service, about 7 % saying they would consider emigration, and just under 14% saying that they would refuse military induction as an act of civil disobedience.

“The fact is that most physicians–let alone medical students–are not familiar with the code of medical ethics,” Dr. Abraham L. Halpern said in an interview. “I feel that any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions.”

Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that when he has instructed medical students in ethics, he noticed that many of the seats in the lecture hall were empty, which he thinks shows that the students knew that they would never be tested on the material.

All medical ethics courses should include 'worldwide acceptance ofthe Geneva Conventions.' DR. HALPERN

Few medical students received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the majority don't realize civilian physicians are subject to being drafted, according to a survey.

Dr. J. Wesley Boyd and colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail. Overall, 1,756 (35%) completed the survey. Of those, a little more than 5% served in the military or have an obligation to serve in the future (Int. J. Health Services 2007;37:643-50).

Of the total, 94% received less than 1 hour of instruction during medical school about the ethical obligations of physicians in the military, 4.3% had 1-5 hours of instruction, and 1.5% had more than 5 hours.

About 6% reported being "very familiar" with the Geneva Conventions, and 66% reported being "somewhat familiar." Nevertheless, only 37% correctly answered that the conventions apply regardless of whether one's country has declared war.

About two-thirds of the students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior. The options were, "when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered," "when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection," "when ordered to inject a lethal drug into a prisoner," "all of the above," or "none of the above." Though 66% correctly answered "all of the above," 27% thought they must only disobey when actually injecting a lethal drug; 6% thought none of the above was the right answer.

"The abuses at Abu Ghraib [in Iraq] and Guantanamo [Bay, in Cuba] have galvanized much of the world against the U.S.," Dr. Boyd wrote. "Those abuses, in part abetted by physicians, will likely go down as one of our century's most egregious ethical lapses. The dearth of teaching about these issues in medical schools is a travesty, and medical schools need to begin teaching military medical ethics to ensure all physicians have a solid understanding of their ethical obligations in times of war."

Congress approved the Health Care Personnel Delivery System in 1987, establishing a process for drafting physicians. Only 3.5% of the students knew this, and only 23.8% thought a medical draft was more likely than a general draft. Less than 50% would willingly serve in such a draft, with 34% saying they would use all legal means to avoid service, about 7% saying they would consider emigration, and just under 14% saying they would refuse military induction as an act of civil disobedience.

"I believe that there should be a mandatory ethics course in every medical school program, and that should include an examination," Dr. Abraham L. Halpern said in an interview. Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that on occasions when he has instructed medical students in ethics, he has noticed that many of the seats in the lecture hall were empty.

"The fact is that most physicians—let alone medical students—are not familiar with the code of medical ethics," he said. "Any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions."

'There should be a mandatory ethics course in every medical school program, and that should include an examination.' DR. HALPERN

Few medical students received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the majority don't realize civilian physicians are subject to being drafted, according to a survey.

Dr. J. Wesley Boyd and colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail. Overall, 1,756 (35%) completed the survey. Of those, a little more than 5% served in the military or have an obligation to serve in the future (Int. J. Health Services 2007;37:643-50).

Of the total, 94% received less than 1 hour of instruction during medical school about the ethical obligations of physicians in the military, 4.3% had 1-5 hours of instruction, and 1.5% had more than 5 hours.

About 6% reported being "very familiar" with the Geneva Conventions, and 66% reported being "somewhat familiar." Nevertheless, only 37% correctly answered that the conventions apply regardless of whether one's country has declared war.

About two-thirds of the students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior. The options were, "when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered," "when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection," "when ordered to inject a lethal drug into a prisoner," "all of the above," or "none of the above." Though 66% correctly answered "all of the above," 27% thought they must only disobey when actually injecting a lethal drug; 6% thought none of the above was the right answer.

"The abuses at Abu Ghraib [in Iraq] and Guantanamo [Bay, in Cuba] have galvanized much of the world against the U.S.," Dr. Boyd wrote. "Those abuses, in part abetted by physicians, will likely go down as one of our century's most egregious ethical lapses. The dearth of teaching about these issues in medical schools is a travesty, and medical schools need to begin teaching military medical ethics to ensure all physicians have a solid understanding of their ethical obligations in times of war."

Congress approved the Health Care Personnel Delivery System in 1987, establishing a process for drafting physicians. Only 3.5% of the students knew this, and only 23.8% thought a medical draft was more likely than a general draft. Less than 50% would willingly serve in such a draft, with 34% saying they would use all legal means to avoid service, about 7% saying they would consider emigration, and just under 14% saying they would refuse military induction as an act of civil disobedience.

