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COCA Conference Call Summaries and Slides:
Recent Developments in Seasonal Influenza Epidemiology and Prevention (May 27, 2008)
NOTE: This document is provided for historical purposes only and may not provide our most accurate and up-to-date information. The most current Clinician's information can be found on the Clinician Home Page.
Recent Developments in Seasonal Influenza Epidemiology and Prevention
Anthony Fiore, MD MPH
May 27, 2008
Coordinator: Welcome and thank you for standing by. At this time all participants are in a listen-only mode. After the presentation we will conduct a question and answer session. At that time to ask a question you press star then 1 on your touch-tone phone. Today's conference is being recorded. If you have any objections you may disconnect at this time.
I would now like to introduce your host for today's conference call, we have Miss Alycia Downs. And ma'am, you may begin.
Alycia Downs: Good afternoon and thank you for joining us for today's COCA conference call entitled "Recent Developments in Seasonal Influenza Epidemiology and Prevention."
We are very pleased to have Dr. Anthony Fiore present on this call.
We will be using a PowerPoint presentation that you should be able to access on our Web site. If you have not already downloaded the presentation, please go to www.emergency.cdc.gov/coca. Click on Conference Call Information Summaries and Slide Sets. The PowerPoint can be found there.
Dr. Fiore is a Medical Officer in the Influenza Division within the National Center for Immunization and Respiratory Diseases here at the Centers for Disease Control and Prevention in Atlanta, Georgia.
Some of his duties include developing and promulgating seasonal influenza vaccination policy, conducting and supervising epidemiologic investigations of influenza outbreaks and assessing influenza prevention strategies.
The objectives for today's call. After this activity the participants will be able to: describe at least two recent developments in influenza epidemiology and prevention, describe recent vaccine effectiveness study findings, and three, describe changes in vaccine recommendations for the 2008-2009 influenza season.
In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters as well as any use of unlabeled products or products under an investigational use.
CDC, our planners and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. This presentation does not involve the unlabeled use of a product or products under investigational use.
I will now turn the call over to Dr. Fiore.
Dr. Anthony Fiore: Thank you, and thank you all for tuning in today. I wanted to provide you with some information about the past influenza season and also describe some of the more recent information we have about what happened during this season, the vaccine effectiveness, and the vaccine coverage data that currently exist. Let's go to the next slide which should be titled Overview.
Now so as I said, we'll start out with a fairly elementary brief review of the clinical presentation epidemiology of influenza, with the idea that there are folks with a number of different backgrounds on this call. We'll review the season, talk about vaccine effectiveness overall in a general sense and also the preliminary data we have from this current season, give you some of the updated recommendations that have accompanied advisory committee on immunization practices, which is CDC advisory committee that makes vaccine recommendations, and then finally give you the coverage data.
Next slide please.
Human influenza is a highly transmissible respiratory illness caused by influenza viruses. And it results in yearly winter epidemics which are referred to as seasonal or inter-pandemic influenza.
Every once in a while though there is a pandemic, sporadic and unpredictable. As you probably know, we've had three of these pandemics in the last 100 years or so. And the what happens with a pandemic is that a new strain of virus shows up that virtually no one is immune to.
Attack rates can be very high and morbidity and mortality are elevated compared to the annual epidemics.
Now these annual epidemics though are not to be underestimated. In an average epidemic year, anywhere from 2.5% to 20% of the population can fall ill with influenza. The highest rates are typically in children. In some towns you'll see children attack rates of over 30%.
On average, 36,000 deaths a year are attributed to influenza. But this ranges widely according to the severity of the season.
Over 90% of the deaths in most seasons are in persons greater than 64 years old.
On average over 200,000 hospitalizations occur each year. Again, this is a wide range for the reasons I just gave for mortality.
About 50% of those who are hospitalized are more than 64 years old. But what's also interesting is that the risk of hospitalization for children younger than two years old is actually similar to the risk in the elderly. So the extremes of life are where you see most of the most severe illness.
Influenza epidemics annually result in a substantial economic impact. The burden was recently estimated at $87.1 billion annually, and that is accounted for both with hospitalization and other medical costs and lost work and then of course the cost of people having long term effects of influenza.
Now influenza viruses come in a variety of different types: Influenza Virus Type A is the one that typically is of most interest and causes the most morbidity and mortality.
Influenza Viruses Type A are subtypes based on the surface glycoproteins. And these proteins exist on the structure of the virus. There are 16 hemoglutinin proteins and nine different neuraminidase proteins that influenza virus can have. Influenza virus just has one of each. But the various combinations result in a large number of different potential influenza Type A viruses.
The currently circulating human subtypes are called H1N1 and H3N2. Influenza Type A viruses are a large proportion of seasonal influenza. They're also the only influenza virus type that can actually cause a pandemic.
These viruses can infect multiple other species, and they can jump between these species amid birds, pigs, horses, dogs and other mammals -- and - other mammals for the most part can be infected with this influenza virus and potentially can serve as a source for other animals.
Birds are the main reservoir though for the new subtypes - that is the new hemoglutinin subtypes.
Now just a word about two different concepts about how influenza viruses change. One of them - and this is antigenic drift and antigenic shift.
Antigenic drift is what's going on all the time. These are small mutations in the viral genes, a continual process that's occurring during the influenza season.
And the result is that over time people have diminished immune responses to strains they've previously been infected with or been immunized against.
So in other words, an H3N2 strain that you were infected with three or four years ago, when it shows up this year it's changed enough that your immune system no longer gives you full protection against it.
The result is that you get yearly epidemics because there's a new wave of susceptible people every year. And this also requires that the vaccine gets updated yearly.
Antigenic shift is a more radical form of genetic change. And that means that you change out the entire hem agglutinin and neuraminidase subtype. And by the way, we should be on the slide entitled Antigenic Drift and Shift. I'm sorry, I don't think I said shift slide.
And this is a sporadic or unpredictable event that result is that there's no immunity within the population. And this is what can result in a pandemic.
However, it's important also to remember that there are many reports of transmission of animal influenza viruses of different hemoglutinin types to humans. And these don't always result in a pandemic.
Obviously you probably have heard about the H5N1 or the so-called bird flu cases. And I'll mention that more in a minute.
But there are also other ones - N7N2, H7N9 - of the various swine influenza viruses that occasionally infect humans, but have not resulted in pandemics.
Next slide.
The influenza A H5N1 is the one of most interest most recently. And this has been a very deadly virus for birds. There have been large scale bird outbreaks in Asia, Africa, Europe, and the Middle East.
The virus is highly lethal to domestic poultry. And we, at any given time, have multiple outbreaks going on around the world, and has resulted in 382 known human cases so far including 241 of those cases that have died since 2003.
Now almost all of these people had very close contact with infected domestic birds. There's been no efficient human to human transmission of N5N1 however, and now obviously H5N1 is the influenza virus of greatest concern at this moment, partly because several hundred humans have been infected, but also because of the high lethality. But there are other influenza viruses that we are also tracking.
Next slide please.
Influenza Virus Types B and C are two other forms of influenza viruses. Type B is only found in humans. It certainly does circulate in the US and worldwide every year, causes lots of illnesses in general, causes less mortality in most years compared to Type A; although that doesn't always hold true.
And its associated with the annual winter epidemics but not pandemics. And every year the influenza vaccine contains one influenza Type B strain.
Influenza C is not well understood. It appears to cause mild sporadic disease. It's not included in the vaccine and not usually discussed much beyond what we just discussed.
Next slide please.
The influenza clinical diagnosis, it's important to remember that these clinical symptoms are non-specific, and they overlap with many other pathogens. There are lots of respiratory illnesses that circulate, especially in the winter. And only a proportion of them are due to influenza viruses.
So what you need in order to establish the diagnosis: laboratory data. There are rapid tests now available that can be done in clinics or in hospitals, and you can get results in 30 minutes or less. But these are most often used, but they sometimes have poor sensitivity in adults, meaning that they don't pick up every influenza case.
Culture and preliminary chain reaction (or PCR) are available. But these are not typically going to be timely enough by clinicians with much information that they can actually use to treat patients.
So again, to make the point that not all respiratory illnesses is influenza even at the peak of influenza season, only about 25% to 35% of specimens who have an acute respiratory infection end up being positive for influenza.
Next slide please.
Now I'll just describe to you some of the information from this most recent influenza season which we just have more or less wrapped up at this point. So this is the 2007-2008 information.
Next slide please.
This diagram depicts how information about influenza surveillance flows into CDC and what we do with it. We get influenza information from a variety of different sources: from laboratories, from providers who agreed to send us specimens and provide us with clinical information about cases, from population-based surveillance systems that look at hospitalizations, from the states territorial epidemiologists, from the vital statistics, and then also through national reporting systems.
