Patrice Wendling

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dana King, M.D., said at the North American Primary Care Research Group annual meeting.

He presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors.

Moreover, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. Participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5).

Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Interestingly, only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dana King, M.D., said at the North American Primary Care Research Group annual meeting.

He presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors.

Moreover, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. Participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5).

Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Interestingly, only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

QUEBEC CITY — Increasing dietary fiber intake might be warranted in patients with diabetes, hypertension, and obesity, Dana King, M.D., said at the North American Primary Care Research Group annual meeting.

He presented a study in which adults with low fiber intake and at least two of the three conditions were twice as likely to have elevated C-reactive protein (CRP) levels, compared with adults with no risk conditions, even after controlling for confounding factors.

Moreover, the influence of fiber on CRP values was greater as the number of conditions increased, said Dr. King, professor at the Medical University of South Carolina, Charleston.

There is some evidence to suggest that dietary fiber reduces cholesterol and influences inflammation. But CRP increases the risk of cardiovascular disease independently from cholesterol, he said.

Both the American Diabetes Association and the American Heart Association suggest adults consume 25–30 g of fiber per day. However, neither group has specific recommendations for higher intake among high-risk patients, Dr. King said.

The cross-sectional study included 7,891 participants in the 1999–2002 National Health and Nutrition Examination Survey at least 20 years of age who had valid high-sensitivity CRP measurements and dietary information. Participants were asked to recall fiber consumption in the previous 24 hours. Fiber supplements were not counted toward total intake.

Individuals with two or more conditions—diabetes, hypertension, or obesity—who consumed 20 g per day or more of fiber had significantly lower median CRP (3.1 mg/L) than people who consumed 8.8 g/day or less (4.5 mg/L).

CRP was four times higher in people with these conditions who consumed less than 8.8 g/day of fiber than people without these conditions (1.4 mg/L).

Even after controlling for age, race, gender, and tobacco use, adults with two or more conditions had double the risk of having elevated CRP (odds ratio 2.3), compared with adults with no risk conditions (OR 1.5).

Only 2%–3% of patients in the study had rheumatoid arthritis, which can raise CRP levels.

Interestingly, only dietary fiber showed a consistent association with CRP. There was no consistent association between CRP and other dietary components such as fat, polyunsaturated fat, protein, carbohydrates, or fish-oil consumption, he said.

It's unclear what biological mechanisms might be at work, but fiber itself might not be the source of the observed benefits.

“We could very well be looking at a surrogate,” Dr. King said. “Fiber may not be changing CRP. There have been a couple of studies, including our own, that have looked at other things that travel along with fiber, other nutrients, such as magnesium.

“There is a high correlation between magnesium intake and fiber intake, and there is a high predictive value of high magnesium intake and lower blood pressure and lower cardiovascular disease. So they may be traveling together. We are still in the process of sorting these things out.”

LOS ANGELES — Electronic health records have been proposed as a way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, so both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection, noting that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on one screen. Also, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors. Rather than presenting critical data in a way that links related information, the electronic record had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, while reports on a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

Such communication failures could be reduced by an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

LOS ANGELES — Electronic health records have been proposed as a way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, so both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection, noting that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on one screen. Also, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors. Rather than presenting critical data in a way that links related information, the electronic record had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, while reports on a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

Such communication failures could be reduced by an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

LOS ANGELES — Electronic health records have been proposed as a way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, so both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection, noting that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on one screen. Also, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors. Rather than presenting critical data in a way that links related information, the electronic record had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, while reports on a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

Such communication failures could be reduced by an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

This Month's Talk Back Question

What has been your experience with medical error reporting?

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

This Month's Talk Back Question

What has been your experience with medical error reporting?

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

This Month's Talk Back Question

What has been your experience with medical error reporting?

QUEBEC CITY — The use of rapid human immunodeficiency virus testing has had a profound impact on primary care settings in New Jersey, Denise Young, M.D., reported in a poster at the annual meeting of the North American Primary Care Research Group.

Because the test doesn't require patients to make a second visit to receive their results, more HIV-positive patients are learning of their HIV status and receiving counseling.

New Jersey, which is fifth in the United States in cumulative reported AIDS cases and first in the proportion of women living with AIDS, introduced rapid HIV testing at publicly funded testing and counseling clinics in November 2003. It is now used in 90 sites throughout the state.

