Damian McNamara

ORLANDO — The risk of death from gastric bypass surgery continues beyond the immediate postoperative period, according to the results of a study reported by P. Jason Granet, M.D., at the annual meeting of the American Society for Bariatric Surgery.

“We are not out of the woods in the first 30 days. The main risk is pulmonary embolism, even after 90 days,” Dr. Granet said in a poster presentation.

Dr. Granet and his associates retrospectively analyzed the records of 1,250 patients who had divided gastric bypass between 1979 and 2003.

All of the operations were performed by John R. Kirkpatrick, M.D., chair of the surgery department at Washington Hospital Center and lead author of the study. All patients were morbidly obese, with a mean body mass index of 58 kg/m

Patients were managed with a standard protocol for 24 months that included prophylactic antibiotics, anticoagulants, and monthly follow-up visits.

High-risk patients routinely received an inferior vena cava (IVC) filter, he added. The researchers identified 44 anastomotic leaks during the 2-year study.

By the study's end, the average weight loss was 173 pounds, or a mean 75% of excess weight, said Dr. Granet, a general surgeon at Washington Hospital Center.

Seven deaths occurred in the immediate postoperative period, including two attributed to leak sepsis, three from pulmonary embolism (PE), one from wound sepsis, and one from respiratory failure.

Another six deaths occurred up to 30 days after surgery, including three from PE and three from sudden death syndrome.

“We had an extra eight deaths from 30 days to 90 days—more PE or suspected PE—and we were doing everything you can do [in terms of prophylaxis],” Dr. Granet said. The additional deaths included four PEs, two cases of sudden death syndrome, and two patients who had intraabdominal sepsis.

An additional five “late deaths” occurred between 90 days and 2 years.

If only the immediate postoperative period is considered, postoperative mortality is low, 0.5%. By 90 days, however, mortality is 1.6%, a “higher than expected” rate, Dr. Granet said. The findings of this study suggest a need to revise postoperative management protocols.

“We're doing high-risk patients. I tell them they can die from this,” he said. “The whole family is involved in counseling. If anything happens, they were aware.”

ORLANDO — The risk of death from gastric bypass surgery continues beyond the immediate postoperative period, according to the results of a study reported by P. Jason Granet, M.D., at the annual meeting of the American Society for Bariatric Surgery.

“We are not out of the woods in the first 30 days. The main risk is pulmonary embolism, even after 90 days,” Dr. Granet said in a poster presentation.

Dr. Granet and his associates retrospectively analyzed the records of 1,250 patients who had divided gastric bypass between 1979 and 2003.

All of the operations were performed by John R. Kirkpatrick, M.D., chair of the surgery department at Washington Hospital Center and lead author of the study. All patients were morbidly obese, with a mean body mass index of 58 kg/m

Patients were managed with a standard protocol for 24 months that included prophylactic antibiotics, anticoagulants, and monthly follow-up visits.

High-risk patients routinely received an inferior vena cava (IVC) filter, he added. The researchers identified 44 anastomotic leaks during the 2-year study.

By the study's end, the average weight loss was 173 pounds, or a mean 75% of excess weight, said Dr. Granet, a general surgeon at Washington Hospital Center.

Seven deaths occurred in the immediate postoperative period, including two attributed to leak sepsis, three from pulmonary embolism (PE), one from wound sepsis, and one from respiratory failure.

Another six deaths occurred up to 30 days after surgery, including three from PE and three from sudden death syndrome.

“We had an extra eight deaths from 30 days to 90 days—more PE or suspected PE—and we were doing everything you can do [in terms of prophylaxis],” Dr. Granet said. The additional deaths included four PEs, two cases of sudden death syndrome, and two patients who had intraabdominal sepsis.

An additional five “late deaths” occurred between 90 days and 2 years.

If only the immediate postoperative period is considered, postoperative mortality is low, 0.5%. By 90 days, however, mortality is 1.6%, a “higher than expected” rate, Dr. Granet said. The findings of this study suggest a need to revise postoperative management protocols.

“We're doing high-risk patients. I tell them they can die from this,” he said. “The whole family is involved in counseling. If anything happens, they were aware.”

ORLANDO — The risk of death from gastric bypass surgery continues beyond the immediate postoperative period, according to the results of a study reported by P. Jason Granet, M.D., at the annual meeting of the American Society for Bariatric Surgery.

“We are not out of the woods in the first 30 days. The main risk is pulmonary embolism, even after 90 days,” Dr. Granet said in a poster presentation.

Dr. Granet and his associates retrospectively analyzed the records of 1,250 patients who had divided gastric bypass between 1979 and 2003.

All of the operations were performed by John R. Kirkpatrick, M.D., chair of the surgery department at Washington Hospital Center and lead author of the study. All patients were morbidly obese, with a mean body mass index of 58 kg/m

Patients were managed with a standard protocol for 24 months that included prophylactic antibiotics, anticoagulants, and monthly follow-up visits.

High-risk patients routinely received an inferior vena cava (IVC) filter, he added. The researchers identified 44 anastomotic leaks during the 2-year study.

By the study's end, the average weight loss was 173 pounds, or a mean 75% of excess weight, said Dr. Granet, a general surgeon at Washington Hospital Center.

Seven deaths occurred in the immediate postoperative period, including two attributed to leak sepsis, three from pulmonary embolism (PE), one from wound sepsis, and one from respiratory failure.

Another six deaths occurred up to 30 days after surgery, including three from PE and three from sudden death syndrome.

“We had an extra eight deaths from 30 days to 90 days—more PE or suspected PE—and we were doing everything you can do [in terms of prophylaxis],” Dr. Granet said. The additional deaths included four PEs, two cases of sudden death syndrome, and two patients who had intraabdominal sepsis.

An additional five “late deaths” occurred between 90 days and 2 years.

If only the immediate postoperative period is considered, postoperative mortality is low, 0.5%. By 90 days, however, mortality is 1.6%, a “higher than expected” rate, Dr. Granet said. The findings of this study suggest a need to revise postoperative management protocols.

“We're doing high-risk patients. I tell them they can die from this,” he said. “The whole family is involved in counseling. If anything happens, they were aware.”

ORLANDO — Psychiatric conditions are more common among patients who seek bariatric surgery than among the general population, according to preliminary results from a study reported by Melissa A. Kalarchian, Ph.D., at the annual meeting of the American Society for Bariatric Surgery.

Dr. Kalarchian and her colleagues screened bariatric surgery candidates with the Structured Clinical Interview for the DSM-IV to determine current and lifetime history of psychiatric disorders.

Preliminary results included 200 surgical candidates.