There are two types of influenza that are on nationally reportable. One of them is deaths in children due to lab confirmed influenza and the other is a novel influenza virus that's not one of the typical ones circulating.
And we send this information back out to the public and public health officials and clinicians and so on.
Next slide please.
Just describe to you in a little bit more detail about influenza surveillance. We'll start off with geographic spread. Next slide.
This is a publication that we've just started this past year that summarizes by week information about the influenza surveillance in the US.
And what you see here is a map of the US. And I'll show you over the next, I guess five or six slides, a series of maps that sort of give you almost a moving picture of what the influenza season did in this last year as far as widespread across states and the severity within these.
In the first slide what you see is for the week ending November 10, we really didn't have a whole lot going on with influenza, just a couple of states reporting local activity.
Things stayed pretty quiet with the next slide, with just a few more states reporting local activity going all the way to the end of December and starting to actually get into the typical Influenza season.
We still had relatively little activity out there with most states reporting only sporadic activity and just a few reporting local or regional activity.
January 5 things started to pick up a little bit. We had our first state report widespread activity.
Again, going to January 19th on the next slide you'll see the few more states added. And then things really hit in February. And February is the peak month for most influenza.
We have multiple states by February 2 reporting widespread activity. By February 23 the whole country was sucked in. And this was a relatively more severe influenza season compared to the last couple where we had widespread activity nationwide for the first time in a couple of years all in the same week.
And then finally on March 15, you can see activity starting to lighten up a bit. And then the last slide I have here is April 26 with most states down to no activity, or just sporadic activity.
I'm sorry, there was one more slide ending May 10, again, showing just about everything gone.
We also monitor influenza by looking at the viruses that are sent in to us for characterization. This is another way to kind of follow the season. What this is showing here is the number of isolates and the percent that are positive for influenza. And remember I told you back even at the peak of the season only 25% to 35% are going to be positive influenza.
And here what you see is by February of this past year we were up over 40% that were positive for influenza.
Now what the pie chart is telling you is that this was a predominately H3N2 year with over half the isolates that were sent to us being characterized as being the H3N2 subtypes, with B coming in second and relatively mild years as far as H1N1 strain goes.
CDC, the laboratories here also do a fairly laborious characterization of the viruses to determine how closely matched the circulating strains are to the vaccine strains.
What you see here is a couple of bullets on the next slide titled Strain Characterization that showed that influenza A H1N1 isolates that have been characterized; 381 have been characterized thus far, and we're continuing to do this.
Sixty-nine percent of them were a pretty good match with the vaccine strain that was in last year's vaccine. That is the 2007-2008 vaccine.
Now for the H3 viruses, the match between the circulating viruses and the vaccine viruses was less good. And then only about 21% matched.
For Influenza B the characterization is a little bit different. There are two main lineages is what they're called, two main subtypes of Influenza B. And we did not match the subtype very well this year with the circulating strain. You can see only 3% of them were in the same subtype.
Next slide please. We'll talk a bit about mortality in the next slide. What you're looking at now is a modeling estimate of pneumonia and influenza mortality that's based upon vital records reporting from 122 US cities. In other words, cities send us the cause of death of people that die in their cities over the course of the influenza season, the two wavy sort of sine wave type lines there are a predicted seasonal baseline on the bottom line and on the top a threshold of which we say there's epidemic influenza causing mortality.
And the red line is the actual data plotted. And so what you see here is five seasons worth of data. If you look to the far right you see that data from this recent influenza season. You see we were well up over the epidemic threshold for, you know, about 10 weeks there.
And this is by comparison to the last two seasons, where you can see we just barely got up above the epidemic threshold. They were much milder seasons and what we just saw.
Going back all the way to the 2003-2004 season you can see on the far left there, a real sharp peak with the red line. And that was the most severe season that we had until this season over the last five years.
In other words we have three relatively mild seasons book ended by the 2003-2004 season and the last one.
I mention that influenza associated pediatric deaths are reportable disease. As of May 14 we've had 71 influenza associated deaths reported. The median age of children that died was 4.5 years. Only five of them were fully vaccinated.
Bacterial co-infections are a source of continuing concern to CDC and some of you may have actually seen some of these.
Among those children that died, 43% had a Staphylococcus aureus co-infection, including 12 that had a methicillin-resistant Staphylococcus aureus infection: something we're keeping an eye on.
Just by way of comparison, compared to the last couple of years we've had anywhere between about 40 and 70 deaths per year. So but the data isn't all complete for this year. It looks like, as far as number of children that died, it looks like a little worse than it had been in the past couple of years.
We also follow outpatient illnesses. We do this through our Sentinel provider system. And in this system providers who - clinicians that is - who see persons with respiratory illness keep track of how many persons with respiratory illness come into their offices.
Some of these same providers also send us viral specimens. And they can get a sense of the influenza season and in general the respiratory virus season by following the trends here.
What you see here is three years worth of data. You see this previous two seasons with the red and blue lines. There's two different systems that are a little complicated to explain here.
But in both of those two different systems we just had a little bit above the expected baseline.
And then in this past season we had a pretty substantial spike up above the baseline. That's the spike on the far right there. Again, just another reflection of this season being somewhat worse than the last couple.
We also follow hospitalizations. We do this in several population-based surveillance systems. I'll just show you one of them here. In this system what you see is this is a three city area of a couple million people.
And we're following hospitalizations in children that are between zero and 4 years old. And you see five years worth of data here.
The most recent year, the one that we just went through is in the red line, and this by comparison can be looked at compared to the 2003-2004 season which is the line that's well above the others, that's -at least on my computer- is light blue and then the past three seasons which are more less the 2007-2008.
And then finally something that probably will be of interest to you which is that the trend of antiviral resistance among influenza isolates.
As of May 10 we tested 1591 isolates to see whether they were resistant to neuraminidase inhibitors. Neuraminidase inhibitors are the class of drugs that are recommended for treatment of influenza right now. Oseltamivir is the oral drug that's used. Zanamivir is the inhaled drug that's used.
And what we found is that 11% of the 969 influenza A H1N1 viruses that have been tested were actually resistant to oseltamivir. All of these had a single particular mutation. And this compares to the 2007 season when only 0.7% of influenza A H1N1 viruses tested for resistant oseltamivir.
But there is some good news here, which is that of the 332 H3N2 viruses and the 290 influenza B viruses, zero of those were resistant to oseltamivir. So and all the tested viruses did remain sensitive to zanamivir.
So overall, given the fact that only one of the three strains, and it wasn't the dominant strain this year, has any resistance to oseltamivir. The overall rate of resistance there's only about 2% this year.
Now, Adamantanes are another class of antiviral drugs. These are rimantadine and amantadine. These drugs are no longer recommended it in the US for treatment of prevention of influenza because of the very high rates of resistance that have been observed.
And you can see here 99% of the H3N2 viruses tested were resistant. And about 14% of the H1N1s were resistant. Next slide please.
Now how does this compare worldwide, because there is worldwide surveillance for antiviral resistance?
Well looking at this slide you can see a list of countries down the Y axis there with - we've put in Canada in the US and a couple others that weren't part of this main reporting system down at the bottom there just by comparison.
What you can see is that Norway at the top leads the pack with 66% of their H1N1. France has over 40%. The USA came in - at least when the graph was made at 10.5%. And - but a number of European countries were around the same range. So clearly this is a worldwide phenomenon.
And interestingly enough, it doesn't appear to have a whole lot to do with actual use of oseltamivir. Because Japan loses uses a lot of oseltamivir and only has 2% resistant. A lot more oseltamivir per capita certainly than Norway or France or Netherlands or any of those other countries you see with very high rates of resistance.
Next slide please.
I wanted to talk a little bit about vaccine effectiveness also because I think that was a source of some confusion in this past year.
There are a number of things that go into just speaking generally now, that go into how people respond to the vaccine.
Of course the obvious one that you probably have seen in your own practice is age: persons that are elderly, and that are infants and the chronically ill, they generally have lower antibody responses to vaccine.
So prior exposure to the virus strains that are similar to those in the vaccine also determines your response to the vaccine.
Of course immune competence, people that are immunocompromised respond less well.
The amount of antigen that's in the vaccine that's - makes it so not such a source of clinical concern, but it does - it is generally true that higher amounts of antigen give you a better response.
And then the viruses themselves differ somewhat as to how robust the immune response is.
Next slide please. And actually my slides were slightly out of order. You can go onto the next slide which is how to measuring seasonal influenza vaccine effectiveness.