Testing has been done with the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Bethlehem, Pa.), which is approved by the Food and Drug Administration for use with whole blood. It is not approved for serum testing or stored samples.

A whole-blood specimen is obtained via fingerstick or venipuncture and inserted into the testing device, which resembles a home pregnancy test kit. Results are ready in 20 minutes.

This compares with 1–2 weeks for the most commonly used initial HIV test, the enzyme immune assay, confirmed with Western blot or immunofluorescence assay.

Prior to rapid testing, only 65% of patients in New Jersey returned for their results.

In contrast, 99.7% of 25,264 patients screened with rapid HIV testing got their results and received counseling, according to an analysis of state databases through July 21, 2005.

A total of 510 (2%) patients were HIV positive. Of these, 327 (64%) were newly diagnosed, reported Dr. Young, Robert Wood Johnson Medical School, New Brunswick, N.J., and her associates.

Further analysis will determine if the seroprevalence at rapid test sites is the same as at traditional testing sites, or if newly diagnosed patients are getting into treatment services in a timely manner, she said.

It's hoped that by providing the opportunity to engage patients more quickly, the test will help decrease the mortality and morbidity associated with HIV infection.

Rapid testing is also being looked at as a way to lessen racial disparities that currently exist in New Jersey, which has one of the highest HIV infection rates in the nation, she said.

One in every 66 African Americans and 1 in every 171 Hispanics in New Jersey is living with HIV/AIDS, according the New Jersey Department of Health and Senior Services.

The state health department encourages the use of rapid testing for occupational exposures and in pregnant women to reduce the risk of mother-to-child transmission, according to statements from the department. But there are trade-offs. More HIV-positive people will get their results. But some people will receive a false-positive result.

Postmarketing surveillance on the OraQuick test initiated by the Centers for Disease Control and Prevention in September 2003 has identified at least five HIV-infected patients who were incorrectly informed that their rapid HIV test results were positive, according to the CDC's Web site.

Publicly funded sites in New Jersey follow CDC protocol, which recommends that all preliminary positive results with rapid HIV testing be confirmed by Western blot or immunofluorescence assay, Dr. Young said.

QUEBEC CITY — The use of rapid human immunodeficiency virus testing has had a profound impact on primary care settings in New Jersey, Denise Young, M.D., reported in a poster at the annual meeting of the North American Primary Care Research Group.

Because the test doesn't require patients to make a second visit to receive their results, more HIV-positive patients are learning of their HIV status and receiving counseling.

New Jersey, which is fifth in the United States in cumulative reported AIDS cases and first in the proportion of women living with AIDS, introduced rapid HIV testing at publicly funded testing and counseling clinics in November 2003. It is now used in 90 sites throughout the state.

Testing has been done with the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Bethlehem, Pa.), which is approved by the Food and Drug Administration for use with whole blood. It is not approved for serum testing or stored samples.

A whole-blood specimen is obtained via fingerstick or venipuncture and inserted into the testing device, which resembles a home pregnancy test kit. Results are ready in 20 minutes.

This compares with 1–2 weeks for the most commonly used initial HIV test, the enzyme immune assay, confirmed with Western blot or immunofluorescence assay.

Prior to rapid testing, only 65% of patients in New Jersey returned for their results.

In contrast, 99.7% of 25,264 patients screened with rapid HIV testing got their results and received counseling, according to an analysis of state databases through July 21, 2005.

A total of 510 (2%) patients were HIV positive. Of these, 327 (64%) were newly diagnosed, reported Dr. Young, Robert Wood Johnson Medical School, New Brunswick, N.J., and her associates.

Further analysis will determine if the seroprevalence at rapid test sites is the same as at traditional testing sites, or if newly diagnosed patients are getting into treatment services in a timely manner, she said.

It's hoped that by providing the opportunity to engage patients more quickly, the test will help decrease the mortality and morbidity associated with HIV infection.

Rapid testing is also being looked at as a way to lessen racial disparities that currently exist in New Jersey, which has one of the highest HIV infection rates in the nation, she said.

One in every 66 African Americans and 1 in every 171 Hispanics in New Jersey is living with HIV/AIDS, according the New Jersey Department of Health and Senior Services.