The average candidate age was 46 years; 89% were white; 85% were female; and their average body mass index (kg/m

The surgical candidates had higher rates of lifetime psychopathology than those reported for individuals in the community in the baseline National Comorbidity Survey (NCS), said Dr. Kalarchian of the Western Psychiatric Institute and Clinic in Pittsburgh. (See graph.)

Anxiety disorders included generalized anxiety, posttraumatic stress disorder, and obsessive-compulsive disorder, as well as agoraphobia, panic disorder, social phobia, and specific phobia.

Prevalence of major depressive disorder (MDD) varied by gender. A total of 10% of female and 13% of male surgery candidates met criteria for MDD at study entry. In addition, 45% of female and 33% of male surgical candidates reported a lifetime history of MDD. In the NCS, 21% of women and 13% of men reported such a history.

The researchers also assessed binge eating. Among the surgical candidates in the study, 34% reported a lifetime history of binge eating and 18% reported current binge eating.

“It's really important to wait for prospective studies before saying binge eating is a contraindication to surgery,” Dr. Kalarchian said. “Binge eating can be treated, and I don't think it would be grounds to deny or delay surgery.”

“Binge eating is strongly associated with depression and obesity,” she added. “There is controversy about whether binge eating disorder is a distinct syndrome or a marker of another psychiatric disorder.”

The findings of the study suggest a need to monitor patients for onset or recurrent psychiatric symptoms, she said. “Patients with unstable psychiatric conditions might be deferred for bariatric surgery until their condition is under control.”

An inability to determine a cause-and-effect relationship between psychiatric morbidity and being severely obese in our culture was a limitation of the study, Dr. Kalarchian said.

“Prospective studies really need to determine how psychosocial factors are related to surgical outcomes, and to identify those who are vulnerable to poor outcomes,” she said.

To encourage subjects in the study who had psychological problems to seek help, Dr. Kalarchian and her associates did not report the results to the surgical team.

“The confidential nature might encourage patients to discuss their mental health issues,” she said.

A meeting attendee asked Dr. Kalarchian if she would inform surgeons if a patient had a major psychiatric concern.

“It would be a rare instance where we would identify something we would need to inform the surgical team about, for example, suicidality, Dr. Kalarchian responded.

Although previous research indicated bariatric surgery patients might have higher rates of psychopathology, the studies were limited methodologically, she said.

Source: Dr. Migliore

ORLANDO — Psychiatric conditions are more common among patients who seek bariatric surgery than among the general population, according to preliminary results from a study reported by Melissa A. Kalarchian, Ph.D., at the annual meeting of the American Society for Bariatric Surgery.

Dr. Kalarchian and her colleagues screened bariatric surgery candidates with the Structured Clinical Interview for the DSM-IV to determine current and lifetime history of psychiatric disorders.

Preliminary results included 200 surgical candidates.

The average candidate age was 46 years; 89% were white; 85% were female; and their average body mass index (kg/m

The surgical candidates had higher rates of lifetime psychopathology than those reported for individuals in the community in the baseline National Comorbidity Survey (NCS), said Dr. Kalarchian of the Western Psychiatric Institute and Clinic in Pittsburgh. (See graph.)

Anxiety disorders included generalized anxiety, posttraumatic stress disorder, and obsessive-compulsive disorder, as well as agoraphobia, panic disorder, social phobia, and specific phobia.

Prevalence of major depressive disorder (MDD) varied by gender. A total of 10% of female and 13% of male surgery candidates met criteria for MDD at study entry. In addition, 45% of female and 33% of male surgical candidates reported a lifetime history of MDD. In the NCS, 21% of women and 13% of men reported such a history.

The researchers also assessed binge eating. Among the surgical candidates in the study, 34% reported a lifetime history of binge eating and 18% reported current binge eating.

“It's really important to wait for prospective studies before saying binge eating is a contraindication to surgery,” Dr. Kalarchian said. “Binge eating can be treated, and I don't think it would be grounds to deny or delay surgery.”

“Binge eating is strongly associated with depression and obesity,” she added. “There is controversy about whether binge eating disorder is a distinct syndrome or a marker of another psychiatric disorder.”

The findings of the study suggest a need to monitor patients for onset or recurrent psychiatric symptoms, she said. “Patients with unstable psychiatric conditions might be deferred for bariatric surgery until their condition is under control.”

An inability to determine a cause-and-effect relationship between psychiatric morbidity and being severely obese in our culture was a limitation of the study, Dr. Kalarchian said.

“Prospective studies really need to determine how psychosocial factors are related to surgical outcomes, and to identify those who are vulnerable to poor outcomes,” she said.

To encourage subjects in the study who had psychological problems to seek help, Dr. Kalarchian and her associates did not report the results to the surgical team.

“The confidential nature might encourage patients to discuss their mental health issues,” she said.

A meeting attendee asked Dr. Kalarchian if she would inform surgeons if a patient had a major psychiatric concern.

“It would be a rare instance where we would identify something we would need to inform the surgical team about, for example, suicidality, Dr. Kalarchian responded.

Although previous research indicated bariatric surgery patients might have higher rates of psychopathology, the studies were limited methodologically, she said.

Source: Dr. Migliore

ORLANDO — Psychiatric conditions are more common among patients who seek bariatric surgery than among the general population, according to preliminary results from a study reported by Melissa A. Kalarchian, Ph.D., at the annual meeting of the American Society for Bariatric Surgery.

Dr. Kalarchian and her colleagues screened bariatric surgery candidates with the Structured Clinical Interview for the DSM-IV to determine current and lifetime history of psychiatric disorders.

Preliminary results included 200 surgical candidates.

The average candidate age was 46 years; 89% were white; 85% were female; and their average body mass index (kg/m

The surgical candidates had higher rates of lifetime psychopathology than those reported for individuals in the community in the baseline National Comorbidity Survey (NCS), said Dr. Kalarchian of the Western Psychiatric Institute and Clinic in Pittsburgh. (See graph.)

Anxiety disorders included generalized anxiety, posttraumatic stress disorder, and obsessive-compulsive disorder, as well as agoraphobia, panic disorder, social phobia, and specific phobia.

Prevalence of major depressive disorder (MDD) varied by gender. A total of 10% of female and 13% of male surgery candidates met criteria for MDD at study entry. In addition, 45% of female and 33% of male surgical candidates reported a lifetime history of MDD. In the NCS, 21% of women and 13% of men reported such a history.

The researchers also assessed binge eating. Among the surgical candidates in the study, 34% reported a lifetime history of binge eating and 18% reported current binge eating.

“It's really important to wait for prospective studies before saying binge eating is a contraindication to surgery,” Dr. Kalarchian said. “Binge eating can be treated, and I don't think it would be grounds to deny or delay surgery.”

“Binge eating is strongly associated with depression and obesity,” she added. “There is controversy about whether binge eating disorder is a distinct syndrome or a marker of another psychiatric disorder.”