Now I mentioned how effectiveness, but before we talked about immunogenicity. And effectiveness is actually how well does the vaccine present disease. And this varies also according to age group and according to risk group. It also varies according to the timing of the season and the intensity of the season.
And finally, it varies according to how well the circulating strains match against the vaccine strains.
Now when you look in the literature or you hear about the studies that talk about vaccine effectiveness, it's important to keep in mind that comparisons across studies are surprisingly difficult to do.
First of all as I say, vaccine effectiveness varies a great deal season to season based on the factors that we just mentioned above. But also studies have different sorts of outcomes that they measure.
For example, some studies might just measure influenza like illness like fever and cough, sore throat as a case definition.
This is a nonspecific outcome. It's relatively easy to ascertain. But you can see that there would be a lot of people who wouldn't actually have Influenza included in this measurement.
So your vaccine effectiveness is going to be somewhat low in these sorts of studies and speaking generally.
Now laboratory confirmed influenza is the best sort of outcome to use. Then you know that everyone who gets sick, you know whether or not they actually had influenza and you know whether the vaccine should have prevented it.
But these are tough studies to do because it requires a lot of laboratory work, a lot of set up ahead of time. And so these are the Cadillac type studies but also the ones that are most difficult to do and represent a minority of what's actually in the literature.
So generally speaking what we found over the years is that vaccine effectiveness conducted in years when what we call drift years when the predominant circulating viruses significantly drifted from the vaccine strain -- and let me pause here and just mention we should be on the next slide which is entitled Vaccine Effectiveness, when vaccine strains are not - circulating strains are not well matched.
In general in these drift years what you see is that the vaccine effectiveness is somewhat lower in preventing this most specific outcome of laboratory confirmed influenza.
In fact when you look at the confidence limits around that estimate of vaccine effectiveness, in some of these years you might actually see that the confidence limit includes zero which means that we can't actually be certain statistically speaking that the vaccine had effectiveness.
However, in some studies in some of these years what we still see is that even if it doesn't - vaccine doesn't prevent actual influenza infection, it might provide some protection for some of the more severe outcomes which of course are the ones we care most about. And that is hospitalization and propensity to seek medical care.
This is presumably due to the fact that the vaccine even when it doesn't match well to strains they're circulating gives some partial protection. [At] the bottom of the slide I listed a couple recent publications that illustrated this phenomenon of partial protection.
Next slide please.
So this slide is a summary slide of the range of effectiveness that we've seen over the years according to age and risk group.
So for example in children that are six months to 16 years, healthy children with a specific lab confirmed outcome of influenza virus infection, effectiveness ranges anywhere from 50% to 90%. And that's also true with healthy adults less than 65.
And for persons that are elderly, the vaccine effectiveness ranges have been generally lower and also can sometimes even be a wider range. So you see effectiveness assessments going down to 30% or even lower. And that's even in years when we think there's a pretty good match.
For elderly in the nursing home lower still in general -- 30% to 40%. But it's actually against hospitalization for those elderly nursing home patients can be more in the range of 30% to 60%.
Next slide please.
So with that in mind, we've had a lot of interest in recent years with getting data more rapidly about vaccine effectiveness so we could tell people even within the season how good the vaccine is working. And this was the first year that we've been able to get this data out within the season.
This next slide gives the title of a publication in our CDC publication Morbidity and Mortality Weekly Report published back in April that was entitled the Interim Within Season Estimates, the Effectiveness of Inactivated Vaccine in Marshfield, Wisconsin which is where our population-based surveillance system exists to actually do this.
So the objectives of this study were to estimate effectiveness for preventing medically attended acute respiratory illness, lab confirmed as influenza.
What that means in shorter words is that we were trying to measure lab confirmed influenza in persons who actually came to see the doctor. So we weren't measuring effectiveness against actually any infection. It was infection that was enough that made people come to see the doctor.
And so the intent here is to provide an interim vaccine effectiveness estimate which is what you'll see in a minute. And then also at some time after the end of the season - probably the end of the summer - to give you sort of the final version of it.
So that final version isn't out yet, but the interim estimate is where you'll see there.
So this study included patients that were enrolled throughout the influenza season in this Marshfield area. They were in 14 different ZIP codes. The moment began when their influenza season picked up on the 21st of January and this interim data goes through February 8th.
So cases in this instance were persons with medically attended acute respiratory illness that were confirmed influenza and controls for persons that came into the doctor with some sort of respiratory illness that turned out to be negative for influenza.
What we found is that despite the fact, that as I mentioned earlier in the surveillance portion, that the match between circulating strains and vaccine strains was not as good this year as we had hoped. In fact two of the three strains did not match well.
The vaccine effectiveness estimate was 44%. And for persons who had H3N2 infection it was actually 58%. However, the vaccine effectiveness could not be distinguished from zero. In other words, we don't know how effective it was but it wasn't very against Influenza B.
So what this is telling us is a couple things. One is that we have to be cautious when we interpret that antigenic characterization data I gave you before, that is the data that in the laboratory tries to match the circulating strains against the strains that are in the vaccine.
We have to interpret that with caution because in fact the clinical effectiveness might be pretty good. And in this instance it was 44% and 58% against the influenza A H3N2 strain.
It also showed us that it is feasible, and it's something that we presumably would be able to do each year: to base within season estimates the vaccine effectiveness. And we will have that final estimate for this year later on this summer sometime.
So in summary for the 2007-2008 flu season: what we saw was a moderately severe season. It had a typical February/March kind of peak. We saw a number of different viral types. But it was Influenza A, H3N2 predominating.
Now for the first time significant levels of oseltamivir resistance which means that we need to increase our global surveillance to monitor the trends and then study to figure out what exactly the clinical impact is of being infected with influenza virus that's resistant to one of the main drugs we used to treat it.
And finally, the vaccine effectiveness most likely moderate, not as good as we'd like but likely did provide some protection despite the fact that the strains circulating were somewhat different than the strains that were in the vaccine.
Next slide please. We're now on the new and updated recommendations from the Advisory Committee on Immunization Practices. And I'll just briefly go through these. There was one major change and a couple of minor ones I'll tell you about in a minute.
First of all just by way of background, there's been increasing interest, as you all know, in universal vaccination against flu. And that's due to a couple of reasons. I think one of them is because there's been a better understanding of the health and the economic impact of influenza, not only among the elderly and the younger children, but also among older children and adults.
There is also recognition that the vaccine doesn't work as well as we'd like particularly in the groups that are at the highest risk for complications such as the elderly or persons with chronic illness.
There's also the idea, although not well proven yet, that if we could reduce community transmission by vaccinating schoolchildren and healthy adults and if we got high enough coverage we could reduce transmission within the community and sort of indirectly protect some of those persons who don't respond so well to the vaccine.
We're also not as concerned as we once were about the vaccine supply. We've gone from two to five manufacturers and we'll probably have a least one or two more in the next couple of years now that we have multiple sources of vaccine now, and they're producing more vaccine than we actually use.
There's the belief that if we could expand the age groups that are recommended for vaccination we might get better coverage overall because the vaccination recommendation would be pretty simple.
And finally there's been increased concern as we alluded to earlier about an influenza pandemic. And we need to learn how to vaccinate a whole population against influenza if we can in the case of a pandemic, and what better way to start then with seasonal influenza, which as we discussed has a substantial impact all on its own.
Now the rationale for expanding vaccination beginning with all school age children and adolescents is summarized on this next slide. And I have listed here the rationale.
And this is not the ACIP words, but sort of a general idea of why we would do this. And it's three main lines that are driving this.
One is that influenza has a substantial adverse impact among school age children in ways that we hadn't typically measured before, so not really talking about hospitalization here and severe outcomes but in things that are more common and take their toll, such as increasing school absenteeism, use of antibiotics inappropriately, medical care visits, and causing their parents to miss work.
There is also evidence - lots of evidence - that the vaccine is effective and safe in school age children.
And finally there's this idea that if we made the vaccination recommendations somewhat simpler that we'd improve the load vaccine coverage we have among the approximately 50% of children who already have an indication for vaccination.
In other words what I didn't tell you before I'll tell you now is that about 50% of school age children already have a reason to be vaccinated. Either they have a chronic illness like asthma or something like that or they have contact with persons in their households. With these contact persons being at higher risk for influenza complications.
In other words, they might have a baby sister. They might have an older brother with asthma. They might be living with the grandmother.
For that reason those children already are recommended to be vaccinated.
The committee has also noted that there is this idea that we could have an indirect effect that I mentioned before if we could reduce influenza among persons who have close contact - sorry, if we could reduce infections among young children, school age children, we could reduce infections overall. That's going to require substantially higher vaccination coverage that we currently have.