The state health department encourages the use of rapid testing for occupational exposures and in pregnant women to reduce the risk of mother-to-child transmission, according to statements from the department. But there are trade-offs. More HIV-positive people will get their results. But some people will receive a false-positive result.

Postmarketing surveillance on the OraQuick test initiated by the Centers for Disease Control and Prevention in September 2003 has identified at least five HIV-infected patients who were incorrectly informed that their rapid HIV test results were positive, according to the CDC's Web site.

Publicly funded sites in New Jersey follow CDC protocol, which recommends that all preliminary positive results with rapid HIV testing be confirmed by Western blot or immunofluorescence assay, Dr. Young said.

QUEBEC CITY — The use of rapid human immunodeficiency virus testing has had a profound impact on primary care settings in New Jersey, Denise Young, M.D., reported in a poster at the annual meeting of the North American Primary Care Research Group.

Because the test doesn't require patients to make a second visit to receive their results, more HIV-positive patients are learning of their HIV status and receiving counseling.

New Jersey, which is fifth in the United States in cumulative reported AIDS cases and first in the proportion of women living with AIDS, introduced rapid HIV testing at publicly funded testing and counseling clinics in November 2003. It is now used in 90 sites throughout the state.

Testing has been done with the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Bethlehem, Pa.), which is approved by the Food and Drug Administration for use with whole blood. It is not approved for serum testing or stored samples.

A whole-blood specimen is obtained via fingerstick or venipuncture and inserted into the testing device, which resembles a home pregnancy test kit. Results are ready in 20 minutes.

This compares with 1–2 weeks for the most commonly used initial HIV test, the enzyme immune assay, confirmed with Western blot or immunofluorescence assay.

Prior to rapid testing, only 65% of patients in New Jersey returned for their results.

In contrast, 99.7% of 25,264 patients screened with rapid HIV testing got their results and received counseling, according to an analysis of state databases through July 21, 2005.

A total of 510 (2%) patients were HIV positive. Of these, 327 (64%) were newly diagnosed, reported Dr. Young, Robert Wood Johnson Medical School, New Brunswick, N.J., and her associates.

Further analysis will determine if the seroprevalence at rapid test sites is the same as at traditional testing sites, or if newly diagnosed patients are getting into treatment services in a timely manner, she said.

It's hoped that by providing the opportunity to engage patients more quickly, the test will help decrease the mortality and morbidity associated with HIV infection.

Rapid testing is also being looked at as a way to lessen racial disparities that currently exist in New Jersey, which has one of the highest HIV infection rates in the nation, she said.

One in every 66 African Americans and 1 in every 171 Hispanics in New Jersey is living with HIV/AIDS, according the New Jersey Department of Health and Senior Services.

The state health department encourages the use of rapid testing for occupational exposures and in pregnant women to reduce the risk of mother-to-child transmission, according to statements from the department. But there are trade-offs. More HIV-positive people will get their results. But some people will receive a false-positive result.

Postmarketing surveillance on the OraQuick test initiated by the Centers for Disease Control and Prevention in September 2003 has identified at least five HIV-infected patients who were incorrectly informed that their rapid HIV test results were positive, according to the CDC's Web site.

Publicly funded sites in New Jersey follow CDC protocol, which recommends that all preliminary positive results with rapid HIV testing be confirmed by Western blot or immunofluorescence assay, Dr. Young said.

CHICAGO — Consider additional tuberculosis screening strategies in patients of certain ethnic backgrounds prior to initiating biologic therapies, Stephen E. Wolverton, M.D., advised at the American Academy of Dermatology's Academy 2005 meeting.

High-risk individuals should get a chest x-ray at baseline, and a consultation or chemoprophylaxis with isoniazid for 9 months should be considered for those patients at highest risk, he said.

The ethnic background of a patient can make an enormous difference. The rate of tuberculosis is almost 17 times greater among Asian and Pacific Islanders than in non-Hispanic, U.S. whites, said Dr. Wolverton of Indiana University, Indianapolis.

Per 100,000 patients, the TB rate is 2.2 among non-Hispanic whites, compared with 35.3 among Asian Pacific Islanders, 16.8 among blacks, and 12.4 among Hispanics, according to data from the Centers for Disease Control and Prevention.