The findings of the study suggest a need to monitor patients for onset or recurrent psychiatric symptoms, she said. “Patients with unstable psychiatric conditions might be deferred for bariatric surgery until their condition is under control.”

An inability to determine a cause-and-effect relationship between psychiatric morbidity and being severely obese in our culture was a limitation of the study, Dr. Kalarchian said.

“Prospective studies really need to determine how psychosocial factors are related to surgical outcomes, and to identify those who are vulnerable to poor outcomes,” she said.

To encourage subjects in the study who had psychological problems to seek help, Dr. Kalarchian and her associates did not report the results to the surgical team.

“The confidential nature might encourage patients to discuss their mental health issues,” she said.

A meeting attendee asked Dr. Kalarchian if she would inform surgeons if a patient had a major psychiatric concern.

“It would be a rare instance where we would identify something we would need to inform the surgical team about, for example, suicidality, Dr. Kalarchian responded.

Although previous research indicated bariatric surgery patients might have higher rates of psychopathology, the studies were limited methodologically, she said.

Source: Dr. Migliore

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is provided by physicians other than cardiologists, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Paul J. Hauptman, M.D., said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists believed that they, and not cardiologists, should initiate end-of-life discussions. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman said. However, he added, most of the generalists reported they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said.

“It's going to take education and discussions at national meetings [to understand that],” he added.

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality-of-life measurements for patients with end-stage heart failure. “This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists surveyed (65%) have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists. With the increasing prevalence of heart failure, Dr. Hauptman said, “more patients are going to show up with a device. Do you turn them off or not turn them off?”

Dr. Hauptman said he hopes that the final results of the survey will provide even more insight about physician attitudes toward end-stage heart failure and that the information can be used to design effective interventions in the future.

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is provided by physicians other than cardiologists, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Paul J. Hauptman, M.D., said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists believed that they, and not cardiologists, should initiate end-of-life discussions. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman said. However, he added, most of the generalists reported they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said.

“It's going to take education and discussions at national meetings [to understand that],” he added.

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality-of-life measurements for patients with end-stage heart failure. “This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists surveyed (65%) have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists. With the increasing prevalence of heart failure, Dr. Hauptman said, “more patients are going to show up with a device. Do you turn them off or not turn them off?”

Dr. Hauptman said he hopes that the final results of the survey will provide even more insight about physician attitudes toward end-stage heart failure and that the information can be used to design effective interventions in the future.

BOCA RATON, FLA. — When it comes to treatment options, palliative care, and decision making for patients with end-stage heart failure, cardiologists, internists, family physicians, and geriatricians are similarly lacking in awareness, according to a national pilot survey.

The American College of Cardiology and the American Heart Association's recommendations for care of heart failure patients include a call for cardiologists to counsel patients about end-of-life issues.

However, most of the care of heart failure patients is provided by physicians other than cardiologists, and there is still uncertainty about which physicians should address end-of-life concerns with end-stage heart failure patients.

“The question is, who is going to have 'the talk'?” Paul J. Hauptman, M.D., said in an interview.

“More and more patients have heart failure, and more and more patients are going to die from heart failure. What are we going to do with this burgeoning population of patients with heart failure?” asked Dr. Hauptman, professor of medicine, division of cardiology, and director of heart failure/transplantation at St. Louis University.

In an attempt to answer that question, Dr. Hauptman and his associates surveyed cardiologists, family physicians, internists, and geriatricians about the management of patients with end-stage heart failure. The investigators randomly selected physicians from the American Medical Association Master File.

The administration of the 51-question survey is ongoing, with the goal of garnering opinions from 1,450 physicians. Preliminary results from 76 responses were given in a poster presentation at the annual meeting of the Heart Failure Society of America.

The survey indicates a similar lack of awareness about published guidelines for heart failure (44% of cardiologists, 47% of noncardiologists), a similar belief in left-ventricular pacing as a life-extending measure (44% of cardiologists, 41% of noncardiologists), and a similar level of uncertainty about when to refer a patient to hospice care (52% of cardiologists, 53% of noncardiologists).

Almost 85% of the noncardiologists believed that they, and not cardiologists, should initiate end-of-life discussions. “The noncardiologists really thought they were better [at that] than the cardiologists,” Dr. Hauptman said. However, he added, most of the generalists reported they had never had such a discussion with a patient or a patient's family.

“Cardiologists have an acute-care perspective. We don't really know about what is going on at the end of life,” Dr. Hauptman said.

“It's going to take education and discussions at national meetings [to understand that],” he added.

The majority of respondents (91% of cardiologists, 67% of noncardiologists) do not use standard quality-of-life measurements for patients with end-stage heart failure. “This would be kind of shocking” if confirmed by the full survey, he said.

Most of the cardiologists surveyed (65%) have discussed implantable cardioverter defibrillator deactivation with an end-stage patient or family member, compared with 35% of noncardiologists. With the increasing prevalence of heart failure, Dr. Hauptman said, “more patients are going to show up with a device. Do you turn them off or not turn them off?”

Dr. Hauptman said he hopes that the final results of the survey will provide even more insight about physician attitudes toward end-stage heart failure and that the information can be used to design effective interventions in the future.

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe that nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

About one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL with nesiritide and 538 pg/mL with standard therapy; by 48 hours, the mean changes were a 474 pg/mL increase with nesiritide and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide didn't enhance the response to furosemide. We hypothesized [it] should have a beneficial effect on renal function—we didn't see that either.” Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects. The next step is to look at a lower dose, which might provide renal protection,” he said.

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe that nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

About one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL with nesiritide and 538 pg/mL with standard therapy; by 48 hours, the mean changes were a 474 pg/mL increase with nesiritide and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide didn't enhance the response to furosemide. We hypothesized [it] should have a beneficial effect on renal function—we didn't see that either.” Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects. The next step is to look at a lower dose, which might provide renal protection,” he said.

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe that nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

About one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL with nesiritide and 538 pg/mL with standard therapy; by 48 hours, the mean changes were a 474 pg/mL increase with nesiritide and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide didn't enhance the response to furosemide. We hypothesized [it] should have a beneficial effect on renal function—we didn't see that either.” Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects. The next step is to look at a lower dose, which might provide renal protection,” he said.

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might actually increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

Approximately one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL for the nesiritide group and 538 pg/mL for the standard therapy group; by 48 hours, the mean changes were a 474 pg/mL increase in the nesiritide group and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide did not enhance the response to furosemide. We hypothesized that nesiritide should have a beneficial effect on renal function—we didn't see that either.”

Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects,” Dr. Redfield commented. “The next step is to look at a lower dose, which might provide renal protection.”