"I believe that there should be a mandatory ethics course in every medical school program, and that should include an examination," Dr. Abraham L. Halpern said in an interview. Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that on occasions when he has instructed medical students in ethics, he has noticed that many of the seats in the lecture hall were empty.

"The fact is that most physicians—let alone medical students—are not familiar with the code of medical ethics," he said. "Any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions."

'There should be a mandatory ethics course in every medical school program, and that should include an examination.' DR. HALPERN

Few medical students received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the majority don't realize civilian physicians are subject to being drafted, according to a survey.

Dr. J. Wesley Boyd and colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail. Overall, 1,756 (35%) completed the survey. Of those, a little more than 5% served in the military or have an obligation to serve in the future (Int. J. Health Services 2007;37:643-50).

Of the total, 94% received less than 1 hour of instruction during medical school about the ethical obligations of physicians in the military, 4.3% had 1-5 hours of instruction, and 1.5% had more than 5 hours.

About 6% reported being "very familiar" with the Geneva Conventions, and 66% reported being "somewhat familiar." Nevertheless, only 37% correctly answered that the conventions apply regardless of whether one's country has declared war.

About two-thirds of the students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.

Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.

The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior. The options were, "when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered," "when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection," "when ordered to inject a lethal drug into a prisoner," "all of the above," or "none of the above." Though 66% correctly answered "all of the above," 27% thought they must only disobey when actually injecting a lethal drug; 6% thought none of the above was the right answer.

"The abuses at Abu Ghraib [in Iraq] and Guantanamo [Bay, in Cuba] have galvanized much of the world against the U.S.," Dr. Boyd wrote. "Those abuses, in part abetted by physicians, will likely go down as one of our century's most egregious ethical lapses. The dearth of teaching about these issues in medical schools is a travesty, and medical schools need to begin teaching military medical ethics to ensure all physicians have a solid understanding of their ethical obligations in times of war."

Congress approved the Health Care Personnel Delivery System in 1987, establishing a process for drafting physicians. Only 3.5% of the students knew this, and only 23.8% thought a medical draft was more likely than a general draft. Less than 50% would willingly serve in such a draft, with 34% saying they would use all legal means to avoid service, about 7% saying they would consider emigration, and just under 14% saying they would refuse military induction as an act of civil disobedience.

"I believe that there should be a mandatory ethics course in every medical school program, and that should include an examination," Dr. Abraham L. Halpern said in an interview. Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that on occasions when he has instructed medical students in ethics, he has noticed that many of the seats in the lecture hall were empty.

"The fact is that most physicians—let alone medical students—are not familiar with the code of medical ethics," he said. "Any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions."

'There should be a mandatory ethics course in every medical school program, and that should include an examination.' DR. HALPERN

Patients taking anti-tumor necrosis factor-? medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer, according to the results of a recent study.

The study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-? (anti-TNF-?) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls.

All three groups achieved about an 80% rate of protection to each of the three components of the vaccine (Ann. Rheum. Dis. 2007;[doi:10.1136/ard.2007.077552]).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those who are treated with anti-TNF-? agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study, including those with gastroenterologic disease, rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, spondyloarthropathy, and inflammatory bowel disease. Their mean age was 49 years (range 18-85 years). Patients in the anti-TNF group had been using the agents for an average of 24 months, with a range of 0.5-78 months.

All study participants were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-? agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with patients not taking an anti-TNF-? agent and with healthy controls.

Nevertheless, more than 80% of the patients in each of the three groups achieved titers high enough to protect them against infection; there were no significant differences among the groups on this measure.

When tested separately, infliximab, etanercept, and adalimumab all had similar effects on the patients' response to vaccination.

None of the patients reported major side effects, and none experienced any deterioration in an underlying condition that was attributed to the influenza vaccine. About 20% of the patients in all groups reported minor side effects following immunization, such as local pain or tenderness at the vaccine injection site, but there were no significant differences among the groups. Similarly, about 14% of all patients experienced systemic reactions such as fever, myalgia, or headache during the 4 weeks after vaccination.

Patients taking anti-tumor necrosis factor-? medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer, according to the results of a recent study.

The study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-? (anti-TNF-?) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls.