Reports of tuberculosis in patients on biologic therapies prompted the Food and Drug Administration to recommend a baseline tuberculin purified protein derivative (PPD) skin test to evaluate the risk of latent TB infection, Dr. Wolverton said. It is important to be aware that rheumatoid arthritis can decrease the activity of the PPD, he added.

There is a trend toward increased risk of TB associated with biologics, but the database on psoriasis patients is too small to make meaningful conclusions, Dr. Wolverton said.

CHICAGO — Consider additional tuberculosis screening strategies in patients of certain ethnic backgrounds prior to initiating biologic therapies, Stephen E. Wolverton, M.D., advised at the American Academy of Dermatology's Academy 2005 meeting.

High-risk individuals should get a chest x-ray at baseline, and a consultation or chemoprophylaxis with isoniazid for 9 months should be considered for those patients at highest risk, he said.

The ethnic background of a patient can make an enormous difference. The rate of tuberculosis is almost 17 times greater among Asian and Pacific Islanders than in non-Hispanic, U.S. whites, said Dr. Wolverton of Indiana University, Indianapolis.

Per 100,000 patients, the TB rate is 2.2 among non-Hispanic whites, compared with 35.3 among Asian Pacific Islanders, 16.8 among blacks, and 12.4 among Hispanics, according to data from the Centers for Disease Control and Prevention.

Reports of tuberculosis in patients on biologic therapies prompted the Food and Drug Administration to recommend a baseline tuberculin purified protein derivative (PPD) skin test to evaluate the risk of latent TB infection, Dr. Wolverton said. It is important to be aware that rheumatoid arthritis can decrease the activity of the PPD, he added.

There is a trend toward increased risk of TB associated with biologics, but the database on psoriasis patients is too small to make meaningful conclusions, Dr. Wolverton said.

CHICAGO — Consider additional tuberculosis screening strategies in patients of certain ethnic backgrounds prior to initiating biologic therapies, Stephen E. Wolverton, M.D., advised at the American Academy of Dermatology's Academy 2005 meeting.

High-risk individuals should get a chest x-ray at baseline, and a consultation or chemoprophylaxis with isoniazid for 9 months should be considered for those patients at highest risk, he said.

The ethnic background of a patient can make an enormous difference. The rate of tuberculosis is almost 17 times greater among Asian and Pacific Islanders than in non-Hispanic, U.S. whites, said Dr. Wolverton of Indiana University, Indianapolis.

Per 100,000 patients, the TB rate is 2.2 among non-Hispanic whites, compared with 35.3 among Asian Pacific Islanders, 16.8 among blacks, and 12.4 among Hispanics, according to data from the Centers for Disease Control and Prevention.

Reports of tuberculosis in patients on biologic therapies prompted the Food and Drug Administration to recommend a baseline tuberculin purified protein derivative (PPD) skin test to evaluate the risk of latent TB infection, Dr. Wolverton said. It is important to be aware that rheumatoid arthritis can decrease the activity of the PPD, he added.

There is a trend toward increased risk of TB associated with biologics, but the database on psoriasis patients is too small to make meaningful conclusions, Dr. Wolverton said.

LOS ANGELES — Revision surgery for cochlear implant is feasible and children continue to benefit with the new implant, according to a retrospective analysis of 27 cases.

The feasibility of postrevision cochlear implants was evaluated after a review of the literature revealed problems achieving the same depth of insertion with a revision surgery, Jose N. Fayad, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

About 5% of children undergoing cochlear implant surgery subsequently require revision surgery, most commonly due to device failure.

“Once it has been confirmed that the implant has failed, it is important to replace it as soon as possible so the child can continue to develop communication skills and language,” Dr. Fayad said in an interview.

The analysis included 496 children, aged 18 months to 16 years, treated at the House Clinic/House Ear Institute in Los Angeles between 1987 and 2005. The interval between surgeries was as short as 8 weeks and up to 6 years. Of the 27 patients who had revision surgery, 18 were reinsertions, and 9 were wound revisions without explantation.

Two patients had their primary surgery performed at another institution, resulting in a reimplantation rate of 3.3% for the institute.