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might actually increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

Approximately one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL for the nesiritide group and 538 pg/mL for the standard therapy group; by 48 hours, the mean changes were a 474 pg/mL increase in the nesiritide group and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide did not enhance the response to furosemide. We hypothesized that nesiritide should have a beneficial effect on renal function—we didn't see that either.”

Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects,” Dr. Redfield commented. “The next step is to look at a lower dose, which might provide renal protection.”

BOCA RATON, FLA. — The brain natriuretic peptide, nesiritide, which is used to treat acute heart failure symptoms, did not facilitate diuresis or protect renal function in a small study of stable hospitalized patients.

Many clinicians believe nesiritide (Natrecor, Scios Inc.) facilitates furosemide diuresis and prevents renal dysfunction, Margaret M. Redfield, M.D., said in an interview. However, a recent metaanalysis indicated that the agent might actually increase the risk of renal dysfunction (Circulation 2005;111:1487–91).

To sort it out, Dr. Redfield and her associates studied 65 patients who were hospitalized for decompensated heart failure and who were treated with a standard dose of nesiritide for relief of their heart failure symptoms. They were randomized to nesiritide as a 2-mcg/kg bolus at admission and a 0.01-mcg/kg per minute infusion at 48 hours (34 patients) or to standard therapy (31 patients).

The participants also received 40-mg b.i.d. intravenous furosemide if they had mild renal dysfunction at baseline, defined as a creatinine clearance of 40–60 mL/min. They received 80-mg b.i.d. intravenous furosemide if they had moderate renal dysfunction, or a creatinine clearance of 20–39 mL/min.

“We looked at nesiritide in the broader heart failure population where you don't need an acute effect,” said Dr. Redfield, professor of medicine, Mayo Clinic College of Medicine, Rochester, Minn.

Approximately one-quarter of heart failure patients experience renal dysfunction during hospitalization, and the researchers sought to determine if nesiritide is protective, Dr. Redfield said during a poster session at the annual meeting of the Heart Failure Society of America.

A secondary objective was to determine if the agent could obviate the need for furosemide diuresis in some patients.

Mean baseline creatinine was 1.8 mg/dL in the nesiritide group and 1.7 mg/dL in the standard therapy group; by 48 hours, the mean changes were increases of 0.12 mg/dL and 0.07 mg/dL, respectively. Mean baseline brain natriuretic peptide level was 640 pg/mL for the nesiritide group and 538 pg/mL for the standard therapy group; by 48 hours, the mean changes were a 474 pg/mL increase in the nesiritide group and a 59 pg/mL decrease in the control group. Total furosemide use was 272 mg in the nesiritide group and 255 mg in the standard treatment group at 48 hours.

“Nesiritide causes no harm, but has no significant benefit,” Dr. Redfield said. “Nesiritide did not enhance the response to furosemide. We hypothesized that nesiritide should have a beneficial effect on renal function—we didn't see that either.”

Systolic blood pressure was lower in the nesiritide group at 24 hours, but not significantly different between groups by 48 hours.

“The standard dose was designed for hemodynamic effects,” Dr. Redfield commented. “The next step is to look at a lower dose, which might provide renal protection.”

BOCA RATON, FLA. — Early worsening of symptoms after initiation of fluoxetine for major depressive disorder occurs in approximately 30% of patients and is associated with poorer outcomes and an increased likelihood of discontinuation, Cristina Cusin, M.D., said in a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Patients should be monitored very carefully in the weeks after new treatment with fluoxetine, she said.

Dr. Cusin and her associates studied 694 outpatients (mean age 39 years) with major depressive disorder. Participants received 20 mg of fluoxetine per day for up to 12 weeks. The investigators assessed participants at regular intervals with a modified Hamilton Depression Rating Scale (mHAM-D) and defined worsening as a 5-point increase in score since the previous visit, occurring at least 1 week after starting treatment. Eli Lilly funded the study.

“Not all patients respond the same way. Some get worse before they get better,” said Dr. Cusin of Massachusetts General Hospital, Boston. Dr. Cusin has no affiliation with Eli Lilly.

A total of 211 patients (30%) had worsening of their depression between weeks 2 and 6. Researchers looked for clinical correlates to predict who might fall into this group. They found no significant differences—based on age, duration of illness, number of previous depressive episodes, baseline mHAM-D scores, or fluoxetine/norfluoxetine plasma levels—between this group and the 483 who reported no worsening.

But an increase in the mHAM-D scores at weeks 2, 3, 4, and 6 was significantly associated with a lower probability of improvement at weeks 8 and 12.

BOCA RATON, FLA. — Early worsening of symptoms after initiation of fluoxetine for major depressive disorder occurs in approximately 30% of patients and is associated with poorer outcomes and an increased likelihood of discontinuation, Cristina Cusin, M.D., said in a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Patients should be monitored very carefully in the weeks after new treatment with fluoxetine, she said.

Dr. Cusin and her associates studied 694 outpatients (mean age 39 years) with major depressive disorder. Participants received 20 mg of fluoxetine per day for up to 12 weeks. The investigators assessed participants at regular intervals with a modified Hamilton Depression Rating Scale (mHAM-D) and defined worsening as a 5-point increase in score since the previous visit, occurring at least 1 week after starting treatment. Eli Lilly funded the study.

“Not all patients respond the same way. Some get worse before they get better,” said Dr. Cusin of Massachusetts General Hospital, Boston. Dr. Cusin has no affiliation with Eli Lilly.

A total of 211 patients (30%) had worsening of their depression between weeks 2 and 6. Researchers looked for clinical correlates to predict who might fall into this group. They found no significant differences—based on age, duration of illness, number of previous depressive episodes, baseline mHAM-D scores, or fluoxetine/norfluoxetine plasma levels—between this group and the 483 who reported no worsening.

But an increase in the mHAM-D scores at weeks 2, 3, 4, and 6 was significantly associated with a lower probability of improvement at weeks 8 and 12.

BOCA RATON, FLA. — Early worsening of symptoms after initiation of fluoxetine for major depressive disorder occurs in approximately 30% of patients and is associated with poorer outcomes and an increased likelihood of discontinuation, Cristina Cusin, M.D., said in a poster presentation at a meeting of the New Clinical Drug Evaluation Unit sponsored by the National Institute of Mental Health.

Patients should be monitored very carefully in the weeks after new treatment with fluoxetine, she said.

Dr. Cusin and her associates studied 694 outpatients (mean age 39 years) with major depressive disorder. Participants received 20 mg of fluoxetine per day for up to 12 weeks. The investigators assessed participants at regular intervals with a modified Hamilton Depression Rating Scale (mHAM-D) and defined worsening as a 5-point increase in score since the previous visit, occurring at least 1 week after starting treatment. Eli Lilly funded the study.

