Doug Brunk

When the woman was admitted, the differential diagnosis was between scleroderma and eosinophilic fasciitis (also known as generalized morphea profunda), according to Dr. Irwin M. Braverman, who presented the case at the Fall Clinical Dermatology Conference.

The woman had plaques of morphea covering her entire body. The edema also affected her breasts but spared the areolae and nipples. She had large plaques on her abdomen. Histology showed deep dermal fibrosis with fibrosis of fat septa extending down to a thickened fascial layer, which is confirmatory for eosinophilic fasciitis, said Dr. Braverman, professor of dermatology at Yale University, New Haven, Conn.

“We have seen about a half-dozen patients with this syndrome in the last 4 years,” he added. “This starts suddenly with patients coming in with tender, painful swelling of the arms, legs, and trunk.”

The woman was started on 20 mg prednisone t.i.d. and tapered to 15 mg once a day over the course of 12 months. The dose was then reduced by 2.5 mg every 6 months. The regimen yielded a prompt decrease in induration, swelling, and pain.

She is currently taking 5 mg prednisone once a day, and her skin has returned almost to normal.

“She will continue to be tapered 2.5 mg every 8 weeks if she shows continued improvement,” Dr. Braverman said at the meeting, which was sponsored by the Center for Bio-Medical Communications, Inc.

He emphasized that eosinophilic fasciitis “is very responsive to steroids. After starting oral prednisone, within a week this woman was feeling no pain and the edema had subsided. It's taken almost 4 years, but over the course of a slow taper, her skin has returned essentially to normal.”

The steroid therapy regimen for eosinophilic fasciitis that has been most effective for his patients is as follows:

Start with 60 mg/day (20 mg t.i.d.) prednisone for 2 weeks tapering to 25 mg per day (10/10/5 mg) over 6 weeks.

Taper 2.5 mg every other week until you reach 15 mg/day (5 mg t.i.d.).

Taper 2.5 mg every 4 weeks (t.i.d. dosing) until you reach 10 mg/day.

Remain on 10 mg/day in a single morning dose for 2 months.

Taper 2.5 mg every 8 weeks.

When the woman was admitted, the differential diagnosis was between scleroderma and eosinophilic fasciitis (also known as generalized morphea profunda), according to Dr. Irwin M. Braverman, who presented the case at the Fall Clinical Dermatology Conference.

The woman had plaques of morphea covering her entire body. The edema also affected her breasts but spared the areolae and nipples. She had large plaques on her abdomen. Histology showed deep dermal fibrosis with fibrosis of fat septa extending down to a thickened fascial layer, which is confirmatory for eosinophilic fasciitis, said Dr. Braverman, professor of dermatology at Yale University, New Haven, Conn.

“We have seen about a half-dozen patients with this syndrome in the last 4 years,” he added. “This starts suddenly with patients coming in with tender, painful swelling of the arms, legs, and trunk.”

The woman was started on 20 mg prednisone t.i.d. and tapered to 15 mg once a day over the course of 12 months. The dose was then reduced by 2.5 mg every 6 months. The regimen yielded a prompt decrease in induration, swelling, and pain.

She is currently taking 5 mg prednisone once a day, and her skin has returned almost to normal.

“She will continue to be tapered 2.5 mg every 8 weeks if she shows continued improvement,” Dr. Braverman said at the meeting, which was sponsored by the Center for Bio-Medical Communications, Inc.

He emphasized that eosinophilic fasciitis “is very responsive to steroids. After starting oral prednisone, within a week this woman was feeling no pain and the edema had subsided. It's taken almost 4 years, but over the course of a slow taper, her skin has returned essentially to normal.”

The steroid therapy regimen for eosinophilic fasciitis that has been most effective for his patients is as follows:

Start with 60 mg/day (20 mg t.i.d.) prednisone for 2 weeks tapering to 25 mg per day (10/10/5 mg) over 6 weeks.

Taper 2.5 mg every other week until you reach 15 mg/day (5 mg t.i.d.).

Taper 2.5 mg every 4 weeks (t.i.d. dosing) until you reach 10 mg/day.

Remain on 10 mg/day in a single morning dose for 2 months.

Taper 2.5 mg every 8 weeks.

When the woman was admitted, the differential diagnosis was between scleroderma and eosinophilic fasciitis (also known as generalized morphea profunda), according to Dr. Irwin M. Braverman, who presented the case at the Fall Clinical Dermatology Conference.

The woman had plaques of morphea covering her entire body. The edema also affected her breasts but spared the areolae and nipples. She had large plaques on her abdomen. Histology showed deep dermal fibrosis with fibrosis of fat septa extending down to a thickened fascial layer, which is confirmatory for eosinophilic fasciitis, said Dr. Braverman, professor of dermatology at Yale University, New Haven, Conn.

“We have seen about a half-dozen patients with this syndrome in the last 4 years,” he added. “This starts suddenly with patients coming in with tender, painful swelling of the arms, legs, and trunk.”

The woman was started on 20 mg prednisone t.i.d. and tapered to 15 mg once a day over the course of 12 months. The dose was then reduced by 2.5 mg every 6 months. The regimen yielded a prompt decrease in induration, swelling, and pain.

She is currently taking 5 mg prednisone once a day, and her skin has returned almost to normal.

“She will continue to be tapered 2.5 mg every 8 weeks if she shows continued improvement,” Dr. Braverman said at the meeting, which was sponsored by the Center for Bio-Medical Communications, Inc.

He emphasized that eosinophilic fasciitis “is very responsive to steroids. After starting oral prednisone, within a week this woman was feeling no pain and the edema had subsided. It's taken almost 4 years, but over the course of a slow taper, her skin has returned essentially to normal.”

The steroid therapy regimen for eosinophilic fasciitis that has been most effective for his patients is as follows:

Start with 60 mg/day (20 mg t.i.d.) prednisone for 2 weeks tapering to 25 mg per day (10/10/5 mg) over 6 weeks.

Taper 2.5 mg every other week until you reach 15 mg/day (5 mg t.i.d.).

Taper 2.5 mg every 4 weeks (t.i.d. dosing) until you reach 10 mg/day.

Remain on 10 mg/day in a single morning dose for 2 months.

Taper 2.5 mg every 8 weeks.

LAS VEGAS — Most cases of disseminated neonatal herpes and CNS neonatal herpes do not present with skin lesions, Dr. M. Jeffrey Maisels noted at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“You can't rely on seeing a herpetic looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

The chief complaint in cases of disseminated neonatal herpes is decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress. Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures may occur.

“When you do the lab tests these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets. “This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy.

LAS VEGAS — Most cases of disseminated neonatal herpes and CNS neonatal herpes do not present with skin lesions, Dr. M. Jeffrey Maisels noted at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“You can't rely on seeing a herpetic looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

The chief complaint in cases of disseminated neonatal herpes is decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress. Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures may occur.

“When you do the lab tests these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets. “This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy.

LAS VEGAS — Most cases of disseminated neonatal herpes and CNS neonatal herpes do not present with skin lesions, Dr. M. Jeffrey Maisels noted at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“You can't rely on seeing a herpetic looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

The chief complaint in cases of disseminated neonatal herpes is decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress. Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures may occur.

“When you do the lab tests these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.

Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets. “This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.

In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy.

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

Merck & Co. funded the study.

There is no difference between risedronate and alendronate in upper GI tolerability. DR. DE PAPP

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

Merck & Co. funded the study.

There is no difference between risedronate and alendronate in upper GI tolerability. DR. DE PAPP

SAN DIEGO — Postmenopausal women with low bone density who received once-weekly alendronate 70 mg had significantly greater increases in bone mineral density and reductions in markers of bone turnover over a 2-year period, compared with those who received once-weekly risedronate 35 mg, results from a randomized, double-blind trial demonstrated.

In addition, there were no differences between the two treatment groups in terms of upper-gastrointestinal adverse events or overall safety and tolerability, Dr. Anne E. de Papp reported during a poster session at the annual meeting of the International Society for Clinical Densitometry.

“There has always been a perception that risedronate is better tolerated,” Dr. de Papp, senior medical director of clinical development for Merck & Co., said in an interview. “This is nice evidence that at least in a clinical trial setting, there is no difference [between risedronate and alendronate] in upper GI tolerability.”

However, she quickly cautioned that this head-to-head study only compared surrogate end points for bone fracture risk, not the actual rate of clinical fractures. “To do a head-to-head fracture trial between two agents that are active therapies for osteoporosis would require huge numbers of patients for many years,” she said. “I think when you're comparing two drugs that work by the same mechanism of action, it's reasonable to compare them using surrogate markers of efficacy.

“We saw greater gains in BMD and greater reductions in [markers of] bone turnover [with alendronate treatment], but the contention is, what does that mean in terms of fracture outcomes? We don't know, but … there is evidence to support that drugs causing greater gains in BMD and greater reductions in bone turnover are associated with greater fracture reduction.”

In the study, led by Dr. Sydney Bonnick of the Denton, Tex.-based Clinical Research Center of North Texas, researchers performed a 1-year extension of the original 1-year, randomized, double-blind Fosamax Actonel Comparison Trial (J. Bone Miner. Res. 2005;20:141–51).

Of the 833 patients, 419 received once-weekly risedronate 35 mg and 414 received once-weekly alendronate 70 mg. Their mean age was 64 years, and all had low bone density. This was defined as greater than or equal to 2.0 standard deviations below young normal mean bone mass in at least one of four sites: total hip, hip trochanter, femoral neck, or lumbar spine (L1-L4).

All patients underwent a DXA and lab analyses of biochemical markers at baseline and at 2 years.

Patients in the alendronate group had significantly greater increases in bone mineral density at 2 years, compared with their counterparts in the risedronate group at the following sites: hip trochanter (4.6% vs. 2.5%), total hip (3.0% vs. 1.3%), femoral neck (2.8% vs. 1.0%), and lumbar spine (5.2% vs. 3.4%).

Significantly greater reductions of serum bone-specific alkaline phosphatase and other bone markers were seen in the alendronate group, compared with the risedronate group.