The cause of revision surgery without explantation was mainly infection; device failure (14 patients), trauma (3 patients), and wound infection (1 patient) preceded the reinsertions. Device failure was not significantly related to device type, although more failures occurred among the older ceramic CLARION CI and CII models, which since have been recalled by Advanced Bionics Corp.

With the exception of one patient with a severe cochlear malformation, a new device was fully inserted without difficulty in all patients at the time of revision surgery.

Soundfield thresholds obtained at 250 Hz, 500 Hz, 1,000 Hz, 2,000 Hz, and 4,000 Hz were completely stable before and after the operation, indicating the audibility levels of the patients did not change between the pre-device failure and postrevision periods, he said.

There was no change in speech recognition, with most patients able to understand nouns and some sentences post revision surgery.

Statistical analysis using paired t-tests and the Wilcoxon signed ranks tests indicated that differences in clinical outcomes between pre-device failure and postrevision did not reach statistical significance.

Dr. Fayad, of the House Ear Clinic in Los Angeles, suggested leaving the electrode within the cochlea as a stent until the surgeon is ready to reinsert to avoid tissue collapsing into the cochlea.

LOS ANGELES — Revision surgery for cochlear implant is feasible and children continue to benefit with the new implant, according to a retrospective analysis of 27 cases.

The feasibility of postrevision cochlear implants was evaluated after a review of the literature revealed problems achieving the same depth of insertion with a revision surgery, Jose N. Fayad, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

About 5% of children undergoing cochlear implant surgery subsequently require revision surgery, most commonly due to device failure.

“Once it has been confirmed that the implant has failed, it is important to replace it as soon as possible so the child can continue to develop communication skills and language,” Dr. Fayad said in an interview.

The analysis included 496 children, aged 18 months to 16 years, treated at the House Clinic/House Ear Institute in Los Angeles between 1987 and 2005. The interval between surgeries was as short as 8 weeks and up to 6 years. Of the 27 patients who had revision surgery, 18 were reinsertions, and 9 were wound revisions without explantation.

Two patients had their primary surgery performed at another institution, resulting in a reimplantation rate of 3.3% for the institute.

The cause of revision surgery without explantation was mainly infection; device failure (14 patients), trauma (3 patients), and wound infection (1 patient) preceded the reinsertions. Device failure was not significantly related to device type, although more failures occurred among the older ceramic CLARION CI and CII models, which since have been recalled by Advanced Bionics Corp.

With the exception of one patient with a severe cochlear malformation, a new device was fully inserted without difficulty in all patients at the time of revision surgery.

Soundfield thresholds obtained at 250 Hz, 500 Hz, 1,000 Hz, 2,000 Hz, and 4,000 Hz were completely stable before and after the operation, indicating the audibility levels of the patients did not change between the pre-device failure and postrevision periods, he said.

There was no change in speech recognition, with most patients able to understand nouns and some sentences post revision surgery.

Statistical analysis using paired t-tests and the Wilcoxon signed ranks tests indicated that differences in clinical outcomes between pre-device failure and postrevision did not reach statistical significance.

Dr. Fayad, of the House Ear Clinic in Los Angeles, suggested leaving the electrode within the cochlea as a stent until the surgeon is ready to reinsert to avoid tissue collapsing into the cochlea.

LOS ANGELES — Revision surgery for cochlear implant is feasible and children continue to benefit with the new implant, according to a retrospective analysis of 27 cases.

The feasibility of postrevision cochlear implants was evaluated after a review of the literature revealed problems achieving the same depth of insertion with a revision surgery, Jose N. Fayad, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

About 5% of children undergoing cochlear implant surgery subsequently require revision surgery, most commonly due to device failure.

“Once it has been confirmed that the implant has failed, it is important to replace it as soon as possible so the child can continue to develop communication skills and language,” Dr. Fayad said in an interview.

The analysis included 496 children, aged 18 months to 16 years, treated at the House Clinic/House Ear Institute in Los Angeles between 1987 and 2005. The interval between surgeries was as short as 8 weeks and up to 6 years. Of the 27 patients who had revision surgery, 18 were reinsertions, and 9 were wound revisions without explantation.

Two patients had their primary surgery performed at another institution, resulting in a reimplantation rate of 3.3% for the institute.