“Not all patients respond the same way. Some get worse before they get better,” said Dr. Cusin of Massachusetts General Hospital, Boston. Dr. Cusin has no affiliation with Eli Lilly.

A total of 211 patients (30%) had worsening of their depression between weeks 2 and 6. Researchers looked for clinical correlates to predict who might fall into this group. They found no significant differences—based on age, duration of illness, number of previous depressive episodes, baseline mHAM-D scores, or fluoxetine/norfluoxetine plasma levels—between this group and the 483 who reported no worsening.

But an increase in the mHAM-D scores at weeks 2, 3, 4, and 6 was significantly associated with a lower probability of improvement at weeks 8 and 12.

MIAMI BEACH – Operator errors are responsible for more than half of the failures of deep brain stimulation to lessen essential tremor or Parkinson's symptoms, according to the findings of one study presented at the American Academy of Neurology annual meeting.

Many of these patients benefit when deep brain stimulation (DBS) is repeated at movement disorder centers by more experienced physicians.

The Food and Drug Administration approved a DBS system (Activa, manufactured by Medtronic Inc.) to treat patients with essential tremor or Parkinson's disease in August 1997.

The agency expanded the system's indication to include patients with dystonia in April 2003.

Although DBS improves quality of life for many patients, some do not respond. Incorrect diagnosis, surgical lead misplacement, and device-related errors are among the preventable problems identified by Michael S. Okun, M.D., and his associates.

“There has been a surge in centers providing DBS after its FDA approval and an increasing number of patients presenting to experienced DBS centers with complaints,” said Dr. Okun, codirector of the Movement Disorders Center at the University of Florida in Gainesville.

“About 12 patients per year are seen by centers of excellence for these referred problems,” he said.

A lack of consensus on patient screening, provider training, and the best multidisciplinary approach contribute to the failure rate, Dr. Okun said.

In addition, there is no consensus on the management of complications, some of which spur referral of the patient to an experienced DBS center for management.

The records of 41 consecutive patients who were treated at the University of Florida movement disorders center or the movement disorders center at the Beth Israel Medical Center in New York City were reviewed.

The patients' average age was 63 years. Thirty patients (73%) saw a movement disorders specialist prior to DBS implantation, and five patients (12%) had significant cognitive dysfunction before implantation.

The patients underwent the following types of DBS implantation: 21, bilateral subthalamic nucleus; 8, unilateral subthalamic nucleus; 8, unilateral ventral intermediate nucleus; 1, unilateral globus pallidus interna; 1, bilateral ventral intermediate nucleus; and 1, bilateral globus pallidus interna.

All of the study participants saw a movement disorders neurologist upon referral.

More than one-third, 36%, of patients had no improvement, and 15% had minimal improvement. However, “51% had significant improvement or were rescued with good outcomes,” Dr. Okun said at the meeting.

“The reasons for DBS failures were not only surgical,” Dr. Okun said.

The researchers identified a timeline of preventable problems associated with DBS surgery. “It is quite interesting because many things were quite correctable,” Dr. Okun said. “There is an expertise factor we can improve on.”

Preventable problems included:

▸ Incorrect diagnosis (10 instances).

▸ Inadequate medication trial/dementia (10).

▸ Misplaced leads (19).

▸ Inadequate device programming (15).

▸ Medication adjustments (30).

Preoperative diagnoses included 31 with Parkinson's disease, 9 with essential tremor, and 1 patient with dystonia.

The actual diagnoses were 26 with Parkinson's disease, 5 with essential tremor, 1 with dystonia, 3 with Parkinson's disease with dementia, 2 with multiple system atrophy, 1 with Parkinson's disease/essential tremor, 1 with corticobasal ganglionic degeneration, 1 with progressive nuclear palsy, and 1 with myoclonus.

Patients improved after 7 of the 19 misplaced leads were replaced, and partially improved after 3 others were replaced, he reported.

Programming problems included inadequate programming (15 patients), no or poor access to programming (7 patients), and difficult access to follow-up because of relocation (2 patients, 2 physicians). Reprogramming was successful for 15 patients and partially successful for 6 patients.

A majority, 73%, of participants required medication changes. Dr. Okun said, “This brings home the point that even after surgery patients often need medication adjustments.”

Selection bias was a possible shortcoming of the study.

Dr. Okun said there are many improvements that can be made to prevent DBS failures and to improve outcomes.

Dr. Okun acknowledged that he teaches courses in programming the Activa DBS system for Medtronic.

Operator errors caused more than half of all deep brain stimulation failures. Shown are DBS lead misplacements in the ventricle (left) and atop the thalamus (right). Photos courtesy Dr. Michael S. Okun

MIAMI BEACH – Operator errors are responsible for more than half of the failures of deep brain stimulation to lessen essential tremor or Parkinson's symptoms, according to the findings of one study presented at the American Academy of Neurology annual meeting.

Many of these patients benefit when deep brain stimulation (DBS) is repeated at movement disorder centers by more experienced physicians.

The Food and Drug Administration approved a DBS system (Activa, manufactured by Medtronic Inc.) to treat patients with essential tremor or Parkinson's disease in August 1997.

The agency expanded the system's indication to include patients with dystonia in April 2003.

Although DBS improves quality of life for many patients, some do not respond. Incorrect diagnosis, surgical lead misplacement, and device-related errors are among the preventable problems identified by Michael S. Okun, M.D., and his associates.

“There has been a surge in centers providing DBS after its FDA approval and an increasing number of patients presenting to experienced DBS centers with complaints,” said Dr. Okun, codirector of the Movement Disorders Center at the University of Florida in Gainesville.

“About 12 patients per year are seen by centers of excellence for these referred problems,” he said.

A lack of consensus on patient screening, provider training, and the best multidisciplinary approach contribute to the failure rate, Dr. Okun said.

In addition, there is no consensus on the management of complications, some of which spur referral of the patient to an experienced DBS center for management.

The records of 41 consecutive patients who were treated at the University of Florida movement disorders center or the movement disorders center at the Beth Israel Medical Center in New York City were reviewed.

The patients' average age was 63 years. Thirty patients (73%) saw a movement disorders specialist prior to DBS implantation, and five patients (12%) had significant cognitive dysfunction before implantation.

The patients underwent the following types of DBS implantation: 21, bilateral subthalamic nucleus; 8, unilateral subthalamic nucleus; 8, unilateral ventral intermediate nucleus; 1, unilateral globus pallidus interna; 1, bilateral ventral intermediate nucleus; and 1, bilateral globus pallidus interna.

All of the study participants saw a movement disorders neurologist upon referral.

More than one-third, 36%, of patients had no improvement, and 15% had minimal improvement. However, “51% had significant improvement or were rescued with good outcomes,” Dr. Okun said at the meeting.

