The incidence of obstructive sleep apnea (OSA) has reached epidemic proportions, and it is an often unrecognized cause of perioperative morbidity and mortality. Profound hypoxic injury from apnea during the postoperative period is often misdiagnosed as cardiac arrest due to other causes. Almost a quarter of patients entering a hospital for elective surgery have OSA, and >80% of these cases are undiagnosed at the time of surgery. The perioperative period puts patients at high risk of apneic episodes because of drug effects from sedatives, narcotics, and general anesthesia, as well as from the effects of postoperative rapid eye movement sleep changes and postoperative positioning in the hospital bed. For adults, preoperative screening using the STOP or STOP-Bang questionnaires can help to identify adult patients at increased risk of OSA. In the pediatric setting, a question about snoring should be part of every preoperative examination. For patients with known OSA, continuous positive airway pressure should be continued postoperatively. Continuous pulse oximetry monitoring with an alarm system can help to prevent apneic catastrophes caused by OSA in the postoperative period.

This article presents sources of information for those in practice, administration, or education to stay up-to-date in vaccine recommendations. Web-based repositories predominate in the provision of information. Other sources include newsletters, conferences, journals, expert opinion, community organizations, and books. The promise of the electronic health record remains unfulfilled but improving.

Vaccines have been highly effective in eliminating or significantly decreasing the occurrence of many once-common diseases. Barriers to immunization are a significant factor in the rising incidence rates of some vaccine-preventable diseases. Cost, reduced accessibility to immunizations, increasingly complex childhood and adolescent/adult immunization schedules, and increasing focus on the potential adverse effects of vaccines all contribute to difficulty in meeting the 2010 immunization goals. Physicians must not only be knowledgeable about vaccines but they must incorporate systems in their offices to record, remind, and recall patients for vaccinations. They must also clearly communicate vaccine benefits and risks while understanding those factors that affect an individual's acceptance and perception of those benefits and risks.

This chapter discusses issues related to semantics and the medical Web. Much health information is available on the Web, but not always effectively found by users. Studies examining various aspects of medical Web searching show that searchers’ do not always use correct medical terminology. This chapter reports results from a longitudinal study of medical/health related searches using commercial Web search engine query data from 1997 to 2004.

With steadily rising use of the Internet as a source of health information, public health authorities have expressed concern about the increasing visibility of unscientific information promulgated on the Internet by opponents of childhood vaccination. Searches were made on the four most popular Internet search engines using different combinations of the terms, "vaccination," "immunization," "immunisation," "immunize," "immunise," "vaccine," and "shots." Thirty results were tabulated for each search engine. Searching with the keyword "vaccination" resulted in a significantly higher percentage of antivaccination websites as compared with searches with all other keywords. Of all child-related websites retrieved, the single keyword "vaccination" yielded 40% provaccination sites and 60% antivaccination sites. By contrast, the single keyword "immunization" yielded 98% provaccination sites and 2% antivaccination sites. Using a combination of the words "vaccination" and "immunization" produced results between these two extremes. Thus, any use of the term "vaccination" during an Internet search is likely to expose a parent to a significant amount of antivaccination information. Recommendations are discussed for future research and methods to reduce the impact of misinformation on health consumers using the Internet.

Background: The incidence of vaccine-preventable diseases is directly related to the number of unvaccinated children. Parents who refuse vaccination of their children frequently express concerns about vaccine safety. The Internet can influence perceptions about vaccines because it is the fastest growing source of consumer health information. However, few studies have analyzed vaccine criticism on the Web.Objective: The purposes of this paper are to examine vaccine criticism on the Internet and to analyze the websites in order to identify common characteristics and ethical allegations.Methods: A structured Web search was conducted for the terms "vaccine," "vaccination," "vaccinate:" and "anti-vaccination" using a metasearch program that incorporated 8 search engines. This yielded 1138 Web pages representing 750 sites. Two researchers reviewed the sites for inclusion/exclusion criteria, resulting in 78 vaccine-critical sites, which were then abstracted for design, content, and allegations.Results: The most common characteristic of vaccine-critical websites was the inclusion of statements linking vaccinations with specific adverse reactions, especially idiopathic chronic diseases such as multiple sclerosis, autism, and diabetes. Other common attributes (>= 70% of websites) were links to other vaccine-critical websites; charges that vaccines contain contaminants, mercury, or "hot lots" that cause adverse events; claims that vaccines provide only temporary protection and that the diseases prevented are mild; appeals for responsible parenting through education and resisting the establishment; allegations of conspiracies and cover-ups to hide the truth about vaccine safety; and charges that civil liberties are violated through mandatory vaccination.Conclusions: Vaccine-critical websites frequently make serious allegations. With the burgeoning of the Internet as a health information source, an undiscerning or incompletely educated public may accept these claims and refuse vaccination of their children. As this occurs, the incidence of vaccine-preventable diseases can be expected to rise.