Next slide please.
So with all this rationale and discussions in mind, the ACIP this past February approved a recommendation to begin vaccinating all school age children. And the way the recommendation is worded is that they say they would like to see this begin in this coming influenza season, that is in 2008-2009, but recognizes that in some instances this may not be feasible. Practices or immunization programs may not be set up to begin vaccinating all children.
And so therefore this recommendation to advance to all children beyond the current recommendations is supposed to begin no later than the 2009-2010 season. It really should begin in 2008-2009 if possible.
Next slide please.
So here the recommendation changes over time for use of influenza vaccine. Just to give you a sense of how quickly these have advanced. Because I know some folks have been somewhat impatient with the pace but I think it's been really pretty fast.
And before 2000 the recommendations were focused on persons 65 and older and persons who had chronic medical conditions that put them at risk, pregnant women, contacts of those persons, and healthcare workers.
And in 2000 the recommendations were advanced to adults 50 and older. In 2004 the recommendation for the first time was all children aged six to 23 months as well as their contacts. And the recommendation for pregnant women was broadened somewhat to include all women who would be pregnant during the flu season.
In 2006 the child recommendation was expanded up to 59 months as well as the contacts of those children. And then in 2008 this new recommendation I just mentioned to you. Now it's for all children aged six months to18 years. Next slide please.
Let me give you a little bit, and wind this up and open it up for questions, with the discussion of some of the influenza vaccine coverage data that's available. Because it gives us a sense of how well we actually dealing with all these new recommendations.
First looking at the coverage in young children. Now remember I mentioned back in 2004 was the first time that children six to 23 months old were recommended for annual vaccination.
And here's some coverage data over three years at six different sites. So what you see is six sets of bar graphs, six sets of three bar each rather, bar graphs. And I think I'd like you to focus on the bottom graph which is entitled Fully Vaccinated. These are children that got, if appropriate, got two doses in their first year.
And what you see is a fairly low coverage, and unfortunately not a whole lot of progress in each of these six sites over the course of these three years. In other words if you picked just looking at the middle of the graph if you picked say Michigan you'd see that they had gone over the course of three years from about 10% to about 20% coverage - you know, some progress there.
On the other hand there was some sites that bounced around or actually even went down a little bit for example Minnesota.
And what this is telling us is that we're really kind of stuck at the 20%, 25% coverage over the last three years for children who are 6 to 23 months old.
And that's not great. I mean I think it reflects the challenges of actually doing this. But it doesn't compare very well to some of the other recently introduced vaccines as I alluded to on the slide here. For example, Varicella, Hepatitis B or pneumococcal vaccine. They actually boosted their coverage up a lot faster than flu vaccine has, recognizing that flu vaccine poses a number of unique challenges which we haven't talked about today.
Next slide please.
This slide shows information from the National Health Interview Survey. And this is mostly adult groups here, actually all adult groups. And what you see is that over time we've had some increases in vaccine coverage, particularly among 65 year olds such that we are now running about 70% or so coverage for 65 year olds versus 65 and older.
Other groups though have had very modest increases or have stalled out in terms of increases. For example, pregnant women, still run about no more than 12% to 15% coverage each year.
For persons, health-care workers for example, shown in the green triangles we see coverage is no more than 40% each year. For high risk 18 to 49-year-olds, those are persons who are recommended for vaccine because of their chronic illness that they have - asthma or sickle cell anemia or cancer or what have you - their coverage is only around - this is looking at the yellow bar - their coverage is not much over 20%.
So really pretty - two things I get out of this - these graphs here. One is that coverage is not very high in most of the groups. The only group that we really are getting anywhere near our goals is in the elderly.
But the others that we've sort of stalled out in our ability to get vaccine to folks. And there are lots and lots of challenges to actually doing this. But certainly the issues of supply that we had a couple of years ago are no longer there. And we have to just figure out how this could best be utilized.
The next slide please.
A couple of the key updates from the 2008 recommendations, and I think that will wrap it up and we'll be able to open it up for questions.
First of all, this is the first annual recommendation that includes the new age group for use of the live attenuated vaccine that's reviewed as your LAIV.
So in other words now you can use either the shot, the TIV or the intranasal Vaccine, LAIV when you're vaccinating healthy persons aged 2 to 49 years old.
There are a couple other wrinkles with this new expanded recommendation. One is that the children being vaccinated for the first time who are eligible for two doses in that first year should have the doses separated by four weeks for both of those two vaccines. And that is children being vaccinated for the first time age 6 months to eight years, have two doses separated by four weeks.
And it used to be a little bit different for the two vaccines, but now it's the same, that is the gap in time between the two doses.
So for children who are 2 to 4, 2 to 4 years that is, 2 to their 5th birthday who are going to get LAIV, they should be screened for reactive airways disease because of a low but significant association among those young children getting LAIV with some wheezing, the wheezing with - handled generally with just inhalers. But the suggestion is that person's who have a predisposition for wheezing, in other words, who have had wheezing in the past should probably discuss with their doctor whether a TIV might be a better vaccine for those very young children.
And in the MMWR I listed here there are some very detailed screening recommendations for determining who would be eligible for LAIV among young children.
Finally the last point I have here is that a healthy as defined here means no chronic underlying medical illness. It doesn't mean a bad knee or psychiatric illness. It's something that puts you at risk for influenza complications.
And so in other words, anyone 2 to 49 who is relatively healthy and then has no chronic medical condition that puts them at risk for flu complications can get either TIV or LAIV.
The second big change for this influenza season is that all three of the strains have been changed out. So the new strains have their names listed here. I won't go into the viral nomenclature. But it is the first time we've changed out all three of the strains for the annual vaccine. Usually one or two strains are changed out.
And finally, keep an eye on this problem with neuraminidase inhibitor resistance that was identified where there may be a fairly - if the resistance were to increase substantially that we may need to keep an eye this coming influenza season on antiviral treatment recommendations because they could change according to what the early surveillance shows us.
But it's important to keep in mind that the Adamantine class of drugs, that is Amantadine or Rimantidine which has not been recommended for several years now continue to not be recommended really high levels of resistance against those drugs.
Next slide please.
That wraps up the talk. So thank you very much for your attention and I'll turn it over now to Ms Downs. And any questions that may come up I'll be happy to answer them.
Alycia Downs: Yes, thank you very much. That was a very informative presentation. So we can go ahead and open up the lines for the question and answer session.
Coordinator: Thank you. If you would like to ask a question, please press star then 1 on your touch-tone phone. Please record your name when prompted. I do need your name in order to introduce the question.
If you do have to withdraw a question you can press star 2. And let's hold a moment for the first question.
The first question your line is open ma'am.
Question Hi. Thank you Dr. Fiore for your presentation. I have two questions. One is does increasing - how can we increase the numbers of pregnant women who are getting vaccinated?
Anecdotally we've seen a lot of healthcare providers who are hesitant to give flu vaccines even during the second and third trimester much less for women who are thinking of getting pregnant.
Does the CDC have information regarding their effectiveness and risk of any type of adverse reactions with pregnant women that we don't have any information on that. So that will be my first question.
And then the second question is regarding the therapy or LAIV being used for vaccinating healthy persons.
The two doses, does that go up to eight years or is it children younger than 9? Because I'm looking at the CIS and that sort of indicates there so just a clarification on what should be said to the public when we give them that advice for the two dose for the first time? Thank you.
Dr. Anthony Fiore: Okay. Two good questions. Let me tackle the second one first…
Question Cont'd: Okay.
Dr. Anthony Fiore: …because I think that's potentially - it's confusing the way we write it. And that's something we - I wish we could do a little better.
The long dash that's between the two ages is meant to include that upper age.
So in other words, the two doses in their first season. That upper range limit for kids is out to their 9th birthday, so through age 8.
So sometimes you'll see that listed 2 long dash 8. Sometimes you'll see that listed less than 9. It's all meant to be the same.
Question cont'd: Okay.
Dr. Anthony Fiore: So for the first question you had, how do we get pregnant women vaccinated better? That is of course a continuing source of concern, not just in CDC but also, for example, the American College of Obstetricians and Gynecologists which has endorsed vaccination of pregnant women for many years.
I think there's a natural reluctance for providers to give anything to pregnant women because of concerns that it could adversely affect either mom or the baby. And then that's of course dates back many years and includes all sorts of medications - not just flu vaccine.
But we have accumulated data over the years that show a couple of things. One is that pregnant women are at higher risk for influenza complications. So you see sort of your calculation of risk and benefit, have to take that into account also.