“The reasons for DBS failures were not only surgical,” Dr. Okun said.

The researchers identified a timeline of preventable problems associated with DBS surgery. “It is quite interesting because many things were quite correctable,” Dr. Okun said. “There is an expertise factor we can improve on.”

Preventable problems included:

▸ Incorrect diagnosis (10 instances).

▸ Inadequate medication trial/dementia (10).

▸ Misplaced leads (19).

▸ Inadequate device programming (15).

▸ Medication adjustments (30).

Preoperative diagnoses included 31 with Parkinson's disease, 9 with essential tremor, and 1 patient with dystonia.

The actual diagnoses were 26 with Parkinson's disease, 5 with essential tremor, 1 with dystonia, 3 with Parkinson's disease with dementia, 2 with multiple system atrophy, 1 with Parkinson's disease/essential tremor, 1 with corticobasal ganglionic degeneration, 1 with progressive nuclear palsy, and 1 with myoclonus.

Patients improved after 7 of the 19 misplaced leads were replaced, and partially improved after 3 others were replaced, he reported.

Programming problems included inadequate programming (15 patients), no or poor access to programming (7 patients), and difficult access to follow-up because of relocation (2 patients, 2 physicians). Reprogramming was successful for 15 patients and partially successful for 6 patients.

A majority, 73%, of participants required medication changes. Dr. Okun said, “This brings home the point that even after surgery patients often need medication adjustments.”

Selection bias was a possible shortcoming of the study.

Dr. Okun said there are many improvements that can be made to prevent DBS failures and to improve outcomes.

Dr. Okun acknowledged that he teaches courses in programming the Activa DBS system for Medtronic.

Operator errors caused more than half of all deep brain stimulation failures. Shown are DBS lead misplacements in the ventricle (left) and atop the thalamus (right). Photos courtesy Dr. Michael S. Okun

MIAMI BEACH – Operator errors are responsible for more than half of the failures of deep brain stimulation to lessen essential tremor or Parkinson's symptoms, according to the findings of one study presented at the American Academy of Neurology annual meeting.

Many of these patients benefit when deep brain stimulation (DBS) is repeated at movement disorder centers by more experienced physicians.

The Food and Drug Administration approved a DBS system (Activa, manufactured by Medtronic Inc.) to treat patients with essential tremor or Parkinson's disease in August 1997.

The agency expanded the system's indication to include patients with dystonia in April 2003.

Although DBS improves quality of life for many patients, some do not respond. Incorrect diagnosis, surgical lead misplacement, and device-related errors are among the preventable problems identified by Michael S. Okun, M.D., and his associates.

“There has been a surge in centers providing DBS after its FDA approval and an increasing number of patients presenting to experienced DBS centers with complaints,” said Dr. Okun, codirector of the Movement Disorders Center at the University of Florida in Gainesville.

“About 12 patients per year are seen by centers of excellence for these referred problems,” he said.

A lack of consensus on patient screening, provider training, and the best multidisciplinary approach contribute to the failure rate, Dr. Okun said.

In addition, there is no consensus on the management of complications, some of which spur referral of the patient to an experienced DBS center for management.

The records of 41 consecutive patients who were treated at the University of Florida movement disorders center or the movement disorders center at the Beth Israel Medical Center in New York City were reviewed.

The patients' average age was 63 years. Thirty patients (73%) saw a movement disorders specialist prior to DBS implantation, and five patients (12%) had significant cognitive dysfunction before implantation.

The patients underwent the following types of DBS implantation: 21, bilateral subthalamic nucleus; 8, unilateral subthalamic nucleus; 8, unilateral ventral intermediate nucleus; 1, unilateral globus pallidus interna; 1, bilateral ventral intermediate nucleus; and 1, bilateral globus pallidus interna.

All of the study participants saw a movement disorders neurologist upon referral.

More than one-third, 36%, of patients had no improvement, and 15% had minimal improvement. However, “51% had significant improvement or were rescued with good outcomes,” Dr. Okun said at the meeting.

“The reasons for DBS failures were not only surgical,” Dr. Okun said.

The researchers identified a timeline of preventable problems associated with DBS surgery. “It is quite interesting because many things were quite correctable,” Dr. Okun said. “There is an expertise factor we can improve on.”

Preventable problems included:

▸ Incorrect diagnosis (10 instances).

▸ Inadequate medication trial/dementia (10).

▸ Misplaced leads (19).

▸ Inadequate device programming (15).

▸ Medication adjustments (30).

Preoperative diagnoses included 31 with Parkinson's disease, 9 with essential tremor, and 1 patient with dystonia.

The actual diagnoses were 26 with Parkinson's disease, 5 with essential tremor, 1 with dystonia, 3 with Parkinson's disease with dementia, 2 with multiple system atrophy, 1 with Parkinson's disease/essential tremor, 1 with corticobasal ganglionic degeneration, 1 with progressive nuclear palsy, and 1 with myoclonus.

Patients improved after 7 of the 19 misplaced leads were replaced, and partially improved after 3 others were replaced, he reported.

Programming problems included inadequate programming (15 patients), no or poor access to programming (7 patients), and difficult access to follow-up because of relocation (2 patients, 2 physicians). Reprogramming was successful for 15 patients and partially successful for 6 patients.

A majority, 73%, of participants required medication changes. Dr. Okun said, “This brings home the point that even after surgery patients often need medication adjustments.”

Selection bias was a possible shortcoming of the study.

Dr. Okun said there are many improvements that can be made to prevent DBS failures and to improve outcomes.

Dr. Okun acknowledged that he teaches courses in programming the Activa DBS system for Medtronic.

Operator errors caused more than half of all deep brain stimulation failures. Shown are DBS lead misplacements in the ventricle (left) and atop the thalamus (right). Photos courtesy Dr. Michael S. Okun

ORLANDO, FLA. — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley advised. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Having patient registration forms available on the practice's Web site, so patients can fill them out ahead of time.

▸ Dedicated check-in and check-out areas.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize using ice packs at home after surgery; Dr. Ceilley suggests that patients use bags of frozen vegetables.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley commented.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” he said.

Dr. Ceilley offered a wide range of practical tips for improving office setup. For example, a communication center that is separate from a patient reception area does not take front desk people away from the patients to answer the telephone. This is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully. Dr. Ceilley said that in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office. “We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said.

ORLANDO, FLA. — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley advised. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Having patient registration forms available on the practice's Web site, so patients can fill them out ahead of time.

▸ Dedicated check-in and check-out areas.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize using ice packs at home after surgery; Dr. Ceilley suggests that patients use bags of frozen vegetables.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley commented.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” he said.

Dr. Ceilley offered a wide range of practical tips for improving office setup. For example, a communication center that is separate from a patient reception area does not take front desk people away from the patients to answer the telephone. This is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully. Dr. Ceilley said that in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office. “We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said.