All three groups achieved about an 80% rate of protection to each of the three components of the vaccine (Ann. Rheum. Dis. 2007;[doi:10.1136/ard.2007.077552]).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those who are treated with anti-TNF-? agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study, including those with gastroenterologic disease, rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, spondyloarthropathy, and inflammatory bowel disease. Their mean age was 49 years (range 18-85 years). Patients in the anti-TNF group had been using the agents for an average of 24 months, with a range of 0.5-78 months.

All study participants were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-? agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with patients not taking an anti-TNF-? agent and with healthy controls.

Nevertheless, more than 80% of the patients in each of the three groups achieved titers high enough to protect them against infection; there were no significant differences among the groups on this measure.

When tested separately, infliximab, etanercept, and adalimumab all had similar effects on the patients' response to vaccination.

None of the patients reported major side effects, and none experienced any deterioration in an underlying condition that was attributed to the influenza vaccine. About 20% of the patients in all groups reported minor side effects following immunization, such as local pain or tenderness at the vaccine injection site, but there were no significant differences among the groups. Similarly, about 14% of all patients experienced systemic reactions such as fever, myalgia, or headache during the 4 weeks after vaccination.

Patients taking anti-tumor necrosis factor-? medications show somewhat impaired antibody response to influenza vaccination, but there is no decrease in the proportion of patients achieving a protective titer, according to the results of a recent study.

The study, by Dr. L.B.S. Gelinck of Leiden (the Netherlands) University Medical Center and colleagues, compared immunologic responses to the influenza vaccine in 64 patients taking anti-tumor necrosis factor-? (anti-TNF-?) medications for various autoimmune diseases with 48 patients with autoimmune diseases who were not taking those drugs. There were 18 healthy controls.

All three groups achieved about an 80% rate of protection to each of the three components of the vaccine (Ann. Rheum. Dis. 2007;[doi:10.1136/ard.2007.077552]).

Guidelines issued by the Centers for Disease Control and Prevention recommend annual vaccination for patients at risk of complications of influenza, including those who are treated with anti-TNF-? agents such as infliximab, etanercept, and adalimumab. On the other hand, findings from earlier studies on the effect of influenza vaccination on these patients were conflicting.

Patients with several autoimmune diseases were represented in the study, including those with gastroenterologic disease, rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, spondyloarthropathy, and inflammatory bowel disease. Their mean age was 49 years (range 18-85 years). Patients in the anti-TNF group had been using the agents for an average of 24 months, with a range of 0.5-78 months.

All study participants were vaccinated in the fall or winter of 2003 with a commercially available trivalent subunit influenza vaccine. Four weeks after vaccination, patients taking an anti-TNF-? agent had significantly lower geometric mean titers to two out of the three vaccine components, compared with patients not taking an anti-TNF-? agent and with healthy controls.

Nevertheless, more than 80% of the patients in each of the three groups achieved titers high enough to protect them against infection; there were no significant differences among the groups on this measure.

When tested separately, infliximab, etanercept, and adalimumab all had similar effects on the patients' response to vaccination.

None of the patients reported major side effects, and none experienced any deterioration in an underlying condition that was attributed to the influenza vaccine. About 20% of the patients in all groups reported minor side effects following immunization, such as local pain or tenderness at the vaccine injection site, but there were no significant differences among the groups. Similarly, about 14% of all patients experienced systemic reactions such as fever, myalgia, or headache during the 4 weeks after vaccination.

Medical societies have jointly issued new performance measures for cardiac rehabilitation that are expected to increase the number of patients referred to rehab services. The measures also promote a safe exercise environment for those patients, but stop short of holding cardiac rehabilitation centers responsible for meeting treatment goals.

Published simultaneously in Circulation and the Journal of the American College of Cardiology, the performance measures were developed by the American College of Cardiology, the Association of Cardiovascular and Pulmonary Rehabilitation, and the American Heart Association.

“Research continues to show that cardiac rehabilitation services, although very effective and helpful for people with cardiac disease, are still being vastly underutilized,” Dr. Randal J. Thomas said in an interview. Dr. Thomas, director of the Cardiovascular Health Clinic at the Mayo Clinic in Rochester, Minn., chaired the committee that wrote the new cardiac rehabilitation (CR) performance measures.

Despite the fact that CR after cardiac illness has been shown to reduce a patient's mortality risk by 20%–25%, and also to improve physical strength and endurance by 20%–50%, less than 30% of eligible patients participate. There are many reasons for this, but foremost among the correctable causes is that many patients are simply never referred to CR.