The cause of revision surgery without explantation was mainly infection; device failure (14 patients), trauma (3 patients), and wound infection (1 patient) preceded the reinsertions. Device failure was not significantly related to device type, although more failures occurred among the older ceramic CLARION CI and CII models, which since have been recalled by Advanced Bionics Corp.

With the exception of one patient with a severe cochlear malformation, a new device was fully inserted without difficulty in all patients at the time of revision surgery.

Soundfield thresholds obtained at 250 Hz, 500 Hz, 1,000 Hz, 2,000 Hz, and 4,000 Hz were completely stable before and after the operation, indicating the audibility levels of the patients did not change between the pre-device failure and postrevision periods, he said.

There was no change in speech recognition, with most patients able to understand nouns and some sentences post revision surgery.

Statistical analysis using paired t-tests and the Wilcoxon signed ranks tests indicated that differences in clinical outcomes between pre-device failure and postrevision did not reach statistical significance.

Dr. Fayad, of the House Ear Clinic in Los Angeles, suggested leaving the electrode within the cochlea as a stent until the surgeon is ready to reinsert to avoid tissue collapsing into the cochlea.

LOS ANGELES — Bone-anchored hearing aid implantation may be better performed in two stages in children to reduce postoperative complications, a retrospective study suggests.

Postoperative complications reported in the literature vary widely from 0% to 19% for extrusion of the titanium fixture and 8% to 61% for skin reactions—the two most common complications in both pediatric and adult populations.

Surgery is considered so simple and straightforward, however, that reports are surfacing of implantation being performed in the office setting under local anesthesia.

Surgery may be better performed under general anesthesia using a two-stage technique for children so that proper osseointegration can occur between stages, Hae-Ok Ana Kim, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. General anesthesia is recommended to allow for meticulous surgical technique in creating the skin flap and establishing hemostasis, and for the comfort of both the patient and the surgeon.

In a single-stage technique, both the titanium fixture and skin flap procedures are performed at the same time. In a two-stage technique, the titanium fixture is installed in the skull and covered by the overlying soft tissue until it has osseointegrated with the surrounding bone. Approximately 3–5 months later, stage two is performed in which the soft tissue surrounding the titanium fixture is debulked and the skin flap created.

The series included 37 patients with 47 implants who received bone-anchored implants at the University of Michigan in Ann Arbor between 1997 and 2004, according to the study performed by Dr. Kim, a neurotology/otology fellow, and senior author H. Alexander Arts, M.D., a neurotologist and professor of otorhinolaryngology and surgery at the university.

Patients ranged in age from 3 years to 80 years, with 26 adult and 11 pediatric patients.

The most common indications for implantation were hearing loss after acoustic neuroma surgery, otosclerosis, sudden idiopathic hearing loss in the single-sided deafness category, and congenital aural atresia in the conductive/mixed hearing loss category.

The most common early postoperative complication was granulation tissue around the abutment post requiring local wound care in 11 implants (23.4%), hypertrophic scarring in 5 implants (10.6%), and implant extrusion requiring wound revision in 3 (6.4%). Granulation tissue was more common in adults than children (9 vs. 2), and occurred anywhere from 1 week to 8 weeks postoperatively. The incidence did not vary by the type of skin flap used, but was more common with the single-stage technique.

All three cases of implant extrusion occurred with the 3-mm titanium fixture implanted in a single stage.

Both of the pediatric extrusions occurred in patients who had skull thickness less than 3 mm.

Patients with greater skull thickness were more likely to have skin graft complications.

Early postoperative granulation tissue around the abutment is the most common complication and requires wound care.

Hypertrophic scar growth over the abutment requires wound revision and occurred in 5 of 47 implants in one series. Photos courtesy Dr. Hae-Ok Ana Kim

LOS ANGELES — Bone-anchored hearing aid implantation may be better performed in two stages in children to reduce postoperative complications, a retrospective study suggests.

Postoperative complications reported in the literature vary widely from 0% to 19% for extrusion of the titanium fixture and 8% to 61% for skin reactions—the two most common complications in both pediatric and adult populations.

Surgery is considered so simple and straightforward, however, that reports are surfacing of implantation being performed in the office setting under local anesthesia.

Surgery may be better performed under general anesthesia using a two-stage technique for children so that proper osseointegration can occur between stages, Hae-Ok Ana Kim, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. General anesthesia is recommended to allow for meticulous surgical technique in creating the skin flap and establishing hemostasis, and for the comfort of both the patient and the surgeon.

In a single-stage technique, both the titanium fixture and skin flap procedures are performed at the same time. In a two-stage technique, the titanium fixture is installed in the skull and covered by the overlying soft tissue until it has osseointegrated with the surrounding bone. Approximately 3–5 months later, stage two is performed in which the soft tissue surrounding the titanium fixture is debulked and the skin flap created.

The series included 37 patients with 47 implants who received bone-anchored implants at the University of Michigan in Ann Arbor between 1997 and 2004, according to the study performed by Dr. Kim, a neurotology/otology fellow, and senior author H. Alexander Arts, M.D., a neurotologist and professor of otorhinolaryngology and surgery at the university.

Patients ranged in age from 3 years to 80 years, with 26 adult and 11 pediatric patients.

The most common indications for implantation were hearing loss after acoustic neuroma surgery, otosclerosis, sudden idiopathic hearing loss in the single-sided deafness category, and congenital aural atresia in the conductive/mixed hearing loss category.

The most common early postoperative complication was granulation tissue around the abutment post requiring local wound care in 11 implants (23.4%), hypertrophic scarring in 5 implants (10.6%), and implant extrusion requiring wound revision in 3 (6.4%). Granulation tissue was more common in adults than children (9 vs. 2), and occurred anywhere from 1 week to 8 weeks postoperatively. The incidence did not vary by the type of skin flap used, but was more common with the single-stage technique.

All three cases of implant extrusion occurred with the 3-mm titanium fixture implanted in a single stage.

Both of the pediatric extrusions occurred in patients who had skull thickness less than 3 mm.

Patients with greater skull thickness were more likely to have skin graft complications.

Early postoperative granulation tissue around the abutment is the most common complication and requires wound care.

Hypertrophic scar growth over the abutment requires wound revision and occurred in 5 of 47 implants in one series. Photos courtesy Dr. Hae-Ok Ana Kim

LOS ANGELES — Bone-anchored hearing aid implantation may be better performed in two stages in children to reduce postoperative complications, a retrospective study suggests.

Postoperative complications reported in the literature vary widely from 0% to 19% for extrusion of the titanium fixture and 8% to 61% for skin reactions—the two most common complications in both pediatric and adult populations.

Surgery is considered so simple and straightforward, however, that reports are surfacing of implantation being performed in the office setting under local anesthesia.

Surgery may be better performed under general anesthesia using a two-stage technique for children so that proper osseointegration can occur between stages, Hae-Ok Ana Kim, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. General anesthesia is recommended to allow for meticulous surgical technique in creating the skin flap and establishing hemostasis, and for the comfort of both the patient and the surgeon.

In a single-stage technique, both the titanium fixture and skin flap procedures are performed at the same time. In a two-stage technique, the titanium fixture is installed in the skull and covered by the overlying soft tissue until it has osseointegrated with the surrounding bone. Approximately 3–5 months later, stage two is performed in which the soft tissue surrounding the titanium fixture is debulked and the skin flap created.

The series included 37 patients with 47 implants who received bone-anchored implants at the University of Michigan in Ann Arbor between 1997 and 2004, according to the study performed by Dr. Kim, a neurotology/otology fellow, and senior author H. Alexander Arts, M.D., a neurotologist and professor of otorhinolaryngology and surgery at the university.

Patients ranged in age from 3 years to 80 years, with 26 adult and 11 pediatric patients.

The most common indications for implantation were hearing loss after acoustic neuroma surgery, otosclerosis, sudden idiopathic hearing loss in the single-sided deafness category, and congenital aural atresia in the conductive/mixed hearing loss category.

The most common early postoperative complication was granulation tissue around the abutment post requiring local wound care in 11 implants (23.4%), hypertrophic scarring in 5 implants (10.6%), and implant extrusion requiring wound revision in 3 (6.4%). Granulation tissue was more common in adults than children (9 vs. 2), and occurred anywhere from 1 week to 8 weeks postoperatively. The incidence did not vary by the type of skin flap used, but was more common with the single-stage technique.

All three cases of implant extrusion occurred with the 3-mm titanium fixture implanted in a single stage.