There's also evidence that protecting the mother against influenza may have some benefits for the baby. It may have direct benefits through passage of antibodies to the baby around the time of birth.
But also remember that the children less than six months old can't be vaccinated because the vaccine doesn't work well in them. And so their only protection is to protect those around them and to avoid having them getting exposed to flu in the first place.
So having mom protected before she gives birth will mean she's protected right after birth so the baby's really at a very vulnerable stage and we don't have anything else to protect them.
There is evidence for safety and for effectiveness out there. They're not CDC publications necessarily but there have been trials showing both safety and effectiveness in women - in pregnant women that is.
And we do carefully track adverse events through a variety of different reporting systems here. And we don't see increases in adverse events associated with giving flu vaccine and pregnancy.
And that being said, I do think we need more studies and we might also benefit from having the labeling be a little bit more clear because the way you these things – vaccines and other medications are labeled for safety in pregnant women really the labeling is fairly stringent. There has to be very specific sorts of trials having been done.
And of course you're between a rock and a hard place a little bit when you're talking about doing trials in pregnant women. Nobody wants to do them. And so you end up not ever being able to prove definitively safety.
So I think we are moving towards better ways to study safety and to assure safety and we continue to monitor it. It's endorsed - vaccination for pregnant women is endorsed by a number of different groups. The American College of Obstetricians and Gynecologists I mentioned, of course CDC and then American Academy of Family Practitioners, American Academy of Pediatricians all endorse it.
There are a number of different people who've looked at safety and effectiveness and come to the conclusion that on balance it's - taking the vaccine is a good thing to do.
And I think just continuing to provide education to clinicians and to pregnant women themselves is really the only thing we can do with the hopes that some of that will eventually become more accepted.
Question Cont'd: Thank you.
Coordinator: The next question.
Question Yes hi. Can you please provide additional information regarding oseltamivir resistant influenza. Regarding that clinical significance, has treatment failure been documented with oseltamivir resistant influenza as well as what about potential treatment options for resistant isolates?
Dr. Anthony Fiore: Okay, that's a good question also. The places that we've seen oseltamivir resistance has in a sense been by accident. I mean we collect lots and lots of viruses to characterize them around the country. And we are in the process of following-up on everyone who is found to have a resistant virus. But what we're finding is that they just had typical flu.
So they weren't people who came in with a severe infection, got oseltamivir, failed treatment and, you know, did poorly because of that. They're people who are getting a virus that really acts - appears to act the same but for whatever reason is resistant to oseltamivir.
It's not - doesn't appear to have anything to do with use of oseltamivir. It's something the virus is - there must be some other advantage to the virus or at least that's the current theory to being resistant to oseltamivir. It may have nothing to do with oseltamivir itself. I am getting a little too detailed with the virology here. But there may be other advantages to carrying the genes that have resistance without necessarily being exposed to oseltamivir.
So we're not seeing treatment failures, at least not that I've heard about. There were previous to this season, instances of people, you know, predominately immuno-compromised who shed virus, who were treated with oseltamivir for many weeks and eventually began shedding resistant viruses.
But that's not what we're seeing here. What we're saying is it's just part of the mix of H1N1s to be resistant.
So that being said, there are options for treatment. I mentioned that none of the viruses thus far have been resistant to Zanamivir which is another similar drug that's given by inhalation. So you could, if you were concerned about it you could use Zanamivir. And that's probably your best option.
I mean some people - we have not advocated or studied any of this. And some people have given dual therapy. It really depends on how ill the person is and how much Oseltamivir resistance you believe to be in your area.
But as far as clinical significance goes, remember last year was a year was predominately H3N2. It was somewhat less B. And then H1N1 came in third place out of three. And it's the only place we've seen resistance is in that H1N1 group.
So overall it's less than 2% of the viruses in the US that were resistant. But we are going to very carefully monitor that.
Did that answer the question?
Question cont'd: That's great. Thank you.
Alycia Downs: Well I want to thank Dr. Fiore again for providing our listeners with this information. And I want to thank the participants for joining us today.
If you think of other questions please send an email to firstname.lastname@example.com. That's firstname.lastname@example.com.
The recording of this call and the transcripts will be posted to the COCA Web site www.emergency.cdc.gov/coca as they come to us.
You have one year to obtain continuing education credits for this call. All continuing education credit calls for COCA conference calls are issued online through the CDC Training and Continuing Education Online System, www.2a.cdc.gov/tce online.
Again, thank you Dr. Fiore and I hope everyone has a wonderful day.
Dr. Anthony Fiore: Thanks.
- Page last updated May 27, 2008
- Content source: CDC Emergency Risk Communication Branch (ERCB), Division of Emergency Operations (DEO), Office of Public Health Preparedness and Response (OPHPR)
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D.J. and BamBam are brother and sister bengal cats. They provide hours of entertainment! So much fun to have them around. The just 16 months old, so we have many fun years to look forward to!
best kitties in town
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Welcome to the homepage of the UWEC French Club. Le Salon Français strives to immerse students in cultural events in Eau Claire as well promote the study of French language and culture.
Next weekend UAC Films will be showing Le Samouraï a 1960s French film. Le Salon Français will be going as a group on Thursday, Nov. 4 to the 8:30pm showing. We will meet by the Davies coffee shop at 7pm to have some café and conversation before heading to Davies Theater. Please join us!
International Folk Fair 2010!
Folk Fair is being held on Sunday, Nov. 7 from 12-4pm.
The French Club theme this year is "French Around the World". We will have info about the French-Speaking World, rice pudding and coffee for sale, as well as having fun games to play. Please come check us out!
To join our e-mail
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Join French Club on Facebook for updates on French Club Events!
This website
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Ireland is essentially a small island off mainland Europe, making he Irish a bunch of islanders, who are very proud of the fact. As such, we have a strange affinity with the sea and are extremely enamored with our beaches and breath-taking coastline.
Many who have grown up in Ireland spent their summer vacation as a child in a cottage down the beach in Clonakilty, County Cork or in a caravan in Bundoran, County Donegal. I guarantee that these were magic holidays and they continue to be perfect spots for a family getaway.
The wonderful thing about a seaside resort - Irish sea side resorts, at least - is that you have the comfort and entertainment of easy access to lively towns while your family members have the freedom to indulge in water sports, golf or just long walks along some of the most stunning beaches in the world.
Although you'll most likely not be spending the days sunbathing by the beach (thanks to Ireland's weather!), in the villages you are sure to find the 'craic agus ceol' (fun and music) that Ireland is famous for in the form of lively bars with live traditional music. You'll also have the chance to sample the local cuisine in some of Ireland's most idyllic spots.
Enniscrone, County Sligo
This small seaside town is renowned for its long, sandy beautiful beach. Located on the Atlantic Ocean, it is quickly becoming one of the best spots for learning to surf in Ireland. The village is just 7km from Ballina, County Mayo but there is plenty to do in Enniscrone itself, whether it's a walk on the beach, a round of golf or soaking in the seaweed baths.
Bundoran, County Donegal
Lahinch, County Clare
Clonakilty, County Cork
Known by the locals as simply "Clon," this town is bustling with life and is just 3km from the beach. It is situated in the postcard perfect west Cork, is lively, welcoming and steeped in history. Clonakilty suffered greatly during the Famine, and was the hometown of Michael Collins. Also, west Cork is Ireland's food capital and you are sure to eat very well.
Tramore, County Waterford
Tramore is the south east's top destination for holidaymakers and is jam packed with amenities, from top class accommodation to Splashworld, surfing, fishing, hiking, horse riding, golf and even an amusement park. In addition to the wonderful surroundings and the great outdoors, there's a huge amount to do.
Strandhill, County Sligo
This beautiful town in the heart of Yeats country is officially a Mecca for surfers - miles of untamed beach, beautiful rocky exposures. It is located at the foot of Knocknarea, just kilometers from Sligo town and close to Sligo airport, which connects with Dublin. Strandhill is also a great spot for golf and seaweed baths and has some great pubs and restaurants.
Clifden, County Galway
Located in the north west of County Galway in the heart of Connemara this small seaside town feels untouched, despite its popularity with tourists. The town is packed with its own entertainment but Clifden is also a great spot to use as a based when exploring the area. Some top things to check out include the Beach Road walk, Connemara National Park and Derrygimla Bog.
Cape Clear, County Cork
Dungarvan, County Waterford
Curracloe, County Wexford
Although Wexford's coastline is peppered with wonderful beaches, Curracloe has a great reputation as a safe bathing spot. The area has been developed around the beach as a spot for visitors to enjoy. There are also great activities surrounding the beach, such as horse rides along the shore, fishing and water sports. Just north of this beach is where the opening scenes for "Saving Private Ryan" were shot.