Dr. Thomas' committee developed two sets of performance measures. One set is intended to improve the referral of eligible patents to CR, and the other is aimed at improving the services offered by CR programs.

In the first set of measures, the committee specified that all hospitalized patients with eligible conditions should be referred to outpatient CR prior to discharge. In addition, outpatients with a qualifying diagnosis during the prior year should also be referred to CR if they have not yet participated.

The qualifying diagnoses are myocardial infarction, acute coronary syndrome, coronary artery bypass graft surgery, percutaneous coronary artery intervention, cardiac valve surgery, cardiac transplantation, and chronic stable angina. Patients with chronic heart failure and peripheral arterial disease should be considered for CR.

In the second set of measures, the committee specified that all CR programs have a physician medical director, a well-trained emergency response team, and equipment and supplies for emergency resuscitation in the exercise area. All patients should receive individualized assessment of and education about their modifiable cardiovascular risk factors.

The committee chose not to hold CR programs responsible for attainment of treatment goals. Dr. Thomas said that while some committee members suggested that CR programs should demonstrate that their patients are achieving LDL-cholesterol levels below 100 mg/dL or 70 mg/dL (for example), ultimately the committee conceded that this was not entirely under the programs' control. Some CR programs do take charge of their patients' prescriptions, but more commonly it's the patients' personal physicians who choose their regimens.

Dr. Thomas acknowledged that existing CR programs could not accommodate the huge influx of new patients that would result if the performance measures were implemented universally.

“We need to work together to establish new models that will help to provide the care necessary for everybody who's not getting the care,” he said. “For example, does everybody need to come into a cardiac rehabilitation center to receive rehabilitation and preventive care? The answer is no. There are a lot of publications showing the benefits of a system where patients would largely carry out their rehabilitation efforts at home or in a local health club, but still under the direction of a nurse and a physician.”

Dr. Thomas said that the insurance industry will have an important role to play if the performance measures are to be implemented. “There is an expectation and a hope, anyway, that the insurance carriers will see the value of some of the novel approaches to rehab and start reimbursing for those models of care, which they're not doing generally now.”

The full text of the cardiac rehabilitation performance measures is available at www.acc.org/qualityandscience/clinical/pdfs/CardiacRehab_PM_sept20.pdf

Medical societies have jointly issued new performance measures for cardiac rehabilitation that are expected to increase the number of patients referred to rehab services. The measures also promote a safe exercise environment for those patients, but stop short of holding cardiac rehabilitation centers responsible for meeting treatment goals.

Published simultaneously in Circulation and the Journal of the American College of Cardiology, the performance measures were developed by the American College of Cardiology, the Association of Cardiovascular and Pulmonary Rehabilitation, and the American Heart Association.

“Research continues to show that cardiac rehabilitation services, although very effective and helpful for people with cardiac disease, are still being vastly underutilized,” Dr. Randal J. Thomas said in an interview. Dr. Thomas, director of the Cardiovascular Health Clinic at the Mayo Clinic in Rochester, Minn., chaired the committee that wrote the new cardiac rehabilitation (CR) performance measures.

Despite the fact that CR after cardiac illness has been shown to reduce a patient's mortality risk by 20%–25%, and also to improve physical strength and endurance by 20%–50%, less than 30% of eligible patients participate. There are many reasons for this, but foremost among the correctable causes is that many patients are simply never referred to CR.

Dr. Thomas' committee developed two sets of performance measures. One set is intended to improve the referral of eligible patents to CR, and the other is aimed at improving the services offered by CR programs.

In the first set of measures, the committee specified that all hospitalized patients with eligible conditions should be referred to outpatient CR prior to discharge. In addition, outpatients with a qualifying diagnosis during the prior year should also be referred to CR if they have not yet participated.

The qualifying diagnoses are myocardial infarction, acute coronary syndrome, coronary artery bypass graft surgery, percutaneous coronary artery intervention, cardiac valve surgery, cardiac transplantation, and chronic stable angina. Patients with chronic heart failure and peripheral arterial disease should be considered for CR.

In the second set of measures, the committee specified that all CR programs have a physician medical director, a well-trained emergency response team, and equipment and supplies for emergency resuscitation in the exercise area. All patients should receive individualized assessment of and education about their modifiable cardiovascular risk factors.

The committee chose not to hold CR programs responsible for attainment of treatment goals. Dr. Thomas said that while some committee members suggested that CR programs should demonstrate that their patients are achieving LDL-cholesterol levels below 100 mg/dL or 70 mg/dL (for example), ultimately the committee conceded that this was not entirely under the programs' control. Some CR programs do take charge of their patients' prescriptions, but more commonly it's the patients' personal physicians who choose their regimens.

Dr. Thomas acknowledged that existing CR programs could not accommodate the huge influx of new patients that would result if the performance measures were implemented universally.

“We need to work together to establish new models that will help to provide the care necessary for everybody who's not getting the care,” he said. “For example, does everybody need to come into a cardiac rehabilitation center to receive rehabilitation and preventive care? The answer is no. There are a lot of publications showing the benefits of a system where patients would largely carry out their rehabilitation efforts at home or in a local health club, but still under the direction of a nurse and a physician.”

Dr. Thomas said that the insurance industry will have an important role to play if the performance measures are to be implemented. “There is an expectation and a hope, anyway, that the insurance carriers will see the value of some of the novel approaches to rehab and start reimbursing for those models of care, which they're not doing generally now.”

The full text of the cardiac rehabilitation performance measures is available at www.acc.org/qualityandscience/clinical/pdfs/CardiacRehab_PM_sept20.pdf

Medical societies have jointly issued new performance measures for cardiac rehabilitation that are expected to increase the number of patients referred to rehab services. The measures also promote a safe exercise environment for those patients, but stop short of holding cardiac rehabilitation centers responsible for meeting treatment goals.

Published simultaneously in Circulation and the Journal of the American College of Cardiology, the performance measures were developed by the American College of Cardiology, the Association of Cardiovascular and Pulmonary Rehabilitation, and the American Heart Association.

“Research continues to show that cardiac rehabilitation services, although very effective and helpful for people with cardiac disease, are still being vastly underutilized,” Dr. Randal J. Thomas said in an interview. Dr. Thomas, director of the Cardiovascular Health Clinic at the Mayo Clinic in Rochester, Minn., chaired the committee that wrote the new cardiac rehabilitation (CR) performance measures.

Despite the fact that CR after cardiac illness has been shown to reduce a patient's mortality risk by 20%–25%, and also to improve physical strength and endurance by 20%–50%, less than 30% of eligible patients participate. There are many reasons for this, but foremost among the correctable causes is that many patients are simply never referred to CR.

Dr. Thomas' committee developed two sets of performance measures. One set is intended to improve the referral of eligible patents to CR, and the other is aimed at improving the services offered by CR programs.

In the first set of measures, the committee specified that all hospitalized patients with eligible conditions should be referred to outpatient CR prior to discharge. In addition, outpatients with a qualifying diagnosis during the prior year should also be referred to CR if they have not yet participated.

The qualifying diagnoses are myocardial infarction, acute coronary syndrome, coronary artery bypass graft surgery, percutaneous coronary artery intervention, cardiac valve surgery, cardiac transplantation, and chronic stable angina. Patients with chronic heart failure and peripheral arterial disease should be considered for CR.

In the second set of measures, the committee specified that all CR programs have a physician medical director, a well-trained emergency response team, and equipment and supplies for emergency resuscitation in the exercise area. All patients should receive individualized assessment of and education about their modifiable cardiovascular risk factors.

The committee chose not to hold CR programs responsible for attainment of treatment goals. Dr. Thomas said that while some committee members suggested that CR programs should demonstrate that their patients are achieving LDL-cholesterol levels below 100 mg/dL or 70 mg/dL (for example), ultimately the committee conceded that this was not entirely under the programs' control. Some CR programs do take charge of their patients' prescriptions, but more commonly it's the patients' personal physicians who choose their regimens.

Dr. Thomas acknowledged that existing CR programs could not accommodate the huge influx of new patients that would result if the performance measures were implemented universally.

“We need to work together to establish new models that will help to provide the care necessary for everybody who's not getting the care,” he said. “For example, does everybody need to come into a cardiac rehabilitation center to receive rehabilitation and preventive care? The answer is no. There are a lot of publications showing the benefits of a system where patients would largely carry out their rehabilitation efforts at home or in a local health club, but still under the direction of a nurse and a physician.”

Dr. Thomas said that the insurance industry will have an important role to play if the performance measures are to be implemented. “There is an expectation and a hope, anyway, that the insurance carriers will see the value of some of the novel approaches to rehab and start reimbursing for those models of care, which they're not doing generally now.”

The full text of the cardiac rehabilitation performance measures is available at www.acc.org/qualityandscience/clinical/pdfs/CardiacRehab_PM_sept20.pdf