Both of the pediatric extrusions occurred in patients who had skull thickness less than 3 mm.

Patients with greater skull thickness were more likely to have skin graft complications.

Early postoperative granulation tissue around the abutment is the most common complication and requires wound care.

Hypertrophic scar growth over the abutment requires wound revision and occurred in 5 of 47 implants in one series. Photos courtesy Dr. Hae-Ok Ana Kim

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine vs. intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine vs. intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes.

Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18).

The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine vs. intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

“Routine reporting does not approximate volume,” said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. “There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes.”

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, laboratory investigations, and diagnostic imaging, while staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

A gene polymorphism of the phosphorylated glycoprotein, osteopontin, appears to be associated with the prognosis of oligoarticular-onset juvenile idiopathic arthritis, but more data are needed before it is considered a reliable disease marker.

Recently proposed to be a new proinflammatory cytokine, osteopontin plays a role in bone resorption and angiogenesis and is known to mediate a number of inflammatory mechanisms.

The current study, led by Renato Marciano, M.D., of the G. Gaslini Institute and the University of Genova, Italy, involved 73 patients with persistent oligoarticular-onset juvenile idiopathic arthritis (o-JIA) and 46 with extended o-JIA (Ann. Rheum. Dis. 2005; doi:10.1136/ard.2005.040626).

Patients were genotyped for the biallelic insertion/deletion variant at +245 in the first intron of the osteopontin gene, which the researchers had previously found to be in strict linkage with molecular variants in the osteopontin promoter region.

The TG polymorphism in the first intron was identified as allele 1, and the TGTG allele as allele 2. The presence of allele 2 was significantly higher (47/73 or 64%) in the persistent oligoarticular group, compared with patients with the extended form (20/46 or 43%), suggesting a dominant effect of the TGTG allele in o-JIA patients.

A gene polymorphism of the phosphorylated glycoprotein, osteopontin, appears to be associated with the prognosis of oligoarticular-onset juvenile idiopathic arthritis, but more data are needed before it is considered a reliable disease marker.

Recently proposed to be a new proinflammatory cytokine, osteopontin plays a role in bone resorption and angiogenesis and is known to mediate a number of inflammatory mechanisms.

The current study, led by Renato Marciano, M.D., of the G. Gaslini Institute and the University of Genova, Italy, involved 73 patients with persistent oligoarticular-onset juvenile idiopathic arthritis (o-JIA) and 46 with extended o-JIA (Ann. Rheum. Dis. 2005; doi:10.1136/ard.2005.040626).

Patients were genotyped for the biallelic insertion/deletion variant at +245 in the first intron of the osteopontin gene, which the researchers had previously found to be in strict linkage with molecular variants in the osteopontin promoter region.

The TG polymorphism in the first intron was identified as allele 1, and the TGTG allele as allele 2. The presence of allele 2 was significantly higher (47/73 or 64%) in the persistent oligoarticular group, compared with patients with the extended form (20/46 or 43%), suggesting a dominant effect of the TGTG allele in o-JIA patients.

A gene polymorphism of the phosphorylated glycoprotein, osteopontin, appears to be associated with the prognosis of oligoarticular-onset juvenile idiopathic arthritis, but more data are needed before it is considered a reliable disease marker.

Recently proposed to be a new proinflammatory cytokine, osteopontin plays a role in bone resorption and angiogenesis and is known to mediate a number of inflammatory mechanisms.

The current study, led by Renato Marciano, M.D., of the G. Gaslini Institute and the University of Genova, Italy, involved 73 patients with persistent oligoarticular-onset juvenile idiopathic arthritis (o-JIA) and 46 with extended o-JIA (Ann. Rheum. Dis. 2005; doi:10.1136/ard.2005.040626).

Patients were genotyped for the biallelic insertion/deletion variant at +245 in the first intron of the osteopontin gene, which the researchers had previously found to be in strict linkage with molecular variants in the osteopontin promoter region.

The TG polymorphism in the first intron was identified as allele 1, and the TGTG allele as allele 2. The presence of allele 2 was significantly higher (47/73 or 64%) in the persistent oligoarticular group, compared with patients with the extended form (20/46 or 43%), suggesting a dominant effect of the TGTG allele in o-JIA patients.