What other coastal spots have we left out?
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Kristina Riggle's Videos, Audio, and Images
About Kristina
A novelist and short story writer living in West Michigan. My first novel, REAL LIFE & LIARS, was a Target "Breakout" pick and a Great Lakes, Great Reads selection. My second novel, THE LIFE YOU'VE IMAGINED, was honored as an IndieNext Notable...
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The Seminar Room contains a computer equipped with Pandora, a search engine complete with all of Greek and Latin literature on CD. The Seminar Room also holds an impressible library of reference works, art books, historical volumes and Greek and Latin texts.
This library was made possible by the generosity of Peter A. Vlachos '58. Other friends of the Classics Department have made gifts of books that enhance this collection. We encourage all our majors to look on the Seminar Room as their own special space where they can feed off each other's ideas and enthusiasm.
The Colby Museum has a small but highly interesting collection of Greek and Roman antiquities.


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Hearty Herb BreadAn aromatic bread containing wheat germ and rolled oats. A contest winner in the 1992 Bob's Red Mill/Fred Meyer Baking Contest.
In a large bowl combine 2 cups of white flour, wheat germ, oats, bran, dry milk, yeast, sugar, salt and seasonings; mix thoroughly. Add hot water and oil; beat at medium speed for 2 minutes with heavy-duty electric mixer. Add 1 cup of white flour and egg; beat at high speed for 1 minute; stir in onion. Combine 2 cups white flour and 1 cup whole wheat flour; stir into dough. Place on floured work surface and knead until smooth.
Cover and let rest 20 minutes; punch down. Divide in half and shape into 2 loaves; place loaves in greased 9" x 5" loaf pans; cover and let rise in warm place, free from draft for 1-2 hours or until doubled in bulk. Preheat oven to 400 degrees F and bake for 20 minutes using the center rack of oven. Makes 2 loaves. |
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Donna April 25, 2012
Just got this;out of the oven! What a wonderful aroma. I used a "starter" but it turned out wonderful. I definitely will add this to my list of breads to give as gifts. It is a great change from all the sweet breads I have been baking.
Nutritional Information


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Property Manager Pleads Guilty to Stealing $1.5 M. from Two Chinatown Buildings
Building owners hire property managers precisely because they do not want the headache of running a building. Unfortunately for the owners of 11 East Broadway and 128 Mott Street, the decision to hire out the task cost them more trouble (and money) than they ever imagined.
Property manager Kee Lin stole more than $1.5 million by writing unauthorized checks payable to cash and to his own company, AIP Realty Services, Inc. Mr. Lin has plead guilty to first-degree larceny, according to the Manhattan District Attorney's office. Read More


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Kirsten Dunst and her boyfriend Garrett Hedlund enjoy a Thanksgiving dinner at Christophers Bar and Grill in Covent Garden. Upon seeing the cameras, Kirsten became shy, and the pair made a dash for their hotel. London, England - 11.22..12
These Hot Boys Will Make Your Day – The Berry | |
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Neville Longbottom Continues To Make Us Drool – Lainey Gossip | |
Cuteness Overload: 32 GIFs That Will Make You Awwwww – The Berry | |
Jared Leto Proves That He's Still Sexy – Lainey Gossip |


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Dracula's Transylvanian Ghoul-ash
This is garlicky enough to keep the most persistent of vampires off your doorstep. One bite and you'll want to nuzzle up to this Ghoul-ash any night of the week!
Serve with Deviled Eyeballs and Bat Wings.
- Salt
- 1 pound extra-large egg noodles
- 4 tablespoons butter, divided
- 3-4 tablespoons fresh dill, chopped
- 3-4 tablespoons chives (20 blades), chopped
- 2 tablespoons extra virgin olive oil (EVOO), plus some for drizzling
- 1 pound sirloin steak – place in the freezer for about 10 minutes, remove and slice against the grain as thin as you can manage (slices should be the size of egg noodles)
- Freshly ground black pepper
- 1/2 cup flour, for dusting steak (eyeball it)
- 1/2 small onion, peeled
- 4-5 cloves garlic, peeled
- 2 teaspoons smoked paprika
- 1 jar chopped pimentos (4 ounces), thoroughly drained
- 2 cups beef stock
- 1/2 cup sour cream
- 1 pound triple-washed spinach, stems removed
- Nutmeg, freshly grated, to taste
Place a large pot of salted water over high heat and bring to a boil. Once boiling, add the egg noodles and cook to al dente, with a bite to them. Drain the noodles and add back to hot pot and toss with butter and half of the dill and chives; stir to combine.
Brown the meat for 2-3 minutes alone, then grate the onion and garlic over the meat and sprinkle with the smoked paprika. Give the skillet a stir and continue to cook for about 2-3 minutes. Add the drained pimentos and beef stock and stir to combine. Bring up to a bubble and simmer until lightly thickened, about 1 minute. Stir in sour cream and give the meat a taste to see if it needs any more salt and pepper.
This is one of many "Yum-o!" recipes – it's good and good for you. To find out more about Yum-o!, Rachael's nonprofit organization, go to www.yum-o.org.


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EAN: 5037821808565 Feel the adrenalin rush as you take the controls of a light plane and soar across the sky! You get one-to-one training with a Civil Aviation Authority licensed instructor, and your flying time counts towards a Private Pilot's licence. This Extended option means you will be flying for a longer time and will have a more in-depth lesson. Your flying lesson starts with a briefing from your instructor before the flight. This will cover safety, and an introduction to some of the controls. Once in the plane, your flight starts from the time the engine turns over. You will be given headphones so that you can hear conversations between your instructor and air traffic control, and so that you can talk with your instructor. Once in the air, you will be able to take the controls but your pilot will generally land the plane and taxi back. Minimum age: 12 (under 18's need parental/guardian consent) - Minimum height: 4 ft 10 inch (147 cm) - Maximum height: 6 ft 4 inch (193 cm) - Maximum weight: 12 stone at County Down, 16 stone at Leeds, 14 to 18 stone at other locations - You should be in reasonable health and agile enough to climb into the aircraft. 40 locations across the UK and Southern Ireland. |
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A new study in the March issue of Anesthesiology suggests epidural analgesia (EA) may be a more effective component in the perioperative care of patients undergoing elective open colorectal surgery than the proposed alternative, continuous wound infiltration of local anesthetics (CWI).
Effective postoperative analgesia allowing early mobilization is an essential component of fast-track anesthesia and surgery programs. While EA can provide such effective analgesia after colorectal surgery, CWI has been proposed as an alternative because it could be cheaper and simpler to use.
A team of anesthesiologists from the University Hospital of Clermont-Ferrand in France compared both EA and CWI in a randomized, double blind controlled trial of patients undergoing colorectal surgery. Findings showed EA produced better patient outcomes including an increase in postoperative pain relief, faster functional recovery and shorter hospital stays than CWI.
The study treated fifty patients with either EA or CWI for 48 hours. In both groups, patients were managed according to the Enhanced Recovery After Surgery (ERAS) program, based on the principle that reducing the body's stress response after surgery reduces the time needed to recuperate. Patients' pain scores were measured 24 hours after surgery using a 100-mm verbal numerical scale.
"We knew CWI was seen as an attractive solution for pain care in abdominal surgery recovery, but it hadn't been directly compared to the tried-and-true epidural method for colorectal surgery patients," said study author Emmanuel Futier, M.D. "Unlike after abdominal surgery, our study found EA was the superior choice after colorectal surgery."
The findings suggest the added cost and complexity of EA are worth it to provide the best form of pain relief for colorectal surgery patients.
For more information, visit the Anesthesiology website at anesthesiology.org and physician-paincare.com.
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 50,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring that physician anesthesiologists evaluate and supervise the medical care of patients before, during, and after surgery to provide the highest quality and safest care that every patient deserves.
For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/WhenSecondsCount. Join the ANESTHESIOLOGYTM 2013 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES2013.
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Wondering if anyone has built one up less xc oriented. Read the Singletrack #75 review and they make it sound more AM oriented. Curious as I consider any size rock or log on the trail a challenge. Why my Stylus has a bash guard.
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0. PLPerl NG - This project is intended to remove the limitations on PLPerl for PostgreSQL, and make it a fully featured server side programming language. It is sponsored by Command Prompt, Inc. (http://www.commandprompt.com) and other PostgreSQL project members. | |
Activity Percentile: 13.93 Activity Ranking: 106.00 Registered: 2004-04-21 00:04 |
1. APLoader - APLoader, or Another Postgres Loader, is a front-end to the Postgresql COPY command written in Ruby. Features include: fault tolerance, a progress meter, failed batch logs, minimal requirements, a programmable API, and excellent performance. | |
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About Scott Lacy ~
This is about more than real estate. It is about your life and your dreams.
I combine old fashioned values of hard work and integrity with the latest technologies and business strategies. The result: Delivering the highest level of customer service, exceeding your expectations and finding a solution tailored for you and your family.
Scott Lacy
Hamilton Mill's Agent on Duty
Client First Philosophy - There are many qualities and skills that go into being an excellent real estate professional: integrity, in-depth knowledge, marketing savvy, effective negotiation skills and a high-quality professional network. Utilizing the latest in technology enables a more efficient and productive environment resulting in a wider range of services for the client. "Putting clients first" means being accessible, being a good listener, being a good communicator and responding to your needs.
Business - Scott is proud to be associated with Keller Williams – Atlanta Partners where the mission statement is "Careers Worth Having, Businesses Worth Owning and Lives Worth Living." The Keller Williams Sugarloaf office is consistently ranked as one of the top producing real estate offices in Gwinnett county. Scott hit the ground running winning the Rookie of the Year award in 2008. After that, he was asked to sit on the Agent Leadership Council, an honor offered to the top 20% of producing agents. As a member of the ALC, Scott helps set office policy and represents other agents by acting as a liaison between the office leadership and its agents. While Scott continues to grow his business in the Hamilton Mill / Dacula areas, he also focuses on Buford, Lawrenceville, Suwanee, Duluth and other surrounding areas.
Personal – Scott currently resides in Hamilton Mill / Dacula and is currently engaged to be married in May, 2010. Scott has two children, Austin (16) and Steven (12). Scott's fiancé Kristin, has three boys Eli (11), Jakob (8) and Joe (6).
Scott graduated from Auburn University in 1986 and was a professional software sales rep most of his career. His New Year's Resolution of 2007 was to attain his real estate license and achieve his goal of becoming a Realtor.
Scott Lacy |
Scott Lacy |


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Cleefoss said:
Joust is the first novel in the Dragon Jousters Quartet, a series by Mercedes Lackey which focuses on, well, dragon jousters, who ride on dragons and try to knock enemy jousters off using lances. In spite of this rather strange concept, the series performs quite admirably, as the fate of two entire nations ends up turning quite believably on the actions of the protagonist.
posted Jun 16, 2010 at 3:03PM
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Scrambles after crumbs in order to eat; overworked as a serf; angry; becomes Ari's dragon boy and caretaker to his dragon.
Dislikes cruelty to animals and people; dragon rider, warrior and jouster for the king; makes Vetch his dragon boy and caretaker of his dragon.


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Cloned feathers to make bird in front of branch, replaced sky, added moon, blended texture.Open discussion thread to see the before image.
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- The Papaver Self-Incompatibility Pollen S-Determinant, PrpS, Functions in Arabidopsis thaliana
The Papaver Self-Incompatibility Pollen S-Determinant, PrpS, Functions in Arabidopsis thaliana
Current Biology, Volume 22, Issue 2, 24 January 2012, Pages 154-159
Barend H.J. de Graaf, Sabina Vatovec, Javier Andrés Juárez-Díaz, Lijun Chai, Kreepa Kooblall, Katie A. Wilkins, Huawen Zou, Thomas Forbes, F. Christopher H. Franklin and Vernonica E. Franklin-Tong
SummaryMany angiosperms use specific interactions between pollen and pistil proteins as "self" recognition and/or rejection mechanisms to prevent self-fertilization. Self-incompatibility (SI) is encoded by a multiallelic S locus, comprising pollen and pistil S-determinants [1, 2,1, 2]. In Papaver rhoeas, cognate pistil and pollen S-determinants, PrpS, a pollen-expressed transmembrane protein, and PrsS, a pistil-expressed secreted protein [3, 4,3, 4], interact to trigger a Ca2+-dependent signaling network [5,6,7,8,9,10], resulting in inhibition of pollen tube growth, cytoskeletal alterations [11,12,13], and programmed cell death (PCD) [14, 15,14, 15] in incompatible pollen. We introduced the PrpS gene into Arabidopsis thaliana, a self-compatible model plant. Exposing transgenic A. thaliana pollen to recombinant Papaver PrsS protein triggered remarkably similar responses to those observed in incompatible Papaver pollen: S-specific inhibition and hallmark features of Papaver SI [11,12,13,14,15]. Our findings demonstrate that Papaver PrpS is functional in a species with no SI system that diverged ∼140 million years ago [16]. This suggests that the Papaver SI system uses cellular targets that are, perhaps, common to all eudicots and that endogenous signaling components can be recruited to elicit a response that most likely never operated in this species. This will be of interest to biologists interested in the evolution of signaling networks in higher plants.
Summary | Full Text | PDF (754 kb) - Cytomechanical Properties of Papaver Pollen Tubes Are Altered after Self-Incompatibility Challenge
Cytomechanical Properties of Papaver Pollen Tubes Are Altered after Self-Incompatibility Challenge
Biophysical Journal, Volume 86, Issue 5, 1 May 2004, Pages 3314-3323
Anja Geitmann, William McConnaughey, Ingeborg Lang-Pauluzzi, Vernonica E. Franklin-Tong and Anne Mie C. Emons
AbstractSelf-incompatibility (SI) in Papaver rhoeas triggers a ligand-mediated signal transduction cascade, resulting in the inhibition of incompatible pollen tube growth. Using a cytomechanical approach we have demonstrated that dramatic changes to the mechanical properties of incompatible pollen tubes are stimulated by SI induction. Microindentation revealed that SI resulted in a reduction of cellular stiffness and an increase in cytoplasmic viscosity. Whereas the former cellular response is likely to be the result of a drop in cellular turgor, we hypothesize that the latter is caused by as yet unidentified cross-linking events. F-actin rearrangements, a characteristic phenomenon for SI challenge in Papaver, displayed a spatiotemporal gradient along the pollen tube; this suggests that signal propagation occurs in a basipetal direction. However, unexpectedly, local application of SI inducing S-protein did not reveal any evidence for localized signal perception in the apical or subapical regions of the pollen tube. To our knowledge this represents the first mechanospatial approach to study signal propagation and cellular responses in a well-characterized plant cell system. Our data provide the first evidence for mechanical changes induced in the cytoplasm of a plant cell stimulated by a defined ligand.
Abstract | Full Text | PDF (229 kb) - Recognition and rejection of self in plant self-incompatibility: comparisons to animal histocompatib...
Recognition and rejection of self in plant self-incompatibility: comparisons to animal histocompatibility
Trends in Immunology, Volume 26, Issue 8, 1 August 2005, Pages 412-418
June B. Nasrallah
AbstractIn many flowering plants, intraspecific barriers to self-fertilization ensure outbreeding by interrupting the path of pollen tube growth before egg–sperm interaction. These self-sterility or self-incompatibility (SI) systems are unique among recognition systems, in that they are based on the recognition and rejection of self, rather than non-self. Consistent with multiple evolutionary origins of SI, different plant families use distinct mechanisms for pollen recognition and inhibition. These mechanisms range from the arrest of pollen tube emergence by specific interactions between surface receptors and ligands and activation of intracellular signaling cascades, to the destruction of pollen tubes by the cytotoxic activity of RNases or by induction of a programmed cell death pathway. These mechanistic differences notwithstanding, all plant SI systems analyzed to date share a high degree of recognition specificity, effected by a large number of highly diverged, genetically linked and co-evolving genes, with immunity and other systems that discriminate between self and non-self.
Abstract | Full Text | PDF (259 kb) - …more
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Copyright © 2003 Elsevier Ltd All rights reserved.
Trends in Plant Science, Volume 8, Issue 12, 598-605, 1 December 2003
Gametophytic self-incompatibility inhibits pollen tube growth using different mechanisms
Noni (V.E.) Franklin-Tong and F.Chris H Franklin
School of Biosciences, The University of Birmingham, Edgbaston, Birmingham, UK B15 2TT
Self-incompatibility (SI) is one of the most important mechanisms used by plants to prevent self-pollination and consequently inbreeding. It is genetically controlled by the S-locus, which allows the recognition and rejection of 'self' (S-phenotypically identical) pollen. Gametophytically controlled SI (GSI) is the most widespread SI system. To date, only two forms have been elucidated in detail at the molecular level, revealing two different stigmatic S-genes. Here we summarize the evidence for the use of two different mechanisms to inhibit incompatible pollen tube growth. Because the limited data suggest the independent evolution of these two GSI systems, it would be interesting to explore other GSI systems to determine the extent of the mechanistic diversity.