Vaccines have been highly effective at eliminating or significantly decreasing the incidence of many once-common diseases. However, the public is now focusing on the potential adverse effects of vaccines. Proper communication of vaccine benefits and risks requires an understanding of factors that affect an individual's acceptance and perception of those benefits and risks. Physicians should be prepared to answer patients' or parents' questions about common as well as alleged vaccine-related adverse events and must utilize the Vaccine Information Statements for vaccines covered under the National Vaccine Injury Compensation Program.

Background: Clinical practice guidelines (CPGs) have been promoted as a strategy to measure and improve the quality of patient care. However, more effort has been expended on creating guidelines than implementing them. We surveyed family physicians about their knowledge of and attitudes toward 3 well-publicized CPGs.Methods: A survey questionnaire was sent to a national sample of 600 family physicians selected at random from a file from the American Academy of Family Physicians ( AAFP).Results: After 2 mailings, the response rate was 71%. For each of the 3 guidelines, roughly 60% of respondents were familiar or somewhat familiar with the CPG. More than half of family physicians studied said they have changed their medical practices based on CPGs, and only 3% said they do not believe in guidelines and would not use them. Use of CPGs was lowest among physicians in solo practice and among those working in rural areas. However, no significant differences in CPG use or familiarity were noted based on number of years in practice. Many respondents indicated an interest in keeping CPGs current via the internet.Conclusions: Most American family physicians find CPGs to be helpful, and familiarity with them is fairly uniform across most subgroups studied.

Author’s Reply To the Editor: We read with interest the comments of Drs. Lember and Rätsep on their study of diabetes mellitus clinical practice guidelines in Estonia. Although their results contradicted our findings in the United States, we suggest that the differences are largely accounted

CONTEXT:Individuals searching the Internet for vaccine information may find antivaccination Web sites. Few published studies have systematically evaluated these sites.OBJECTIVES:To examine antivaccination Web site attributes and to delineate the specific claims and concerns expressed by antivaccination groups.DESIGN AND SETTING:In late 2000, using a metasearch program that incorporates 10 other search engines, we reviewed and analyzed 772 links to find 12 Web sites that promulgated antivaccination information. Analyzing links from these 12 sites yielded another 10 sites, producing a total of 22 sites for study. Using a standardized form, 2 authors (R.M.W., L.K.S.) systematically evaluated these sites based on specific content and design attributes.MAIN OUTCOME MEASURES:Presence or absence of 11 Web site content attributes (antivaccination claims) and 10 Web site design attributes.RESULTS:The most commonly found content claims were that vaccines cause idiopathic illness (100% of sites), vaccines erode immunity (95%), adverse vaccine reactions are underreported (95%), and vaccination policy is motivated by profit (91%). The most common design attributes were the presence of links to other antivaccination sites (100%of sites), information for legally avoiding immunizations (64%), and the use of emotionally charged stories of children who had allegedly been killed or harmed by vaccines (55%).CONCLUSION:Antivaccination Web sites express a range of concerns related to vaccine safety and varying levels of distrust in medicine. The sites rely heavily on emotional appeal to convey their message.

(2002). Vaccine safety activists on the Internet. Expert Review of Vaccines: Vol. 1, No. 3, pp. 249-252.

The British Vaccination Act of 1840 was the first incursion of the state, in the name of public health, into traditional civil liberties. The activities of today's propagandists against immunisations are directly descended from, indeed little changed from, those of the anti-vaccinationists of the late nineteenth century, say Robert Wolfe and Lisa Sharp.