ORLANDO, FLA. — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley advised. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Having patient registration forms available on the practice's Web site, so patients can fill them out ahead of time.

▸ Dedicated check-in and check-out areas.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize using ice packs at home after surgery; Dr. Ceilley suggests that patients use bags of frozen vegetables.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley commented.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” he said.

Dr. Ceilley offered a wide range of practical tips for improving office setup. For example, a communication center that is separate from a patient reception area does not take front desk people away from the patients to answer the telephone. This is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully. Dr. Ceilley said that in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office. “We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said.

BOCA RATON, FLA. — The cost of fixed-dose isosorbide dinitrate and hydralazine is more than offset by decreases in health care resource utilization by African Americans with moderate to severe heart failure, according to a poster presented at the annual meeting of the Heart Failure Society of America.

Primary end points of the African Americans Heart Failure Trial (A-HeFT) were death, first hospitalization for heart failure, and change in quality of life (N. Engl. J. Med. 2004;351:2049–57).

In addition, the researchers collected enough data to assess the economic impact of the drug combination and other factors during the trial.

“We looked at all resource utilization,” Walter T. Linde-Zwirble said in an interview. “There is, nowadays, an economic story, not just a clinical story,” with new medications.

“A therapy has to decrease the cost of care or provide enough of a definable outcome at an acceptable price,” said Mr. Linde-Zwirble, a consultant hired by Nitromed Inc., the makers of fixed-dose isosorbide dinitrate and hydralazine (BiDil).

“Knowing it's a study sponsored by industry, I took every possible bias against the drug into account,” explained Mr. Linde-Zwirble, who is vice president and chief science officer at ZD Associates in Perkasie, Pa.

The researchers calculated hospital costs according to length of stay, gender, and hospital survival by using 2003 Medicare data adjusted to 2004 dollars. They estimated background care, such as unscheduled physician and emergency department visits, by using average payments for a 5% sample of patients in the Medicare Part B database.

Medication costs were estimated by using average wholesale prices from the 2004 Red Book. The cost of fixed-dose isosorbide dinitrate and hydralazine included the manufacturer's announced price of $1.80 per tablet, the average prescribed dose, and compliance data from the A-HeFT.

“The only things that made a big difference were the costs of hospitalizations and the cost of BiDil,” Mr. Linde-Zwirble said. Treatment was associated with a smaller number of hospitalizations and shorter hospital stays.

The heart failure costs—including the cost of the drug combination—were 6% lower in the treatment group, compared with the placebo group.

“The drug provided a $533 cost savings with 23 additional days of survival, an astounding increase in survival,” Mr. Linde-Zwirble said.

“The more you use the intervention on appropriate patients, the more money you will save,” Mr. Linde-Zwirble said. “Cardiologists 5 years from now will have a good idea of how BiDil fits in—it's still new.”

BOCA RATON, FLA. — The cost of fixed-dose isosorbide dinitrate and hydralazine is more than offset by decreases in health care resource utilization by African Americans with moderate to severe heart failure, according to a poster presented at the annual meeting of the Heart Failure Society of America.

Primary end points of the African Americans Heart Failure Trial (A-HeFT) were death, first hospitalization for heart failure, and change in quality of life (N. Engl. J. Med. 2004;351:2049–57).

In addition, the researchers collected enough data to assess the economic impact of the drug combination and other factors during the trial.

“We looked at all resource utilization,” Walter T. Linde-Zwirble said in an interview. “There is, nowadays, an economic story, not just a clinical story,” with new medications.

“A therapy has to decrease the cost of care or provide enough of a definable outcome at an acceptable price,” said Mr. Linde-Zwirble, a consultant hired by Nitromed Inc., the makers of fixed-dose isosorbide dinitrate and hydralazine (BiDil).

“Knowing it's a study sponsored by industry, I took every possible bias against the drug into account,” explained Mr. Linde-Zwirble, who is vice president and chief science officer at ZD Associates in Perkasie, Pa.

The researchers calculated hospital costs according to length of stay, gender, and hospital survival by using 2003 Medicare data adjusted to 2004 dollars. They estimated background care, such as unscheduled physician and emergency department visits, by using average payments for a 5% sample of patients in the Medicare Part B database.

Medication costs were estimated by using average wholesale prices from the 2004 Red Book. The cost of fixed-dose isosorbide dinitrate and hydralazine included the manufacturer's announced price of $1.80 per tablet, the average prescribed dose, and compliance data from the A-HeFT.

“The only things that made a big difference were the costs of hospitalizations and the cost of BiDil,” Mr. Linde-Zwirble said. Treatment was associated with a smaller number of hospitalizations and shorter hospital stays.

The heart failure costs—including the cost of the drug combination—were 6% lower in the treatment group, compared with the placebo group.

“The drug provided a $533 cost savings with 23 additional days of survival, an astounding increase in survival,” Mr. Linde-Zwirble said.

“The more you use the intervention on appropriate patients, the more money you will save,” Mr. Linde-Zwirble said. “Cardiologists 5 years from now will have a good idea of how BiDil fits in—it's still new.”

BOCA RATON, FLA. — The cost of fixed-dose isosorbide dinitrate and hydralazine is more than offset by decreases in health care resource utilization by African Americans with moderate to severe heart failure, according to a poster presented at the annual meeting of the Heart Failure Society of America.

Primary end points of the African Americans Heart Failure Trial (A-HeFT) were death, first hospitalization for heart failure, and change in quality of life (N. Engl. J. Med. 2004;351:2049–57).

In addition, the researchers collected enough data to assess the economic impact of the drug combination and other factors during the trial.

“We looked at all resource utilization,” Walter T. Linde-Zwirble said in an interview. “There is, nowadays, an economic story, not just a clinical story,” with new medications.

“A therapy has to decrease the cost of care or provide enough of a definable outcome at an acceptable price,” said Mr. Linde-Zwirble, a consultant hired by Nitromed Inc., the makers of fixed-dose isosorbide dinitrate and hydralazine (BiDil).

“Knowing it's a study sponsored by industry, I took every possible bias against the drug into account,” explained Mr. Linde-Zwirble, who is vice president and chief science officer at ZD Associates in Perkasie, Pa.

The researchers calculated hospital costs according to length of stay, gender, and hospital survival by using 2003 Medicare data adjusted to 2004 dollars. They estimated background care, such as unscheduled physician and emergency department visits, by using average payments for a 5% sample of patients in the Medicare Part B database.

Medication costs were estimated by using average wholesale prices from the 2004 Red Book. The cost of fixed-dose isosorbide dinitrate and hydralazine included the manufacturer's announced price of $1.80 per tablet, the average prescribed dose, and compliance data from the A-HeFT.