Merck & Co. funded the study.

There is no difference between risedronate and alendronate in upper GI tolerability. DR. DE PAPP

The number of palliative care programs in U.S. hospitals grew from 632 in 2000 to 1,027 in 2003, an increase of 63%, according to results from a large study.

The study “demonstrates the increasing recognition by hospitals in the United States and those providing primary care for patients with advanced illness of the need for palliative care services,” said Dr. R. Sean Morrison, the study's primary author.

“This is becoming part of what should be routine medical care. We have seen growth from a fraction of hospitals having hospital-based palliative care programs to where now 1 in 4 hospitals have a program. I'm not going to be satisfied until 100% of hospitals have [a palliative care program], but for patients and families, I think we're at the point where they do have access to this type of care. I think we are at a tipping point,” said Dr. Morrison, vice chair of research in the department of geriatrics at Mount Sinai Medical Center, New York.

He and his associates obtained data from the 2001–2004 American Hospital Association annual surveys, which covered calendar years 2000–2003. The AHA's annual survey defines a palliative care program as “an organized program providing specialized medical care, drugs, or therapies for the management of acute or chronic pain and/or the control of symptoms administered by specially trained physicians and other clinicians; and supportive care services, such as counseling on advanced directives, spiritual care, and social services, to patients with advanced disease and their families.”

The researchers identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds, and then used multivariate logistic regression to pinpoint factors that were associated with the presence of an adult palliative care program in the 2003 survey data (J. Palliat. Med. 2005;8:1127–34).

They found that hospitals in the Northeast, Pacific, and Mountain areas of the country are more likely than those in other geographic regions to have programs. The greater the number of hospital beds and acute care beds, the more likely a facility has a palliative care program. Similarly, being a Veterans Affairs hospital or a not-for-profit hospital increases the likelihood.

Among the factors associated with having a palliative care program are being a member of the American Association of Medical Colleges Council of Teaching Hospitals and being a cancer hospital approved by the American College of Surgeons.

“The fact that the American College of Surgeons would want to incorporate access to palliative care as one of their benchmarks of good care in a cancer setting is a sign that palliative care has been very successful in legitimizing its place in the continuum of medical practice,” said Dr. Geoffrey P. Dunn, an Erie, Pa.-based surgeon who cochairs the ACS's Surgical Palliative Care Task Force.

“People are becoming increasingly aware that palliative care is an extension of the already well-known and very successful hospice programs in this country. As this study shows, there are more occasions where they will have the opportunity for those services. I think that's going to increasingly generate that expectation in care, whether it's at a cancer center or elsewhere,” said Dr. Dunn.

Dr. Daniel B. Hinshaw, medical director of the palliative care consult team at the Ann Arbor (Mich.) VA Medical Center, said the increasing presence of palliative care programs in the nation's hospitals “gives us an opportunity to keep that message out there that this [component of care] is not just a matter of fighting disease. It's really about caring for the whole person who might have a bad disease,” he said. “We may not always be able to cure their problem, but we should always try our best to provide comfort and relief of distress and symptoms.”

For-profit hospitals, however, are significantly less likely to have programs, according to the study. Dr. Morrison said part of the reason may be the fact that palliative care programs started in academic medical centers and branched out to teaching hospitals. “The majority of teaching hospitals in the United States are still not-for-profit,” he said. “I don't think there is a lot of communication [about palliative care programs] between the not-for-profit sector and the for-profit sector, but it's something we'd like to address.”

Dr. Dunn called the current funding landscape for hospital-based palliative care programs “tenuous” even though numerous demonstration projects have shown them to be cost-effective. “What will be a challenge in 5–10 years will be the physician staffing of these [programs],” he said. “Very shortly the American Board of Hospice and Palliative Medicine is expecting to receive credentialing from the American Board of Medical Specialties. Once that happens, that is going to put a pretty narrow lock on the pool of people who are considered certified and qualified to run these programs. I'm concerned that with this rapid proliferation of programs, how are we going to fill the demand for physicians who have some degree of training in this to do it?”

Dr. Morrison's study noted that there were 1,892 certified palliative medicine physicians as of July 2005 and 5,500 certified palliative nurses as of March 2005. It also noted that the number of postgraduate palliative medicine fellowships increased from 17 in 2000 to 53 in 2005.

Dr. Morrison said that the cost of a hospital-based palliative care program is directly related to the size of the hospital. At Mount Sinai Medical Center, which is a 1,000-bed teaching hospital, the palliative care program consists of two full-time physicians, four full-time nurse-practitioners, two full-time social workers, and consultation with chaplaincy and physical therapy.

“The expense of the program is far outweighed by the cost savings to our hospital for having it,” said Dr. Morrison, whose study was funded by the Robert Wood Johnson Foundation. “For a 300-bed hospital, the team is probably going to be a physician, a nurse, a social worker, and consultation with other core services. For a 50-bed rural hospital, it may be that the primary person is a nurse-practitioner with a part-time physician as backup in consultation with other services in the hospital.”

To access a financial calculator that helps you estimate the cost of a palliative care program and the cost savings to your hospital, visit the Center to Advance Palliative Care's Web site at www.capc.org

'The expense of the program is far outweighed by the cost savings to our hospital for having it.' DR. MORRISON

The number of palliative care programs in U.S. hospitals grew from 632 in 2000 to 1,027 in 2003, an increase of 63%, according to results from a large study.

The study “demonstrates the increasing recognition by hospitals in the United States and those providing primary care for patients with advanced illness of the need for palliative care services,” said Dr. R. Sean Morrison, the study's primary author.

“This is becoming part of what should be routine medical care. We have seen growth from a fraction of hospitals having hospital-based palliative care programs to where now 1 in 4 hospitals have a program. I'm not going to be satisfied until 100% of hospitals have [a palliative care program], but for patients and families, I think we're at the point where they do have access to this type of care. I think we are at a tipping point,” said Dr. Morrison, vice chair of research in the department of geriatrics at Mount Sinai Medical Center, New York.

He and his associates obtained data from the 2001–2004 American Hospital Association annual surveys, which covered calendar years 2000–2003. The AHA's annual survey defines a palliative care program as “an organized program providing specialized medical care, drugs, or therapies for the management of acute or chronic pain and/or the control of symptoms administered by specially trained physicians and other clinicians; and supportive care services, such as counseling on advanced directives, spiritual care, and social services, to patients with advanced disease and their families.”

The researchers identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds, and then used multivariate logistic regression to pinpoint factors that were associated with the presence of an adult palliative care program in the 2003 survey data (J. Palliat. Med. 2005;8:1127–34).

They found that hospitals in the Northeast, Pacific, and Mountain areas of the country are more likely than those in other geographic regions to have programs. The greater the number of hospital beds and acute care beds, the more likely a facility has a palliative care program. Similarly, being a Veterans Affairs hospital or a not-for-profit hospital increases the likelihood.

Among the factors associated with having a palliative care program are being a member of the American Association of Medical Colleges Council of Teaching Hospitals and being a cancer hospital approved by the American College of Surgeons.

“The fact that the American College of Surgeons would want to incorporate access to palliative care as one of their benchmarks of good care in a cancer setting is a sign that palliative care has been very successful in legitimizing its place in the continuum of medical practice,” said Dr. Geoffrey P. Dunn, an Erie, Pa.-based surgeon who cochairs the ACS's Surgical Palliative Care Task Force.

“People are becoming increasingly aware that palliative care is an extension of the already well-known and very successful hospice programs in this country. As this study shows, there are more occasions where they will have the opportunity for those services. I think that's going to increasingly generate that expectation in care, whether it's at a cancer center or elsewhere,” said Dr. Dunn.

Dr. Daniel B. Hinshaw, medical director of the palliative care consult team at the Ann Arbor (Mich.) VA Medical Center, said the increasing presence of palliative care programs in the nation's hospitals “gives us an opportunity to keep that message out there that this [component of care] is not just a matter of fighting disease. It's really about caring for the whole person who might have a bad disease,” he said. “We may not always be able to cure their problem, but we should always try our best to provide comfort and relief of distress and symptoms.”

For-profit hospitals, however, are significantly less likely to have programs, according to the study. Dr. Morrison said part of the reason may be the fact that palliative care programs started in academic medical centers and branched out to teaching hospitals. “The majority of teaching hospitals in the United States are still not-for-profit,” he said. “I don't think there is a lot of communication [about palliative care programs] between the not-for-profit sector and the for-profit sector, but it's something we'd like to address.”

Dr. Dunn called the current funding landscape for hospital-based palliative care programs “tenuous” even though numerous demonstration projects have shown them to be cost-effective. “What will be a challenge in 5–10 years will be the physician staffing of these [programs],” he said. “Very shortly the American Board of Hospice and Palliative Medicine is expecting to receive credentialing from the American Board of Medical Specialties. Once that happens, that is going to put a pretty narrow lock on the pool of people who are considered certified and qualified to run these programs. I'm concerned that with this rapid proliferation of programs, how are we going to fill the demand for physicians who have some degree of training in this to do it?”

Dr. Morrison's study noted that there were 1,892 certified palliative medicine physicians as of July 2005 and 5,500 certified palliative nurses as of March 2005. It also noted that the number of postgraduate palliative medicine fellowships increased from 17 in 2000 to 53 in 2005.

Dr. Morrison said that the cost of a hospital-based palliative care program is directly related to the size of the hospital. At Mount Sinai Medical Center, which is a 1,000-bed teaching hospital, the palliative care program consists of two full-time physicians, four full-time nurse-practitioners, two full-time social workers, and consultation with chaplaincy and physical therapy.

“The expense of the program is far outweighed by the cost savings to our hospital for having it,” said Dr. Morrison, whose study was funded by the Robert Wood Johnson Foundation. “For a 300-bed hospital, the team is probably going to be a physician, a nurse, a social worker, and consultation with other core services. For a 50-bed rural hospital, it may be that the primary person is a nurse-practitioner with a part-time physician as backup in consultation with other services in the hospital.”

To access a financial calculator that helps you estimate the cost of a palliative care program and the cost savings to your hospital, visit the Center to Advance Palliative Care's Web site at www.capc.org

'The expense of the program is far outweighed by the cost savings to our hospital for having it.' DR. MORRISON

The number of palliative care programs in U.S. hospitals grew from 632 in 2000 to 1,027 in 2003, an increase of 63%, according to results from a large study.

The study “demonstrates the increasing recognition by hospitals in the United States and those providing primary care for patients with advanced illness of the need for palliative care services,” said Dr. R. Sean Morrison, the study's primary author.

“This is becoming part of what should be routine medical care. We have seen growth from a fraction of hospitals having hospital-based palliative care programs to where now 1 in 4 hospitals have a program. I'm not going to be satisfied until 100% of hospitals have [a palliative care program], but for patients and families, I think we're at the point where they do have access to this type of care. I think we are at a tipping point,” said Dr. Morrison, vice chair of research in the department of geriatrics at Mount Sinai Medical Center, New York.

He and his associates obtained data from the 2001–2004 American Hospital Association annual surveys, which covered calendar years 2000–2003. The AHA's annual survey defines a palliative care program as “an organized program providing specialized medical care, drugs, or therapies for the management of acute or chronic pain and/or the control of symptoms administered by specially trained physicians and other clinicians; and supportive care services, such as counseling on advanced directives, spiritual care, and social services, to patients with advanced disease and their families.”

The researchers identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds, and then used multivariate logistic regression to pinpoint factors that were associated with the presence of an adult palliative care program in the 2003 survey data (J. Palliat. Med. 2005;8:1127–34).

They found that hospitals in the Northeast, Pacific, and Mountain areas of the country are more likely than those in other geographic regions to have programs. The greater the number of hospital beds and acute care beds, the more likely a facility has a palliative care program. Similarly, being a Veterans Affairs hospital or a not-for-profit hospital increases the likelihood.

Among the factors associated with having a palliative care program are being a member of the American Association of Medical Colleges Council of Teaching Hospitals and being a cancer hospital approved by the American College of Surgeons.

“The fact that the American College of Surgeons would want to incorporate access to palliative care as one of their benchmarks of good care in a cancer setting is a sign that palliative care has been very successful in legitimizing its place in the continuum of medical practice,” said Dr. Geoffrey P. Dunn, an Erie, Pa.-based surgeon who cochairs the ACS's Surgical Palliative Care Task Force.

“People are becoming increasingly aware that palliative care is an extension of the already well-known and very successful hospice programs in this country. As this study shows, there are more occasions where they will have the opportunity for those services. I think that's going to increasingly generate that expectation in care, whether it's at a cancer center or elsewhere,” said Dr. Dunn.

Dr. Daniel B. Hinshaw, medical director of the palliative care consult team at the Ann Arbor (Mich.) VA Medical Center, said the increasing presence of palliative care programs in the nation's hospitals “gives us an opportunity to keep that message out there that this [component of care] is not just a matter of fighting disease. It's really about caring for the whole person who might have a bad disease,” he said. “We may not always be able to cure their problem, but we should always try our best to provide comfort and relief of distress and symptoms.”

For-profit hospitals, however, are significantly less likely to have programs, according to the study. Dr. Morrison said part of the reason may be the fact that palliative care programs started in academic medical centers and branched out to teaching hospitals. “The majority of teaching hospitals in the United States are still not-for-profit,” he said. “I don't think there is a lot of communication [about palliative care programs] between the not-for-profit sector and the for-profit sector, but it's something we'd like to address.”

Dr. Dunn called the current funding landscape for hospital-based palliative care programs “tenuous” even though numerous demonstration projects have shown them to be cost-effective. “What will be a challenge in 5–10 years will be the physician staffing of these [programs],” he said. “Very shortly the American Board of Hospice and Palliative Medicine is expecting to receive credentialing from the American Board of Medical Specialties. Once that happens, that is going to put a pretty narrow lock on the pool of people who are considered certified and qualified to run these programs. I'm concerned that with this rapid proliferation of programs, how are we going to fill the demand for physicians who have some degree of training in this to do it?”

Dr. Morrison's study noted that there were 1,892 certified palliative medicine physicians as of July 2005 and 5,500 certified palliative nurses as of March 2005. It also noted that the number of postgraduate palliative medicine fellowships increased from 17 in 2000 to 53 in 2005.

Dr. Morrison said that the cost of a hospital-based palliative care program is directly related to the size of the hospital. At Mount Sinai Medical Center, which is a 1,000-bed teaching hospital, the palliative care program consists of two full-time physicians, four full-time nurse-practitioners, two full-time social workers, and consultation with chaplaincy and physical therapy.

“The expense of the program is far outweighed by the cost savings to our hospital for having it,” said Dr. Morrison, whose study was funded by the Robert Wood Johnson Foundation. “For a 300-bed hospital, the team is probably going to be a physician, a nurse, a social worker, and consultation with other core services. For a 50-bed rural hospital, it may be that the primary person is a nurse-practitioner with a part-time physician as backup in consultation with other services in the hospital.”

To access a financial calculator that helps you estimate the cost of a palliative care program and the cost savings to your hospital, visit the Center to Advance Palliative Care's Web site at www.capc.org

'The expense of the program is far outweighed by the cost savings to our hospital for having it.' DR. MORRISON

SAN DIEGO – Heart disease and suicide were the leading causes of death in a large study of patients with mental illness in Ohio.

Moreover, these patients died at a mean age of 48 years, which represented 32 years of potential life lost, Dr. Brian J. Miller reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“That is a strikingly high figure,” said Dr. Miller, a psychiatry resident at the Medical College of Georgia, Augusta. The findings underscore the importance of integrating the delivery of health care services to patients with serious mental illness and targeting interventions that improve their quality of life, such as monitoring blood glucose levels, taking waist circumference measurements, and looking for metabolic syndrome.

The study results “confirm findings of previous reports that patients with serious mental illness are at increased risk of death,” said Dr. Miller, who conducted the research while a medical student at Ohio State University in Columbus. “The cited literature suggests a 1.6- to 2.8-fold increased risk of premature death. We found a 3.2-fold increased risk of premature death.”

He and his associates analyzed Ohio Department of Mental Health records for 20,018 patients discharged from an Ohio public psychiatric hospital between 1998 and 2002, and matched them against Ohio Department of Health records for the same time period. They identified 608 deaths and calculated leading causes of death, medical comorbidities, age-adjusted mortality, years of potential life lost, and standardized mortality ratios.

Most patients (72%) died within 2 years of discharge from the psychiatric hospital. The leading causes of death were heart disease (21%), suicide (18%), and accidents (14%). The most prevalent medical comorbidities were obesity (24%), hypertension (22%), and diabetes mellitus (12%).

The overall standardized mortality ratio was 3.2, which corresponded to 417 excess deaths.

“What's interesting is that we found that the leading medical comorbidities–specifically, obesity, hypertension, diabetes, and COPD–are consistent with the risk factors for the observed leading [medical] causes of death: heart disease, COPD, and diabetes,” Dr. Miller said.

In the text of their poster, the investigators acknowledged that the findings may not apply to other populations with serious mental illness. “While our statistical models adjusted for age and gender differences, there are many other demographic, health, and socioeconomic factors that are difficult to adequately and accurately control,” they wrote.

The investigators said that their data came entirely from state mental health inpatient records. The study population was largely male, unmarried, and uneducated–a group for which alcohol and substance abuse were well documented.

Patients died at a mean age of 48 years, which represented 32 years of potential life lost. DR. MILLER

SAN DIEGO – Heart disease and suicide were the leading causes of death in a large study of patients with mental illness in Ohio.

Moreover, these patients died at a mean age of 48 years, which represented 32 years of potential life lost, Dr. Brian J. Miller reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“That is a strikingly high figure,” said Dr. Miller, a psychiatry resident at the Medical College of Georgia, Augusta. The findings underscore the importance of integrating the delivery of health care services to patients with serious mental illness and targeting interventions that improve their quality of life, such as monitoring blood glucose levels, taking waist circumference measurements, and looking for metabolic syndrome.

The study results “confirm findings of previous reports that patients with serious mental illness are at increased risk of death,” said Dr. Miller, who conducted the research while a medical student at Ohio State University in Columbus. “The cited literature suggests a 1.6- to 2.8-fold increased risk of premature death. We found a 3.2-fold increased risk of premature death.”

He and his associates analyzed Ohio Department of Mental Health records for 20,018 patients discharged from an Ohio public psychiatric hospital between 1998 and 2002, and matched them against Ohio Department of Health records for the same time period. They identified 608 deaths and calculated leading causes of death, medical comorbidities, age-adjusted mortality, years of potential life lost, and standardized mortality ratios.

Most patients (72%) died within 2 years of discharge from the psychiatric hospital. The leading causes of death were heart disease (21%), suicide (18%), and accidents (14%). The most prevalent medical comorbidities were obesity (24%), hypertension (22%), and diabetes mellitus (12%).

The overall standardized mortality ratio was 3.2, which corresponded to 417 excess deaths.

“What's interesting is that we found that the leading medical comorbidities–specifically, obesity, hypertension, diabetes, and COPD–are consistent with the risk factors for the observed leading [medical] causes of death: heart disease, COPD, and diabetes,” Dr. Miller said.

In the text of their poster, the investigators acknowledged that the findings may not apply to other populations with serious mental illness. “While our statistical models adjusted for age and gender differences, there are many other demographic, health, and socioeconomic factors that are difficult to adequately and accurately control,” they wrote.

The investigators said that their data came entirely from state mental health inpatient records. The study population was largely male, unmarried, and uneducated–a group for which alcohol and substance abuse were well documented.

Patients died at a mean age of 48 years, which represented 32 years of potential life lost. DR. MILLER

SAN DIEGO – Heart disease and suicide were the leading causes of death in a large study of patients with mental illness in Ohio.

Moreover, these patients died at a mean age of 48 years, which represented 32 years of potential life lost, Dr. Brian J. Miller reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“That is a strikingly high figure,” said Dr. Miller, a psychiatry resident at the Medical College of Georgia, Augusta. The findings underscore the importance of integrating the delivery of health care services to patients with serious mental illness and targeting interventions that improve their quality of life, such as monitoring blood glucose levels, taking waist circumference measurements, and looking for metabolic syndrome.

The study results “confirm findings of previous reports that patients with serious mental illness are at increased risk of death,” said Dr. Miller, who conducted the research while a medical student at Ohio State University in Columbus. “The cited literature suggests a 1.6- to 2.8-fold increased risk of premature death. We found a 3.2-fold increased risk of premature death.”

He and his associates analyzed Ohio Department of Mental Health records for 20,018 patients discharged from an Ohio public psychiatric hospital between 1998 and 2002, and matched them against Ohio Department of Health records for the same time period. They identified 608 deaths and calculated leading causes of death, medical comorbidities, age-adjusted mortality, years of potential life lost, and standardized mortality ratios.

Most patients (72%) died within 2 years of discharge from the psychiatric hospital. The leading causes of death were heart disease (21%), suicide (18%), and accidents (14%). The most prevalent medical comorbidities were obesity (24%), hypertension (22%), and diabetes mellitus (12%).

The overall standardized mortality ratio was 3.2, which corresponded to 417 excess deaths.

“What's interesting is that we found that the leading medical comorbidities–specifically, obesity, hypertension, diabetes, and COPD–are consistent with the risk factors for the observed leading [medical] causes of death: heart disease, COPD, and diabetes,” Dr. Miller said.

In the text of their poster, the investigators acknowledged that the findings may not apply to other populations with serious mental illness. “While our statistical models adjusted for age and gender differences, there are many other demographic, health, and socioeconomic factors that are difficult to adequately and accurately control,” they wrote.

The investigators said that their data came entirely from state mental health inpatient records. The study population was largely male, unmarried, and uneducated–a group for which alcohol and substance abuse were well documented.

Patients died at a mean age of 48 years, which represented 32 years of potential life lost. DR. MILLER

SAN DIEGO – Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no apparent effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand name Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani went on to note that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

Eszopiclone did not affect the frequency or duration of daytime hot flashes, but it did yield significant benefits in the Montgomery Asberg Depression Rating scale score and in the vasomotor and physical domains of the Menopause Quality of Life scale.

SAN DIEGO – Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no apparent effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand name Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani went on to note that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

Eszopiclone did not affect the frequency or duration of daytime hot flashes, but it did yield significant benefits in the Montgomery Asberg Depression Rating scale score and in the vasomotor and physical domains of the Menopause Quality of Life scale.

SAN DIEGO – Perimenopausal women who took eszopiclone for 1 month experienced significant improvements in sleep problems brought on by hot flashes, results from a randomized trial have found.

The drug had no apparent effect on the number or severity of daytime and nighttime hot flashes, however, Rob Mariani, Ph.D., reported during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“I think this is another example of how you can improve the quality of your life in great part by improving how well you can sleep at night, especially in perimenopausal women who complain of sleep difficulties,” said Dr. Mariani, senior medical liaison for Sepracor Inc., which markets eszopiclone under the brand name Lunesta. The nonbenzodiazepine drug was approved by the Food and Drug Administration in 2004 for the treatment of insomnia.

Dr. Mariani went on to note that most of the published studies in the area of menopause and sleep “indicate that there are really not any significant sleep architecture changes in patients at menopause or perimenopausal age. Yet at the same time, women who are perimenopausal and postmenopausal complain about a significant number of sleep problems, especially those who have vasomotor symptoms.”

In a study funded by Sepracor Inc., Dr. Mariani and his associates enrolled 410 perimenopausal women aged 40–60 years who met the Stages of Reproductive Aging Workshop criteria for early menopausal transition, late menopausal transition, and early postmenopause, and who reported sleep latency of 30 minutes or more and total sleep time of 6 hours or less per night at least three times a week for 1 month.

Investigators randomized 201 women to receive 3 mg eszopiclone and 209 to receive placebo nightly for 4 weeks. Study end points included sleep latency, wake time after sleep onset, total sleep time, awakenings due to hot flashes, daytime hot flashes, and physician global evaluations.

Compared with the women in the placebo group, those who took eszopiclone had significant changes in median sleep latency (reduction from baseline of 18.6 minutes vs. 8.1 minutes) and in median wake time after sleep onset (reduction of 30.6 minutes vs. 16 minutes). The increase in median total sleep time was greater among women who took eszopiclone (48.9 minutes per day vs. 29.7 minutes).

Eszopiclone did not affect the frequency or duration of daytime hot flashes, but it did yield significant benefits in the Montgomery Asberg Depression Rating scale score and in the vasomotor and physical domains of the Menopause Quality of Life scale.

SAN DIEGO — Patients who underwent meniscectomy had a 10- to 18-fold increased likelihood of developing tibiofemoral osteoarthritis in the operated knee at follow-up of 15–22 years, compared with a group of controls, results from a large Swedish study demonstrated.

Moreover, these patients were significantly more likely than controls to develop concomitant patellofemoral osteoarthritis (OA) in the index knee and tibiofemoral OA in the contralateral, nonoperated knee, Dr. Stefan Lohmander reported at a symposium sponsored by the International Cartilage Repair Society.

“A meniscus tear is not simply a meniscus tear,” said Dr. Lohmander, of the department of orthopedics at Lund (Sweden) University Hospital. “We need to differentiate between a tear in a healthy meniscus in a normal joint and a tear in a degenerated meniscus in a joint that may already be developing OA. We suggest that a degenerative meniscus lesion is an early signal of OA susceptibility. As a consequence, postinjury OA as a catch-all term for the OA associated with this kind of meniscus injury is not correct. The same disease process that leads to cartilage damage in the OA joint can even earlier lead to a damaged meniscus, prone to a tear.”

He went on to speculate that patients with meniscus lesions “are actually young patients with old knees. The symptoms of their OA actually start at the meniscus, and the meniscus tear is just a signal event in the development of OA.”

In an effort to determine the long-term consequences of meniscal injury and repair, he and his associates studied a group of 319 patients with isolated meniscus lesions who had no radiographic OA at index arthroscopy and no previous surgery. Postoperative follow-up ranged from 15 to 22 years and included standardized radiographs, validated questionnaires, functional tests, and biomarkers.

The average patient age at assessment was 54 years, and most (79%) were men. The mean body mass index of patients was 26 kg/m

A control group of 68 age-matched, uninjured patients was used as a reference.

At 15- to 22-year follow-up, 45% of patients who underwent medial meniscectomy and 57% of patients who underwent lateral meniscectomy had tibiofemoral OA in their index knee, which translated into adjusted odds ratios of 9.5 and 18.3, respectively.

In addition, 19% of patients who underwent medial meniscectomy and 27% of patients who underwent lateral meniscectomy had patellofemoral OA in their index knee at follow-up, which translated into adjusted odds ratios of 2.6 and 5.3, respectively.

Finally, 22% of patients who underwent medial meniscectomy and 21% of patients who underwent lateral meniscectomy had tibiofemoral OA in their nonoperated contralateral knee at the 15- to 22-year follow-up, which translated into adjusted odds ratios of 3.5 and 4.4, respectively. Dr. Lohmander noted that this increased risk of OA in the “other knee” may be another sign that these individuals have a higher-than-average risk for OA in general.

There was no major difference in the OA risk for those who had subtotal removal of their meniscus and those who had only a partial removal by surgery. There are no published randomized studies to support the suggestion that meniscal repair or retransplantation can prevent future OA development.

Dr. Lohmander called for more controlled, randomized, blinded prospective trials to evaluate the long-term outcome of meniscal injury and repair.

Tibiofemoral OA developed in this contralateral, nonoperated knee. Courtesy Dr. Stefan Lohmander

SAN DIEGO — Patients who underwent meniscectomy had a 10- to 18-fold increased likelihood of developing tibiofemoral osteoarthritis in the operated knee at follow-up of 15–22 years, compared with a group of controls, results from a large Swedish study demonstrated.

Moreover, these patients were significantly more likely than controls to develop concomitant patellofemoral osteoarthritis (OA) in the index knee and tibiofemoral OA in the contralateral, nonoperated knee, Dr. Stefan Lohmander reported at a symposium sponsored by the International Cartilage Repair Society.

“A meniscus tear is not simply a meniscus tear,” said Dr. Lohmander, of the department of orthopedics at Lund (Sweden) University Hospital. “We need to differentiate between a tear in a healthy meniscus in a normal joint and a tear in a degenerated meniscus in a joint that may already be developing OA. We suggest that a degenerative meniscus lesion is an early signal of OA susceptibility. As a consequence, postinjury OA as a catch-all term for the OA associated with this kind of meniscus injury is not correct. The same disease process that leads to cartilage damage in the OA joint can even earlier lead to a damaged meniscus, prone to a tear.”

He went on to speculate that patients with meniscus lesions “are actually young patients with old knees. The symptoms of their OA actually start at the meniscus, and the meniscus tear is just a signal event in the development of OA.”

In an effort to determine the long-term consequences of meniscal injury and repair, he and his associates studied a group of 319 patients with isolated meniscus lesions who had no radiographic OA at index arthroscopy and no previous surgery. Postoperative follow-up ranged from 15 to 22 years and included standardized radiographs, validated questionnaires, functional tests, and biomarkers.

The average patient age at assessment was 54 years, and most (79%) were men. The mean body mass index of patients was 26 kg/m

A control group of 68 age-matched, uninjured patients was used as a reference.

At 15- to 22-year follow-up, 45% of patients who underwent medial meniscectomy and 57% of patients who underwent lateral meniscectomy had tibiofemoral OA in their index knee, which translated into adjusted odds ratios of 9.5 and 18.3, respectively.

In addition, 19% of patients who underwent medial meniscectomy and 27% of patients who underwent lateral meniscectomy had patellofemoral OA in their index knee at follow-up, which translated into adjusted odds ratios of 2.6 and 5.3, respectively.

Finally, 22% of patients who underwent medial meniscectomy and 21% of patients who underwent lateral meniscectomy had tibiofemoral OA in their nonoperated contralateral knee at the 15- to 22-year follow-up, which translated into adjusted odds ratios of 3.5 and 4.4, respectively. Dr. Lohmander noted that this increased risk of OA in the “other knee” may be another sign that these individuals have a higher-than-average risk for OA in general.

There was no major difference in the OA risk for those who had subtotal removal of their meniscus and those who had only a partial removal by surgery. There are no published randomized studies to support the suggestion that meniscal repair or retransplantation can prevent future OA development.

Dr. Lohmander called for more controlled, randomized, blinded prospective trials to evaluate the long-term outcome of meniscal injury and repair.

Tibiofemoral OA developed in this contralateral, nonoperated knee. Courtesy Dr. Stefan Lohmander

SAN DIEGO — Patients who underwent meniscectomy had a 10- to 18-fold increased likelihood of developing tibiofemoral osteoarthritis in the operated knee at follow-up of 15–22 years, compared with a group of controls, results from a large Swedish study demonstrated.

Moreover, these patients were significantly more likely than controls to develop concomitant patellofemoral osteoarthritis (OA) in the index knee and tibiofemoral OA in the contralateral, nonoperated knee, Dr. Stefan Lohmander reported at a symposium sponsored by the International Cartilage Repair Society.

“A meniscus tear is not simply a meniscus tear,” said Dr. Lohmander, of the department of orthopedics at Lund (Sweden) University Hospital. “We need to differentiate between a tear in a healthy meniscus in a normal joint and a tear in a degenerated meniscus in a joint that may already be developing OA. We suggest that a degenerative meniscus lesion is an early signal of OA susceptibility. As a consequence, postinjury OA as a catch-all term for the OA associated with this kind of meniscus injury is not correct. The same disease process that leads to cartilage damage in the OA joint can even earlier lead to a damaged meniscus, prone to a tear.”

He went on to speculate that patients with meniscus lesions “are actually young patients with old knees. The symptoms of their OA actually start at the meniscus, and the meniscus tear is just a signal event in the development of OA.”

In an effort to determine the long-term consequences of meniscal injury and repair, he and his associates studied a group of 319 patients with isolated meniscus lesions who had no radiographic OA at index arthroscopy and no previous surgery. Postoperative follow-up ranged from 15 to 22 years and included standardized radiographs, validated questionnaires, functional tests, and biomarkers.

The average patient age at assessment was 54 years, and most (79%) were men. The mean body mass index of patients was 26 kg/m

A control group of 68 age-matched, uninjured patients was used as a reference.

At 15- to 22-year follow-up, 45% of patients who underwent medial meniscectomy and 57% of patients who underwent lateral meniscectomy had tibiofemoral OA in their index knee, which translated into adjusted odds ratios of 9.5 and 18.3, respectively.

In addition, 19% of patients who underwent medial meniscectomy and 27% of patients who underwent lateral meniscectomy had patellofemoral OA in their index knee at follow-up, which translated into adjusted odds ratios of 2.6 and 5.3, respectively.

Finally, 22% of patients who underwent medial meniscectomy and 21% of patients who underwent lateral meniscectomy had tibiofemoral OA in their nonoperated contralateral knee at the 15- to 22-year follow-up, which translated into adjusted odds ratios of 3.5 and 4.4, respectively. Dr. Lohmander noted that this increased risk of OA in the “other knee” may be another sign that these individuals have a higher-than-average risk for OA in general.

There was no major difference in the OA risk for those who had subtotal removal of their meniscus and those who had only a partial removal by surgery. There are no published randomized studies to support the suggestion that meniscal repair or retransplantation can prevent future OA development.

Dr. Lohmander called for more controlled, randomized, blinded prospective trials to evaluate the long-term outcome of meniscal injury and repair.

Tibiofemoral OA developed in this contralateral, nonoperated knee. Courtesy Dr. Stefan Lohmander

YOSEMITE, CALIF. — “As you follow the research in pediatric emergency medicine, it really parallels the practice model of the community,” Dr. Richard M. Cantor said during a pediatric conference sponsored by Symposia Medicus.

On topics from bacteremia, to migraines, to mononucleosis, he summarized recent studies in the literature that have affected the practice of pediatric emergency medicine.

“Any of you who have been in practice for more than 5 or 7 years can see the trends and where these issues have come from,” said Dr. Cantor, director of pediatric emergency services at University Hospital in Syracuse, N.Y.

Young Febrile Infants

Dr. Bema K. Bonsu of Children's Hospital, Columbus, Ohio, and Dr. Marvin B. Harper of Children's Hospital, Boston, set out to estimate the accuracy of the total peripheral white blood count as a screening tool for bacteremia in febrile young infants. They evaluated logistic models for predicting bacteremia that are based on the total peripheral white blood cell count by following 3,810 infants aged 0–89 days who had a temperature in triage of greater than or equal to 100.4° F. (Ann. Emerg. Med. 2003;42:216–25).

The rate of bacteremia was 1% (38/3,810), but the sensitivity and specificity of the white blood count test was 79% and 5%, respectively, at a cutoff of greater than or equal to 5,000 cells/mm

“Thus, decisions to obtain blood cultures should not rely on this test,” said Dr. Cantor, who also is associate professor of emergency medicine and pediatrics at State University of New York (Syracuse) Upstate Medical University.

Risk for Serious Bacterial Infections

Dr. M. Olivia Titus and Dr. Seth W. Wright of Vanderbilt University Medical Center, Nashville, Tenn., investigated the prevalence of serious bacterial infections (SBI) in 174 febrile infants who were younger than 8 weeks of age and had documented respiratory syncytial virus (RSV) and compared them with 174 gender- and age-matched control subjects who were febrile and RSV-negative.

Overall, only 2 patients in the RSV group had SBI (both urinary tract infections), compared with 22 in the control group (17 were UTIs). They concluded that the risk of SBI in febrile infants with RSV infection is very low (Pediatrics 2003;112:282–4).

“Full septic work-ups may not be necessary, and it is prudent to look at the urine [for evidence of UTI],” Dr. Cantor said. “This is important.”

Bacteremia, Antibiotic Use in RSV

A separate study was conducted by Dr. P. Bloomfield and associates at the Children's Hospital at Westmead, New South Wales, Australia, to examine the frequency of and risk factors for bacteremia in 1,795 children aged 0–14 years hospitalized with RSV infection over a 4-year period (Arch. Dis. Child. 2004;89:363–7).

Only 11 (0.6%) of the 1,795 RSV-positive children had bacteremia. RSV-positive children were more likely to be bacteremic if they had nosocomial RSV (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the pediatric ICU (2.9%). “They concluded that bacteremia is rare and that certain characteristics help you identify bacteremic children,” Dr. Cantor said.

Rapid Diagnosis of Influenza

Dr. Aleta B. Bonner and her colleagues at the University of Alabama, Birmingham, attempted to determine the impact of the rapid diagnosis of influenza in the pediatric emergency department on physician decision making and patient management.

The investigators screened 391 patients aged 2 months to 21 years for fever and cough, coryza, myalgias, headache, and/or malaise and randomized them to one of two groups; 202 were influenza positive and ended up randomized roughly equally in the two groups.

In group 1, the attending physician was aware of the rapid influenza test results. Nasopharyngeal swabs were obtained and immediately tested with the flu optical immunoassay (FluOIA) test for influenza A and B, and the results were placed on the chart before the patient was evaluated by the attending physician.

In group 2, the attending physician was unaware of the test results. Nasopharyngeal swabs were obtained, stored, and tested within 24 hours.

Physician awareness of a rapid diagnosis of influenza significantly reduced the number of laboratory tests and radiographs ordered, as well as the associated charges; decreased antibiotic use; increased antiviral use; and reduced the length of time to discharge (Pediatrics 2003;112:363–7).

“This is a big deal,” Dr. Cantor remarked. “You go into the exam room and you say, 'Good news. Your baby has the flu.' They ask, 'Is my child gonna die?' I've had that question. What do you tell them? [I say] 'I have this bank of testing in front of me that gives me viral answers.'”

Human Metapneumovirus in Infants

The aim of this study by Dr. John V. Williams and his associates at Vanderbilt University Medical Center was to determine the role of human metapneumovirus in lower respiratory tract illness in previously healthy infants and children.

The investigators tested nasal-wash specimens obtained from 2,009 infants and children who presented with acute respiratory tract illness between 1976 and 2001. There were 408 visits for lower respiratory tract illness by 321 children for which no cause was identified.

Of these 321 children, specimens from 248 were available. Of these 248 specimens, 49 (20%) contained human metapneumovirus RNA or viable virus (N. Engl. J. Med. 2004;350:443–50).

“Thus, 20% of all previously virus-negative lower respiratory tract illnesses were attributable to human metapneumovirus, which means that 12% of all lower respiratory tract illnesses in this cohort were most likely due to this virus,” Dr. Cantor said.

The virus was associated with bronchiolitis in 59% of cases, croup in 18%, pneumonia in 8%, and an exacerbation of asthma in 14%.

The findings suggest that human metapneumovirus “may be one of the primary causes of bronchiolitis,” Dr. Cantor said. “This was a great study.”

Antibiotic Tx For Urinary Tract Infection

The purpose of this metaanalysis by Dr. M. Michael and associates at the Children's Hospital at Westmead, New South Wales, Australia, was to compare the effectiveness of 2–4 days oral antibiotic therapy (short therapy) with 7–14 days (standard duration therapy) for children with urinary tract infections. The study population consisted of 652 children with lower tract UTI recruited from outpatient or emergency departments (Arch. Dis. Child. 2002;87:118–23).

The investigators found no significant differences in the frequency of positive urine cultures between the short and standard duration therapy for UTI in children 0–7 days after treatment and at 10 days to 15 months after treatment.

There also were no significant differences between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment or in recurrent UTI.

“We can probably get away with a shorter course of antibiotics [for this patient population],” Dr. Cantor said.

Interventions for Impetigo

A metaanalysis by S. Koning and colleagues was done to assess the effects of treatments for impetigo in 3,533 subjects who participated in 57 randomized, controlled trials of 20 different oral and 18 topical treatments for the condition (Cochrane Database Syst. Rev.[2]:CD003261.pub2, 2003).

Topical antibiotics showed better cure rates than placebo, and no topical antibiotic was superior.

Topical mupirocin was superior to oral erythromycin, but in most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials that compared oral antibiotics.

The reviewers concluded there is good evidence that topical mupirocin and topical fusidic acid are equally or more effective than oral treatment for people with limited disease.

It remains unclear whether oral antibiotics are superior to topical antibiotics for people with extensive impetigo.

Treating Pediatric Migraines

A prospective, randomized, double-blind study by Dr. David C. Brousseau and his colleagues at the Medical College of Wisconsin, Milwaukee, compared the efficacy of IV ketorolac and IV prochlorperazine in the treatment of pediatric migraines. The study population consisted of 62 children aged 5–18 years who presented with migraine headaches to the emergency departments at two children's hospitals (Ann. Emerg. Med. 2004;43:256–62).

Investigators defined successful treatment as a 50% or greater reduction in the McGrath Facial Affective Scale (nine faces pain scale) score at 60 minutes.

At 60 minutes, 16 (55.2%) of the 29 children who received ketorolac and 28 (84.8%) of the 33 children who received prochlorperazine were successfully treated. About 30% of children in each group had a recurrence of some headache symptoms.

“They recommend prochlorperazine,” Dr. Cantor said. “I do, too. Pick your drug and go with it.”

ED Analgesia for Fracture Pain

A study by Dr. Julie C. Brown and her colleagues compared the use of analgesics for fracture pain in adults and children based on an analysis of the emergency department component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 (Ann. Emerg. Med. 2003;42:197–205).

Of the 2,828 patients who had isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Compared with adults, a lower proportion of children received any analgesic or a narcotic analgesic.

“This demonstrates that pain meds [for fracture pain] were not part of the armamentarium,” Dr. Cantor said. “Kids should get pain meds for fractures the minute they walk in the door, before they're processed.”

YOSEMITE, CALIF. — “As you follow the research in pediatric emergency medicine, it really parallels the practice model of the community,” Dr. Richard M. Cantor said during a pediatric conference sponsored by Symposia Medicus.

On topics from bacteremia, to migraines, to mononucleosis, he summarized recent studies in the literature that have affected the practice of pediatric emergency medicine.

“Any of you who have been in practice for more than 5 or 7 years can see the trends and where these issues have come from,” said Dr. Cantor, director of pediatric emergency services at University Hospital in Syracuse, N.Y.

Young Febrile Infants

Dr. Bema K. Bonsu of Children's Hospital, Columbus, Ohio, and Dr. Marvin B. Harper of Children's Hospital, Boston, set out to estimate the accuracy of the total peripheral white blood count as a screening tool for bacteremia in febrile young infants. They evaluated logistic models for predicting bacteremia that are based on the total peripheral white blood cell count by following 3,810 infants aged 0–89 days who had a temperature in triage of greater than or equal to 100.4° F. (Ann. Emerg. Med. 2003;42:216–25).

The rate of bacteremia was 1% (38/3,810), but the sensitivity and specificity of the white blood count test was 79% and 5%, respectively, at a cutoff of greater than or equal to 5,000 cells/mm

“Thus, decisions to obtain blood cultures should not rely on this test,” said Dr. Cantor, who also is associate professor of emergency medicine and pediatrics at State University of New York (Syracuse) Upstate Medical University.

Risk for Serious Bacterial Infections

Dr. M. Olivia Titus and Dr. Seth W. Wright of Vanderbilt University Medical Center, Nashville, Tenn., investigated the prevalence of serious bacterial infections (SBI) in 174 febrile infants who were younger than 8 weeks of age and had documented respiratory syncytial virus (RSV) and compared them with 174 gender- and age-matched control subjects who were febrile and RSV-negative.

Overall, only 2 patients in the RSV group had SBI (both urinary tract infections), compared with 22 in the control group (17 were UTIs). They concluded that the risk of SBI in febrile infants with RSV infection is very low (Pediatrics 2003;112:282–4).

“Full septic work-ups may not be necessary, and it is prudent to look at the urine [for evidence of UTI],” Dr. Cantor said. “This is important.”

Bacteremia, Antibiotic Use in RSV

A separate study was conducted by Dr. P. Bloomfield and associates at the Children's Hospital at Westmead, New South Wales, Australia, to examine the frequency of and risk factors for bacteremia in 1,795 children aged 0–14 years hospitalized with RSV infection over a 4-year period (Arch. Dis. Child. 2004;89:363–7).

Only 11 (0.6%) of the 1,795 RSV-positive children had bacteremia. RSV-positive children were more likely to be bacteremic if they had nosocomial RSV (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the pediatric ICU (2.9%). “They concluded that bacteremia is rare and that certain characteristics help you identify bacteremic children,” Dr. Cantor said.

Rapid Diagnosis of Influenza

Dr. Aleta B. Bonner and her colleagues at the University of Alabama, Birmingham, attempted to determine the impact of the rapid diagnosis of influenza in the pediatric emergency department on physician decision making and patient management.

The investigators screened 391 patients aged 2 months to 21 years for fever and cough, coryza, myalgias, headache, and/or malaise and randomized them to one of two groups; 202 were influenza positive and ended up randomized roughly equally in the two groups.

In group 1, the attending physician was aware of the rapid influenza test results. Nasopharyngeal swabs were obtained and immediately tested with the flu optical immunoassay (FluOIA) test for influenza A and B, and the results were placed on the chart before the patient was evaluated by the attending physician.

In group 2, the attending physician was unaware of the test results. Nasopharyngeal swabs were obtained, stored, and tested within 24 hours.

Physician awareness of a rapid diagnosis of influenza significantly reduced the number of laboratory tests and radiographs ordered, as well as the associated charges; decreased antibiotic use; increased antiviral use; and reduced the length of time to discharge (Pediatrics 2003;112:363–7).

“This is a big deal,” Dr. Cantor remarked. “You go into the exam room and you say, 'Good news. Your baby has the flu.' They ask, 'Is my child gonna die?' I've had that question. What do you tell them? [I say] 'I have this bank of testing in front of me that gives me viral answers.'”

Human Metapneumovirus in Infants

The aim of this study by Dr. John V. Williams and his associates at Vanderbilt University Medical Center was to determine the role of human metapneumovirus in lower respiratory tract illness in previously healthy infants and children.

The investigators tested nasal-wash specimens obtained from 2,009 infants and children who presented with acute respiratory tract illness between 1976 and 2001. There were 408 visits for lower respiratory tract illness by 321 children for which no cause was identified.

Of these 321 children, specimens from 248 were available. Of these 248 specimens, 49 (20%) contained human metapneumovirus RNA or viable virus (N. Engl. J. Med. 2004;350:443–50).

“Thus, 20% of all previously virus-negative lower respiratory tract illnesses were attributable to human metapneumovirus, which means that 12% of all lower respiratory tract illnesses in this cohort were most likely due to this virus,” Dr. Cantor said.

The virus was associated with bronchiolitis in 59% of cases, croup in 18%, pneumonia in 8%, and an exacerbation of asthma in 14%.

The findings suggest that human metapneumovirus “may be one of the primary causes of bronchiolitis,” Dr. Cantor said. “This was a great study.”

Antibiotic Tx For Urinary Tract Infection

The purpose of this metaanalysis by Dr. M. Michael and associates at the Children's Hospital at Westmead, New South Wales, Australia, was to compare the effectiveness of 2–4 days oral antibiotic therapy (short therapy) with 7–14 days (standard duration therapy) for children with urinary tract infections. The study population consisted of 652 children with lower tract UTI recruited from outpatient or emergency departments (Arch. Dis. Child. 2002;87:118–23).

The investigators found no significant differences in the frequency of positive urine cultures between the short and standard duration therapy for UTI in children 0–7 days after treatment and at 10 days to 15 months after treatment.

There also were no significant differences between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment or in recurrent UTI.

“We can probably get away with a shorter course of antibiotics [for this patient population],” Dr. Cantor said.

Interventions for Impetigo

A metaanalysis by S. Koning and colleagues was done to assess the effects of treatments for impetigo in 3,533 subjects who participated in 57 randomized, controlled trials of 20 different oral and 18 topical treatments for the condition (Cochrane Database Syst. Rev.[2]:CD003261.pub2, 2003).

Topical antibiotics showed better cure rates than placebo, and no topical antibiotic was superior.

Topical mupirocin was superior to oral erythromycin, but in most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials that compared oral antibiotics.

The reviewers concluded there is good evidence that topical mupirocin and topical fusidic acid are equally or more effective than oral treatment for people with limited disease.

It remains unclear whether oral antibiotics are superior to topical antibiotics for people with extensive impetigo.

Treating Pediatric Migraines

A prospective, randomized, double-blind study by Dr. David C. Brousseau and his colleagues at the Medical College of Wisconsin, Milwaukee, compared the efficacy of IV ketorolac and IV prochlorperazine in the treatment of pediatric migraines. The study population consisted of 62 children aged 5–18 years who presented with migraine headaches to the emergency departments at two children's hospitals (Ann. Emerg. Med. 2004;43:256–62).

Investigators defined successful treatment as a 50% or greater reduction in the McGrath Facial Affective Scale (nine faces pain scale) score at 60 minutes.

At 60 minutes, 16 (55.2%) of the 29 children who received ketorolac and 28 (84.8%) of the 33 children who received prochlorperazine were successfully treated. About 30% of children in each group had a recurrence of some headache symptoms.

“They recommend prochlorperazine,” Dr. Cantor said. “I do, too. Pick your drug and go with it.”

ED Analgesia for Fracture Pain

A study by Dr. Julie C. Brown and her colleagues compared the use of analgesics for fracture pain in adults and children based on an analysis of the emergency department component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 (Ann. Emerg. Med. 2003;42:197–205).

Of the 2,828 patients who had isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Compared with adults, a lower proportion of children received any analgesic or a narcotic analgesic.

“This demonstrates that pain meds [for fracture pain] were not part of the armamentarium,” Dr. Cantor said. “Kids should get pain meds for fractures the minute they walk in the door, before they're processed.”

YOSEMITE, CALIF. — “As you follow the research in pediatric emergency medicine, it really parallels the practice model of the community,” Dr. Richard M. Cantor said during a pediatric conference sponsored by Symposia Medicus.

On topics from bacteremia, to migraines, to mononucleosis, he summarized recent studies in the literature that have affected the practice of pediatric emergency medicine.

“Any of you who have been in practice for more than 5 or 7 years can see the trends and where these issues have come from,” said Dr. Cantor, director of pediatric emergency services at University Hospital in Syracuse, N.Y.

Young Febrile Infants

Dr. Bema K. Bonsu of Children's Hospital, Columbus, Ohio, and Dr. Marvin B. Harper of Children's Hospital, Boston, set out to estimate the accuracy of the total peripheral white blood count as a screening tool for bacteremia in febrile young infants. They evaluated logistic models for predicting bacteremia that are based on the total peripheral white blood cell count by following 3,810 infants aged 0–89 days who had a temperature in triage of greater than or equal to 100.4° F. (Ann. Emerg. Med. 2003;42:216–25).

The rate of bacteremia was 1% (38/3,810), but the sensitivity and specificity of the white blood count test was 79% and 5%, respectively, at a cutoff of greater than or equal to 5,000 cells/mm

“Thus, decisions to obtain blood cultures should not rely on this test,” said Dr. Cantor, who also is associate professor of emergency medicine and pediatrics at State University of New York (Syracuse) Upstate Medical University.

Risk for Serious Bacterial Infections

Dr. M. Olivia Titus and Dr. Seth W. Wright of Vanderbilt University Medical Center, Nashville, Tenn., investigated the prevalence of serious bacterial infections (SBI) in 174 febrile infants who were younger than 8 weeks of age and had documented respiratory syncytial virus (RSV) and compared them with 174 gender- and age-matched control subjects who were febrile and RSV-negative.

Overall, only 2 patients in the RSV group had SBI (both urinary tract infections), compared with 22 in the control group (17 were UTIs). They concluded that the risk of SBI in febrile infants with RSV infection is very low (Pediatrics 2003;112:282–4).

“Full septic work-ups may not be necessary, and it is prudent to look at the urine [for evidence of UTI],” Dr. Cantor said. “This is important.”

Bacteremia, Antibiotic Use in RSV

A separate study was conducted by Dr. P. Bloomfield and associates at the Children's Hospital at Westmead, New South Wales, Australia, to examine the frequency of and risk factors for bacteremia in 1,795 children aged 0–14 years hospitalized with RSV infection over a 4-year period (Arch. Dis. Child. 2004;89:363–7).

Only 11 (0.6%) of the 1,795 RSV-positive children had bacteremia. RSV-positive children were more likely to be bacteremic if they had nosocomial RSV (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the pediatric ICU (2.9%). “They concluded that bacteremia is rare and that certain characteristics help you identify bacteremic children,” Dr. Cantor said.

Rapid Diagnosis of Influenza

Dr. Aleta B. Bonner and her colleagues at the University of Alabama, Birmingham, attempted to determine the impact of the rapid diagnosis of influenza in the pediatric emergency department on physician decision making and patient management.

The investigators screened 391 patients aged 2 months to 21 years for fever and cough, coryza, myalgias, headache, and/or malaise and randomized them to one of two groups; 202 were influenza positive and ended up randomized roughly equally in the two groups.

In group 1, the attending physician was aware of the rapid influenza test results. Nasopharyngeal swabs were obtained and immediately tested with the flu optical immunoassay (FluOIA) test for influenza A and B, and the results were placed on the chart before the patient was evaluated by the attending physician.

In group 2, the attending physician was unaware of the test results. Nasopharyngeal swabs were obtained, stored, and tested within 24 hours.

Physician awareness of a rapid diagnosis of influenza significantly reduced the number of laboratory tests and radiographs ordered, as well as the associated charges; decreased antibiotic use; increased antiviral use; and reduced the length of time to discharge (Pediatrics 2003;112:363–7).

“This is a big deal,” Dr. Cantor remarked. “You go into the exam room and you say, 'Good news. Your baby has the flu.' They ask, 'Is my child gonna die?' I've had that question. What do you tell them? [I say] 'I have this bank of testing in front of me that gives me viral answers.'”

Human Metapneumovirus in Infants

The aim of this study by Dr. John V. Williams and his associates at Vanderbilt University Medical Center was to determine the role of human metapneumovirus in lower respiratory tract illness in previously healthy infants and children.

The investigators tested nasal-wash specimens obtained from 2,009 infants and children who presented with acute respiratory tract illness between 1976 and 2001. There were 408 visits for lower respiratory tract illness by 321 children for which no cause was identified.

Of these 321 children, specimens from 248 were available. Of these 248 specimens, 49 (20%) contained human metapneumovirus RNA or viable virus (N. Engl. J. Med. 2004;350:443–50).

“Thus, 20% of all previously virus-negative lower respiratory tract illnesses were attributable to human metapneumovirus, which means that 12% of all lower respiratory tract illnesses in this cohort were most likely due to this virus,” Dr. Cantor said.

The virus was associated with bronchiolitis in 59% of cases, croup in 18%, pneumonia in 8%, and an exacerbation of asthma in 14%.

The findings suggest that human metapneumovirus “may be one of the primary causes of bronchiolitis,” Dr. Cantor said. “This was a great study.”

Antibiotic Tx For Urinary Tract Infection

The purpose of this metaanalysis by Dr. M. Michael and associates at the Children's Hospital at Westmead, New South Wales, Australia, was to compare the effectiveness of 2–4 days oral antibiotic therapy (short therapy) with 7–14 days (standard duration therapy) for children with urinary tract infections. The study population consisted of 652 children with lower tract UTI recruited from outpatient or emergency departments (Arch. Dis. Child. 2002;87:118–23).

The investigators found no significant differences in the frequency of positive urine cultures between the short and standard duration therapy for UTI in children 0–7 days after treatment and at 10 days to 15 months after treatment.

There also were no significant differences between short and standard duration therapy in the development of resistant organisms in UTI at the end of treatment or in recurrent UTI.

“We can probably get away with a shorter course of antibiotics [for this patient population],” Dr. Cantor said.

Interventions for Impetigo

A metaanalysis by S. Koning and colleagues was done to assess the effects of treatments for impetigo in 3,533 subjects who participated in 57 randomized, controlled trials of 20 different oral and 18 topical treatments for the condition (Cochrane Database Syst. Rev.[2]:CD003261.pub2, 2003).

Topical antibiotics showed better cure rates than placebo, and no topical antibiotic was superior.

Topical mupirocin was superior to oral erythromycin, but in most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials that compared oral antibiotics.

The reviewers concluded there is good evidence that topical mupirocin and topical fusidic acid are equally or more effective than oral treatment for people with limited disease.

It remains unclear whether oral antibiotics are superior to topical antibiotics for people with extensive impetigo.

Treating Pediatric Migraines

A prospective, randomized, double-blind study by Dr. David C. Brousseau and his colleagues at the Medical College of Wisconsin, Milwaukee, compared the efficacy of IV ketorolac and IV prochlorperazine in the treatment of pediatric migraines. The study population consisted of 62 children aged 5–18 years who presented with migraine headaches to the emergency departments at two children's hospitals (Ann. Emerg. Med. 2004;43:256–62).

Investigators defined successful treatment as a 50% or greater reduction in the McGrath Facial Affective Scale (nine faces pain scale) score at 60 minutes.

At 60 minutes, 16 (55.2%) of the 29 children who received ketorolac and 28 (84.8%) of the 33 children who received prochlorperazine were successfully treated. About 30% of children in each group had a recurrence of some headache symptoms.

“They recommend prochlorperazine,” Dr. Cantor said. “I do, too. Pick your drug and go with it.”

ED Analgesia for Fracture Pain

A study by Dr. Julie C. Brown and her colleagues compared the use of analgesics for fracture pain in adults and children based on an analysis of the emergency department component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 (Ann. Emerg. Med. 2003;42:197–205).

Of the 2,828 patients who had isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Compared with adults, a lower proportion of children received any analgesic or a narcotic analgesic.

“This demonstrates that pain meds [for fracture pain] were not part of the armamentarium,” Dr. Cantor said. “Kids should get pain meds for fractures the minute they walk in the door, before they're processed.”

The Centers for Disease Control and Prevention closed out 2005 by updating its 1994 guidelines for preventing Mycobacterium tuberculosis in health care settings.

The exhaustive guidelines were updated in an effort to respond to “shifts in the epidemiology of TB, advances in scientific understanding, and changes in health care practice that have occurred in the United States during the previous decade,” wrote the authors, led by Paul A. Jensen, Ph.D., in the division of tuberculosis elimination at the CDC's National Center for HIV, STD, and TB Prevention (MMWR 2005;54[RR-17]:1–121).

TB rates have declined in recent years, but “the 2004 rate of 4.9 per 100,000 remained higher than the 2000 goal of 3.5. This goal was established as part of the national strategic plan for TB elimination,” the authors noted. Also, health care workers (HCWs) in different areas of the country face different risks.

One key change that makes these guidelines different is the use of the term “tuberculin skin tests” instead of purified protein derivative. Also, the guidelines state that the QuantiFERON-TB Gold test can be used instead of tuberculin skin tests in TB screening programs for health care workers. This one-step blood assay for M. tuberculosis (BAMT) is approved by the Food and Dug Administration.

Other changes include the following:

▸ Expansion of settings. The guidelines have site-specific recommendations for more inpatient and outpatient setting types.

▸ More concise criteria for who needs serial testing for TB infection. Recommendations vary depending on the type of health care setting. In some settings, the frequency of TB screening for HCWs has been decreased.

▸ New airborne terms. The term “airborne isolation” replaces “respiratory isolation” while the term “airborne infection isolation room” (AII room) is defined as “a special negative-pressure room for the specific purpose of isolating persons who might have suspected or confirmed infectious TB disease from other parts of the [health care] setting.”

▸ Instructions on proper respirator use. This includes criteria for selecting respirators and recommendations for annual training and fit testing.

▸ A nine-page “frequently asked questions” section. One of the questions posed is: “Do health care settings or areas in the United States exist for which baseline two-step skin TST for newly hired HCWs is not needed?”

The reply reads: “Ideally, all newly hired HCWs who might share air space with patients should receive baseline two-step TST (or one-step BAMT) before starting duties. In certain settings, a choice might be offered not to perform baseline TST on HCWs who will never be in contact with or share air space with patients who have TB disease, or will never be in contact with clinical specimens (e.g., telephone operators in a separate building from patients).”

The Centers for Disease Control and Prevention closed out 2005 by updating its 1994 guidelines for preventing Mycobacterium tuberculosis in health care settings.

The exhaustive guidelines were updated in an effort to respond to “shifts in the epidemiology of TB, advances in scientific understanding, and changes in health care practice that have occurred in the United States during the previous decade,” wrote the authors, led by Paul A. Jensen, Ph.D., in the division of tuberculosis elimination at the CDC's National Center for HIV, STD, and TB Prevention (MMWR 2005;54[RR-17]:1–121).

TB rates have declined in recent years, but “the 2004 rate of 4.9 per 100,000 remained higher than the 2000 goal of 3.5. This goal was established as part of the national strategic plan for TB elimination,” the authors noted. Also, health care workers (HCWs) in different areas of the country face different risks.

One key change that makes these guidelines different is the use of the term “tuberculin skin tests” instead of purified protein derivative. Also, the guidelines state that the QuantiFERON-TB Gold test can be used instead of tuberculin skin tests in TB screening programs for health care workers. This one-step blood assay for M. tuberculosis (BAMT) is approved by the Food and Dug Administration.

Other changes include the following:

▸ Expansion of settings. The guidelines have site-specific recommendations for more inpatient and outpatient setting types.

▸ More concise criteria for who needs serial testing for TB infection. Recommendations vary depending on the type of health care setting. In some settings, the frequency of TB screening for HCWs has been decreased.

▸ New airborne terms. The term “airborne isolation” replaces “respiratory isolation” while the term “airborne infection isolation room” (AII room) is defined as “a special negative-pressure room for the specific purpose of isolating persons who might have suspected or confirmed infectious TB disease from other parts of the [health care] setting.”

▸ Instructions on proper respirator use. This includes criteria for selecting respirators and recommendations for annual training and fit testing.

▸ A nine-page “frequently asked questions” section. One of the questions posed is: “Do health care settings or areas in the United States exist for which baseline two-step skin TST for newly hired HCWs is not needed?”

The reply reads: “Ideally, all newly hired HCWs who might share air space with patients should receive baseline two-step TST (or one-step BAMT) before starting duties. In certain settings, a choice might be offered not to perform baseline TST on HCWs who will never be in contact with or share air space with patients who have TB disease, or will never be in contact with clinical specimens (e.g., telephone operators in a separate building from patients).”

The Centers for Disease Control and Prevention closed out 2005 by updating its 1994 guidelines for preventing Mycobacterium tuberculosis in health care settings.

The exhaustive guidelines were updated in an effort to respond to “shifts in the epidemiology of TB, advances in scientific understanding, and changes in health care practice that have occurred in the United States during the previous decade,” wrote the authors, led by Paul A. Jensen, Ph.D., in the division of tuberculosis elimination at the CDC's National Center for HIV, STD, and TB Prevention (MMWR 2005;54[RR-17]:1–121).

TB rates have declined in recent years, but “the 2004 rate of 4.9 per 100,000 remained higher than the 2000 goal of 3.5. This goal was established as part of the national strategic plan for TB elimination,” the authors noted. Also, health care workers (HCWs) in different areas of the country face different risks.

One key change that makes these guidelines different is the use of the term “tuberculin skin tests” instead of purified protein derivative. Also, the guidelines state that the QuantiFERON-TB Gold test can be used instead of tuberculin skin tests in TB screening programs for health care workers. This one-step blood assay for M. tuberculosis (BAMT) is approved by the Food and Dug Administration.

Other changes include the following:

▸ Expansion of settings. The guidelines have site-specific recommendations for more inpatient and outpatient setting types.

▸ More concise criteria for who needs serial testing for TB infection. Recommendations vary depending on the type of health care setting. In some settings, the frequency of TB screening for HCWs has been decreased.

▸ New airborne terms. The term “airborne isolation” replaces “respiratory isolation” while the term “airborne infection isolation room” (AII room) is defined as “a special negative-pressure room for the specific purpose of isolating persons who might have suspected or confirmed infectious TB disease from other parts of the [health care] setting.”

▸ Instructions on proper respirator use. This includes criteria for selecting respirators and recommendations for annual training and fit testing.

▸ A nine-page “frequently asked questions” section. One of the questions posed is: “Do health care settings or areas in the United States exist for which baseline two-step skin TST for newly hired HCWs is not needed?”

The reply reads: “Ideally, all newly hired HCWs who might share air space with patients should receive baseline two-step TST (or one-step BAMT) before starting duties. In certain settings, a choice might be offered not to perform baseline TST on HCWs who will never be in contact with or share air space with patients who have TB disease, or will never be in contact with clinical specimens (e.g., telephone operators in a separate building from patients).”

SAN DIEGO – The presence of paratonia in patients with Alzheimer's disease may be a sign of cognitive decline, according to the results of a small study.

“Paratonia may be useful as a way of looking at the progression of Alzheimer's disease, because it can be seen, and it's not affected by medications, depression, or how well the person is functioning,” Dr. Ipsit V. Vahia said in an interview during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“We think it's an almost pure indicator of the rate of degeneration, which is the basic pathology in Alzheimer's disease. It may be useful clinically as a way of monitoring the progress of the disease process, not the disease manifestation,” he said.

He and his associates studied 80 consecutive patients who were evaluated at the Brooklyn Alzheimer's Disease Assistance Center at the State University of New York Downstate Medical Center. Their mean age was 77 years, 79% were female, and 76% were black.

Each patient underwent a battery of tests, including the Hamilton Depression Rating Scale, the Blessed Dementia Scale, the Global Deterioration Scale, and the paratonia rating scale, said Dr. Vahia of the department of psychiatry at the medical center.

The investigators found that paratonia was significantly associated with the stage of illness as defined by the Global Deterioration Scale and number of frontal lobe symptoms, but not with other variables including age, race, level of education, gender, and general physical health. Paratonia was not correlated with the level of functioning in Alzheimer's disease, suggesting that the condition may serve as a marker of frontal lobe degeneration.

“We need to establish if it is a sensitive and specific clinical sign. It needs to be studied in other forms of dementia. How well it indicates brain degeneration will determine whether it is useful [as a marker] or not,” Dr. Vahia said.

The study was partly supported by a National Institute on Aging grant.

SAN DIEGO – The presence of paratonia in patients with Alzheimer's disease may be a sign of cognitive decline, according to the results of a small study.

“Paratonia may be useful as a way of looking at the progression of Alzheimer's disease, because it can be seen, and it's not affected by medications, depression, or how well the person is functioning,” Dr. Ipsit V. Vahia said in an interview during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“We think it's an almost pure indicator of the rate of degeneration, which is the basic pathology in Alzheimer's disease. It may be useful clinically as a way of monitoring the progress of the disease process, not the disease manifestation,” he said.

He and his associates studied 80 consecutive patients who were evaluated at the Brooklyn Alzheimer's Disease Assistance Center at the State University of New York Downstate Medical Center. Their mean age was 77 years, 79% were female, and 76% were black.

Each patient underwent a battery of tests, including the Hamilton Depression Rating Scale, the Blessed Dementia Scale, the Global Deterioration Scale, and the paratonia rating scale, said Dr. Vahia of the department of psychiatry at the medical center.

The investigators found that paratonia was significantly associated with the stage of illness as defined by the Global Deterioration Scale and number of frontal lobe symptoms, but not with other variables including age, race, level of education, gender, and general physical health. Paratonia was not correlated with the level of functioning in Alzheimer's disease, suggesting that the condition may serve as a marker of frontal lobe degeneration.

“We need to establish if it is a sensitive and specific clinical sign. It needs to be studied in other forms of dementia. How well it indicates brain degeneration will determine whether it is useful [as a marker] or not,” Dr. Vahia said.

The study was partly supported by a National Institute on Aging grant.

SAN DIEGO – The presence of paratonia in patients with Alzheimer's disease may be a sign of cognitive decline, according to the results of a small study.

“Paratonia may be useful as a way of looking at the progression of Alzheimer's disease, because it can be seen, and it's not affected by medications, depression, or how well the person is functioning,” Dr. Ipsit V. Vahia said in an interview during a poster session at the American Psychiatric Association's Institute on Psychiatric Services.

“We think it's an almost pure indicator of the rate of degeneration, which is the basic pathology in Alzheimer's disease. It may be useful clinically as a way of monitoring the progress of the disease process, not the disease manifestation,” he said.

He and his associates studied 80 consecutive patients who were evaluated at the Brooklyn Alzheimer's Disease Assistance Center at the State University of New York Downstate Medical Center. Their mean age was 77 years, 79% were female, and 76% were black.

Each patient underwent a battery of tests, including the Hamilton Depression Rating Scale, the Blessed Dementia Scale, the Global Deterioration Scale, and the paratonia rating scale, said Dr. Vahia of the department of psychiatry at the medical center.

The investigators found that paratonia was significantly associated with the stage of illness as defined by the Global Deterioration Scale and number of frontal lobe symptoms, but not with other variables including age, race, level of education, gender, and general physical health. Paratonia was not correlated with the level of functioning in Alzheimer's disease, suggesting that the condition may serve as a marker of frontal lobe degeneration.

“We need to establish if it is a sensitive and specific clinical sign. It needs to be studied in other forms of dementia. How well it indicates brain degeneration will determine whether it is useful [as a marker] or not,” Dr. Vahia said.

The study was partly supported by a National Institute on Aging grant.