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Hudson and Fournier: Catholic Countdown to Election 2012, Day 38: Ryan, Biden and Selective Press Coverage
I am proud of his accomplishments as a native son, and a brother in the faith, and my prayers go with him and especially with his family as they endure the unbelievable demands of a presidential campaign here in the United States
When a politician's own ordinary is willing to make such a statement in support of a seated political representation from his own diocese that, in effect, more than offsets the criticism coming from any other bishop.
WASHINGTON,DC (Catholic Online) - From the moment Congressman Paul Ryan was announced as Mitt Romney's running mate, the Obama Catholic supporters have been flogging him for a letter sent by two individual bishops to members of Congress critical of his 2012 GOP budget. From the coverage, you would think that Ryan, a Catholic from Wisconsin, had been universally condemned by the bishops' conference.
Not only is that wrong - and a complete misrepresentation - the Ryan story was told without any mention of the problems his counterpart, Vice President Joe Biden, also a Catholic, has had with bishops over many years.
A recent article by Bill Donohue, president of the Catholic League, sets the record straight. Donohue, writing at Newsmax, lists 15 instances of bishops' criticism being directed at Biden.
To provide one example stemming from the 2008 presidential campaign, Biden made some inaccurate comments on Meet the Press about Catholic doctrine on the beginning of life.
Cardinal Justin F. Rigali, chairman of the USCCB's Committee on Pro-Life Activities, and Bishop William E. Lori, chairman of the USCCB's Committee on Doctrine, issued a joint statement "to correct the misrepresentations" of Church teachings advanced by Biden. Indeed, they argued that "the senator's claim that the beginning of human life is a 'personal and private' matter of religious faith, one that cannot be 'imposed' on others, does not reflect the truth of the matter."
Archbishop Chaput, who was still in Denver at the time, considered it such a serious matter he stated, "I certainly presume his good will and integrity and I presume that his integrity will lead him to refrain from presenting himself for Communion."
It should be added that while Ryan was, in fact, criticized by two bishops, he also received a public letter from the president of the USCCB, Cardinal Timothy Dolan of New York, praising him for his application of the Church's social teaching to the budgetary process. In fact,
Perhaps even more importantly, Ryan's own bishop, Bishop Robert Morlino of Madison, WS, published a column clearly intended to offset the growing chorus of criticism. Bishop Morlino could hardly have stated his support for Ryan more plainly, without, of course, endorsing him:
"It was no shock at all for me to learn that our diocesan native son, Paul Ryan, had been chosen to be a candidate for the Vice Presidency of the United States. I am proud of his accomplishments as a native son, and a brother in the faith, and my prayers go with him and especially with his family as they endure the unbelievable demands of a presidential campaign here in the United States. It is not for the bishop or priests to endorse particular candidates or political parties. Any efforts on the part of any bishop or priest to do so should be set aside. And you can be assured that no priest who promotes a partisan agenda is acting in union with me or with the Universal Church".
When a politician's own ordinary is willing to make such a statement in support of a seated political representation from his own diocese that, in effect, more than offsets the criticism coming from any other bishop. Case closed!
Speaking of our friend Bill Donohue, he has a huge fight brewing in his home city of New York which may quickly morph into a political hot potato for the Democratic party elites of that city. Donohue is well known for taking on needless, reckless, and deliberate attacks on the Church and the Catholic faith -- this time it's another "exhibition" by Andres Serrano, called "Piss Christ". (Friends, we have come a long, long way from the days when artists, even those who did not believe, used as their subjects the great characters and narrative of Sacred Scriptures and the stories of the saints.)
Donohue, believe it or not, was not allowed to enter the exhibit at the Edward Tyler Nahem gallery on W. 57th St. -- in direct violation of his First Amendment rights. Here is what happened in Donohue's words:
"When I entered the lobby, I was stopped by a man who works for the building. He asked for ID and requested that I sign in. I said okay, and then asked if I could go to the gallery. He said the gallery and the building are two different entities, and that I had to ask the men from the gallery; they were right in front of me in the lobby. I then asked them if I could enter, and they said no, without explanation. At that point I turned to the crowd behind me explaining that my First Amendment rights were being censored by the same people who were proudly displaying Serrano's crucifix in a jar of urine.No one else was barred from entering the gallery. Just me. We have all of this on tape, and the quality of both the audio and the video are excellent. Stay tuned".
When Bill Donohue says, "stay tuned," you better believe it! Such an egregious slap in the face of a national Catholic leader who is seen and heard in major media every week could become an issue in the campaign, and become particularly tricky for the Obama-Biden team which always courts the money and influence of the arts community.
The story we broke at Catholic Online a few days ago about the "push calls" being made to Catholic voters by the Obama campaign continues to gather momentum. Peter Roff, writing at US News & World Report, combines that story with one about a leading Obama supporter in the Diocese of Cleveland being allowed to lead seminars on "Faithful Citizenship," an attempt to repeat the tactics of 2008 when "Faithful Citizenship" was cherry-picked to make it appear the bishops didn't mind if Catholic voters voted for pro-abortion politicians.
When the bishops added a "New Introduction" to their document "Faithful Citizenship" this past November, they were asking that such liberties should no longer be taken with their intended meaning.
Here is what the administrative committee of the U.S. Conference of Catholic Bishops' wrote:
"Although it has at times been misused to present an incomplete or distorted view of the demands of faith in politics, this statement remains a faithful and challenging call to discipleship in the world of politics. It does not offer a voter's guide, scorecard of issues, or direction on how to vote. It applies Catholic moral principles to a range of important issues and warns against misguided appeals to 'conscience' to ignore fundamental moral claims, to reduce Catholic moral concerns to one or two matters, or to justify choices simply to advance partisan, ideological, or personal interests."
Deal W. Hudson is president of the Pennsylvania Catholics Networks and former publisher/editor of Crisis Magazine. Deacon Keith Fournier is the Editor in Chief of Catholic Online and a constitutional lawyer who is currently writing his dissertation for the PhD in Moral Theology at the Catholic University of America.
Pope Francis calls for your 'Prayer and Action'
� 2014 - Distributed by THE NEWS CONSORTIUM
Pope Francis Prayer Intentions for March 2014
Respect for Women: That all cultures may respect the rights and dignity of women.
Vocations: That many young people may accept the Lord�s invitation to consecrate their lives to proclaiming the Gospel.
Keywords: Paul Ryan, Joe Biden, Mitt Romney, Barack Obama, Catholic Vote, Bill Donohue, Catholic League, Bishop Robert Morlino, Social teaching, Social justice, Deal W. Hudson, Deacon Keith Fournier
Rate This Article
1 - 3 of 3 Comments
1 year ago
The critical issues of the world require reflection on the whole of Catholic Social Doctrine. This article becomes petty when the focus is on what happened to one man not allowed into an art exhibition. What about the principle of Universal Destination of Goods, the Goals of Business, the Role of the Free Market, International Financial Systems, Global Economy? Let us grow together through encounters of love in our understanding of the totality of Catholic Social Doctrine.
1 year ago
Bill Donahue is awesome. We need more Catholics like him.
1 year ago
If Biden & Ryan were to be compared on the basis of the Christian Faith , then Biden stands out -as an Atheist, even a Hypocrite -He who talks of his Faith but follows it not, through the works.
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Meeting of Ministers of Health of the Americas Starts Today |
Washington, September 27, 2010 (PAHO) — Ministers of Health of all the countries of the Americas gather from today until Friday at the headquarters of the Pan American Health Organization (PAHO) in Washington, D.C. for their annual Directing Council meeting.
During these five days, the health leaders will analyze the health situation in the region and discuss key resolutions on public health problems facing the Americas.
The agenda for the meeting covers a series of key public health topics including:
PAHO Director Dr. Mirta Roses will present her annual report, offering a panoramic view of the most important public health topics in the America and future challenges in the Organization's work to improve the quality of life of the people of the region.
One special feature this year is the Sept. 28 observance of the 30th Anniversary of Smallpox Eradication and the establishment of the PAHO Revolving Fund for Vaccine Procurement, with Dr. D.A. Henderson, who led the World Health Organization's smallpox eradication effort, and Sarah Parker, director of the Edward Jenner Museum in England
PAHO, which also serves as the Regional Office for the Americas of the World Health Organization, has been working since 1902 with all the countries of the Americas to improve the health and raise the living standards of their peoples.
Links of Interest:
For more information please contact
at (202) 974-3459, Communication Office, Pan American Health Organization.
Regional Office for the Americas of the World Health Organization |