“The only things that made a big difference were the costs of hospitalizations and the cost of BiDil,” Mr. Linde-Zwirble said. Treatment was associated with a smaller number of hospitalizations and shorter hospital stays.

The heart failure costs—including the cost of the drug combination—were 6% lower in the treatment group, compared with the placebo group.

“The drug provided a $533 cost savings with 23 additional days of survival, an astounding increase in survival,” Mr. Linde-Zwirble said.

“The more you use the intervention on appropriate patients, the more money you will save,” Mr. Linde-Zwirble said. “Cardiologists 5 years from now will have a good idea of how BiDil fits in—it's still new.”

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

"Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had," said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—"some older patients have a component of lip reading"—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. "Laying on of hands lets the patients know that you care."

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. "Look at the patient before you leave. Ask: 'Is there anything else you need?'"

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Wet gauze placed over patients' eyes before dermatologic surgery. "Tell them it will help prevent a headache from the bright lights," Dr. Ceilley said. "That's true, but it also helps ease the patients because they don't see all the needles and instruments."

▸ Absorbable sutures when indicated. "Patients who travel a great distance really appreciate not having to return for suture removal," he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. "Humor is very important," Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining, for example, Mohs surgery or a cosmetic procedure. Physicians must give patients realistic expectations.

"We provide warnings about swelling, hematoma, drainage, and infection, particularly when working on the forehead or scalp," he said.

Always make a follow-up call to ascertain how patients are faring after surgery, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. "When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted." He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. A dermatologic surgeon should have an ongoing relationship with a dermatopathologist, surgical consultant, and oncologist, Dr. Ceilley said. "That way, you don't call them only when you are in trouble."

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act.

The communication center staff can make appointments and referrals, and recall cancer patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. "The biggest waste of office time is medication refills and the time it takes to call in refills," he said.

Another time-consuming task for staff is to assist patients who show up without a referral. Have a telephone in the waiting room for patients to call the referring physician themselves, he suggested.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. "Just stick them on [documents] when needed, such as pathology requests."

When a patient is diagnosed with skin cancer, document all skin malignancies using anatomic diagrams, Dr. Ceilley advised. Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician after the cancer is treated. "That way, no one falls through the cracks."

Standardization and organization are key to managing surgical equipment in the office. "We have each room in all three offices set up the same way for materials and supplies," Dr. Ceilley said. He suggested limiting the number of different suture types in the office. "For the rare cases where you need a different suture, keep them in a separate bin," he said.

Arrange the surgical tray in a standard fashion. "We color-code instruments by room. This saves us time after autoclaving," Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. "We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive."

Trim and place dressings carefully, Dr. Ceilley said. "Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed."

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

"Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had," said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—"some older patients have a component of lip reading"—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. "Laying on of hands lets the patients know that you care."

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. "Look at the patient before you leave. Ask: 'Is there anything else you need?'"

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Wet gauze placed over patients' eyes before dermatologic surgery. "Tell them it will help prevent a headache from the bright lights," Dr. Ceilley said. "That's true, but it also helps ease the patients because they don't see all the needles and instruments."

▸ Absorbable sutures when indicated. "Patients who travel a great distance really appreciate not having to return for suture removal," he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. "Humor is very important," Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining, for example, Mohs surgery or a cosmetic procedure. Physicians must give patients realistic expectations.

"We provide warnings about swelling, hematoma, drainage, and infection, particularly when working on the forehead or scalp," he said.

Always make a follow-up call to ascertain how patients are faring after surgery, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. "When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted." He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. A dermatologic surgeon should have an ongoing relationship with a dermatopathologist, surgical consultant, and oncologist, Dr. Ceilley said. "That way, you don't call them only when you are in trouble."

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act.

The communication center staff can make appointments and referrals, and recall cancer patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. "The biggest waste of office time is medication refills and the time it takes to call in refills," he said.

Another time-consuming task for staff is to assist patients who show up without a referral. Have a telephone in the waiting room for patients to call the referring physician themselves, he suggested.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. "Just stick them on [documents] when needed, such as pathology requests."

When a patient is diagnosed with skin cancer, document all skin malignancies using anatomic diagrams, Dr. Ceilley advised. Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician after the cancer is treated. "That way, no one falls through the cracks."

Standardization and organization are key to managing surgical equipment in the office. "We have each room in all three offices set up the same way for materials and supplies," Dr. Ceilley said. He suggested limiting the number of different suture types in the office. "For the rare cases where you need a different suture, keep them in a separate bin," he said.

Arrange the surgical tray in a standard fashion. "We color-code instruments by room. This saves us time after autoclaving," Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. "We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive."

Trim and place dressings carefully, Dr. Ceilley said. "Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed."

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

"Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had," said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—"some older patients have a component of lip reading"—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. "Laying on of hands lets the patients know that you care."

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. "Look at the patient before you leave. Ask: 'Is there anything else you need?'"

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Wet gauze placed over patients' eyes before dermatologic surgery. "Tell them it will help prevent a headache from the bright lights," Dr. Ceilley said. "That's true, but it also helps ease the patients because they don't see all the needles and instruments."

▸ Absorbable sutures when indicated. "Patients who travel a great distance really appreciate not having to return for suture removal," he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. "Humor is very important," Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining, for example, Mohs surgery or a cosmetic procedure. Physicians must give patients realistic expectations.

"We provide warnings about swelling, hematoma, drainage, and infection, particularly when working on the forehead or scalp," he said.

Always make a follow-up call to ascertain how patients are faring after surgery, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. "When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted." He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. A dermatologic surgeon should have an ongoing relationship with a dermatopathologist, surgical consultant, and oncologist, Dr. Ceilley said. "That way, you don't call them only when you are in trouble."

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act.

The communication center staff can make appointments and referrals, and recall cancer patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. "The biggest waste of office time is medication refills and the time it takes to call in refills," he said.

Another time-consuming task for staff is to assist patients who show up without a referral. Have a telephone in the waiting room for patients to call the referring physician themselves, he suggested.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. "Just stick them on [documents] when needed, such as pathology requests."

When a patient is diagnosed with skin cancer, document all skin malignancies using anatomic diagrams, Dr. Ceilley advised. Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician after the cancer is treated. "That way, no one falls through the cracks."

Standardization and organization are key to managing surgical equipment in the office. "We have each room in all three offices set up the same way for materials and supplies," Dr. Ceilley said. He suggested limiting the number of different suture types in the office. "For the rare cases where you need a different suture, keep them in a separate bin," he said.

Arrange the surgical tray in a standard fashion. "We color-code instruments by room. This saves us time after autoclaving," Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. "We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive."

Trim and place dressings carefully, Dr. Ceilley said. "Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed."