Sherry Boschert

SAN FRANCISCO — Giving high-dose nitroglycerin to patients with heart failure who come to the emergency department between midnight and 8 a.m. may shorten their length of stay by nearly a day, John R. Allegra, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

Nineteen patients treated by physicians who use high-dose nitroglycerin went home after a mean of 3.7 days in the hospital, compared with 4.6 mean days of hospitalization for 105 patients seen by emergency physicians who don't use high-dose nitroglycerin, said Dr. Allegra of Morristown (N.J.) Memorial Hospital. The difference of 0.9 days was statistically significant.

The retrospective analysis used data from a previous study which showed that patients arriving in the emergency department (ED) between midnight and 8 a.m. were more likely than patients arriving at other times to benefit from aggressive nitroglycerin therapy in the ED.

The investigators chose to study that time period because patients seen in the ED between midnight and 8 a.m. had the highest rates of intubation and mechanical ventilation, Dr. Allegra said in an interview. “If we were to see any effects of the nitroglycerin, it would be in those patients,” he explained.

The current analysis included patients seen in the ED during those hours over a 20-month period who were admitted for heart failure. To lessen the influence of statistical outliers on the results, the analysis excluded patients who spent more than 10 days in the hospital.

A prior survey on the treatment of heart failure in the hospital's ED asked physicians if they use nitroglycerin boluses to treat heart failure. Based on responses to that survey, investigators assigned patients in the current study to nitroglycerin or no-nitroglycerin groups depending on the treating ED physician.

Several previous studies have shown that high-dose nitroglycerin treatment decreased the incidence of death, myocardial infarction, and the use of mechanical ventilation in patients with heart failure.

The current data show that patients who arrive in the ED during the first 8 hours of the day spend almost 1 less day in the hospital if they receive nitroglycerine boluses in the ED, compared with patients who don't get nitroglycerin, Dr. Allegra said.

SAN FRANCISCO — Giving high-dose nitroglycerin to patients with heart failure who come to the emergency department between midnight and 8 a.m. may shorten their length of stay by nearly a day, John R. Allegra, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

Nineteen patients treated by physicians who use high-dose nitroglycerin went home after a mean of 3.7 days in the hospital, compared with 4.6 mean days of hospitalization for 105 patients seen by emergency physicians who don't use high-dose nitroglycerin, said Dr. Allegra of Morristown (N.J.) Memorial Hospital. The difference of 0.9 days was statistically significant.

The retrospective analysis used data from a previous study which showed that patients arriving in the emergency department (ED) between midnight and 8 a.m. were more likely than patients arriving at other times to benefit from aggressive nitroglycerin therapy in the ED.

The investigators chose to study that time period because patients seen in the ED between midnight and 8 a.m. had the highest rates of intubation and mechanical ventilation, Dr. Allegra said in an interview. “If we were to see any effects of the nitroglycerin, it would be in those patients,” he explained.

The current analysis included patients seen in the ED during those hours over a 20-month period who were admitted for heart failure. To lessen the influence of statistical outliers on the results, the analysis excluded patients who spent more than 10 days in the hospital.

A prior survey on the treatment of heart failure in the hospital's ED asked physicians if they use nitroglycerin boluses to treat heart failure. Based on responses to that survey, investigators assigned patients in the current study to nitroglycerin or no-nitroglycerin groups depending on the treating ED physician.

Several previous studies have shown that high-dose nitroglycerin treatment decreased the incidence of death, myocardial infarction, and the use of mechanical ventilation in patients with heart failure.

The current data show that patients who arrive in the ED during the first 8 hours of the day spend almost 1 less day in the hospital if they receive nitroglycerine boluses in the ED, compared with patients who don't get nitroglycerin, Dr. Allegra said.

SAN FRANCISCO — Giving high-dose nitroglycerin to patients with heart failure who come to the emergency department between midnight and 8 a.m. may shorten their length of stay by nearly a day, John R. Allegra, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

Nineteen patients treated by physicians who use high-dose nitroglycerin went home after a mean of 3.7 days in the hospital, compared with 4.6 mean days of hospitalization for 105 patients seen by emergency physicians who don't use high-dose nitroglycerin, said Dr. Allegra of Morristown (N.J.) Memorial Hospital. The difference of 0.9 days was statistically significant.

The retrospective analysis used data from a previous study which showed that patients arriving in the emergency department (ED) between midnight and 8 a.m. were more likely than patients arriving at other times to benefit from aggressive nitroglycerin therapy in the ED.

The investigators chose to study that time period because patients seen in the ED between midnight and 8 a.m. had the highest rates of intubation and mechanical ventilation, Dr. Allegra said in an interview. “If we were to see any effects of the nitroglycerin, it would be in those patients,” he explained.

The current analysis included patients seen in the ED during those hours over a 20-month period who were admitted for heart failure. To lessen the influence of statistical outliers on the results, the analysis excluded patients who spent more than 10 days in the hospital.

A prior survey on the treatment of heart failure in the hospital's ED asked physicians if they use nitroglycerin boluses to treat heart failure. Based on responses to that survey, investigators assigned patients in the current study to nitroglycerin or no-nitroglycerin groups depending on the treating ED physician.

Several previous studies have shown that high-dose nitroglycerin treatment decreased the incidence of death, myocardial infarction, and the use of mechanical ventilation in patients with heart failure.

The current data show that patients who arrive in the ED during the first 8 hours of the day spend almost 1 less day in the hospital if they receive nitroglycerine boluses in the ED, compared with patients who don't get nitroglycerin, Dr. Allegra said.

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%–90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%–20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levo-floxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levo-floxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%–90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%–20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levo-floxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levo-floxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%–90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%–20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levo-floxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levo-floxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

SAN FRANCISCO — Use of forceps or vacuum extractor during a vaginal delivery seldom is the sole cause of litigation, but you can reduce that risk even more, several speakers said at a conference on ob.gyn., perinatal medicine, neonatology, and the law.

Operative vaginal delivery can invite litigation when one of the following happens, according to Larry C. Gilstrap III, M.D., professor and chair of ob.gyn. and reproductive services at the University of Texas at Houston:

▸ Forceps or vacuum are used for an inappropriate indication, and the baby is damaged. Indications include a prolonged second stage of labor, fetal compromise, or a need to shorten the second stage for maternal health reasons. A prolonged second stage for nulliparous women is defined as 2 hours of labor, or 3 hours with regional anesthesia. In multiparous women, a prolonged second stage is 1 hour of labor, or 2 hours with regional anesthesia.

▸ Forceps or vacuum are used for convenience. Labor and delivery are going well, but the physician grabs the forceps or vacuum to speed things along to get to a party or a tee time. “That sounds kind of ridiculous, but I've been asked to look at [such] cases. You can't defend that case,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ The mother doesn't know what to expect. Inform her of the indications, the procedure, and what to expect, Dr. Gilstrap said. “The residents and nurses are amazed sometimes at how much time I take when I go up to the head of the table and I explain to the patient why I'm going to use forceps, for example.”

He shows the mother the instrument and describes how it is going to fit on the baby's cheek, not the top of the head. He explains that the forceps will make an indentation on the cheeks that may be coded as trauma by the pediatrician and emphasizes that it is not trauma and will go away.

“I explain to them that several of my daughters and several grandchildren were delivered by forceps,” he added.

“I think this is a problem of public perception,” agreed Dennis J. Sinclitico, J.D., in a commentary on Dr. Gilstrap's presentation. Many childbirth classes don't mention operative vaginal deliveries. Trying to educate the woman and obtain informed consent in the midst of a delivery is not an ideal situation. It is better to give the patient information about the potential for operative vaginal delivery before labor starts, said Mr. Sinclitico, who is a defense attorney in Long Beach, Calif.

▸ An inexperienced operator wields the forceps or vacuum. It is okay to have a resident perform the operative vaginal delivery as long as an experienced teacher is present, Dr. Gilstrap said.

With trends toward increased numbers of cesarean sections and fewer forceps deliveries over the last 2 decades, skill levels with forceps are dropping, Mr. Sinclitico added.

▸ Forceps or the vacuum are applied incorrectly. Forceps should be placed halfway between the eyes and ears and down on the face, not the skull, Dr. Gilstrap said. Position the center of a vacuum cup 3 cm from the posterior fontanel, which puts the leading part of the cup about 3 cm from the anterior fontanel.

▸ Precautions are inadequate. If the fetus has “considerable evidence of nonreassuring heart tones,” it may be appropriate to attempt forceps or vacuum delivery, but start setting up for a C-section at the same time, James S. Bostwick, J.D., advised in a separate commentary. Or move the patient to the operating room before trying the forceps or vacuum, said Mr. Bostwick, a plaintiff's attorney in San Francisco, Calif.

▸ There is inadequate documentation. A lack of a written description of what happened, and when, leads to reliance on potentially conflicting oral accounts by physicians, nurses, and the baby's parents.

Be sure to document why you acted as you did, Mr. Sinclitico stressed. “These cases are easier to defend when my client has done something and has exercised his or her clinical judgment” rather than standing by or waiting for something to happen, he said.

SAN FRANCISCO — Use of forceps or vacuum extractor during a vaginal delivery seldom is the sole cause of litigation, but you can reduce that risk even more, several speakers said at a conference on ob.gyn., perinatal medicine, neonatology, and the law.

Operative vaginal delivery can invite litigation when one of the following happens, according to Larry C. Gilstrap III, M.D., professor and chair of ob.gyn. and reproductive services at the University of Texas at Houston:

▸ Forceps or vacuum are used for an inappropriate indication, and the baby is damaged. Indications include a prolonged second stage of labor, fetal compromise, or a need to shorten the second stage for maternal health reasons. A prolonged second stage for nulliparous women is defined as 2 hours of labor, or 3 hours with regional anesthesia. In multiparous women, a prolonged second stage is 1 hour of labor, or 2 hours with regional anesthesia.

▸ Forceps or vacuum are used for convenience. Labor and delivery are going well, but the physician grabs the forceps or vacuum to speed things along to get to a party or a tee time. “That sounds kind of ridiculous, but I've been asked to look at [such] cases. You can't defend that case,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ The mother doesn't know what to expect. Inform her of the indications, the procedure, and what to expect, Dr. Gilstrap said. “The residents and nurses are amazed sometimes at how much time I take when I go up to the head of the table and I explain to the patient why I'm going to use forceps, for example.”

He shows the mother the instrument and describes how it is going to fit on the baby's cheek, not the top of the head. He explains that the forceps will make an indentation on the cheeks that may be coded as trauma by the pediatrician and emphasizes that it is not trauma and will go away.

“I explain to them that several of my daughters and several grandchildren were delivered by forceps,” he added.

“I think this is a problem of public perception,” agreed Dennis J. Sinclitico, J.D., in a commentary on Dr. Gilstrap's presentation. Many childbirth classes don't mention operative vaginal deliveries. Trying to educate the woman and obtain informed consent in the midst of a delivery is not an ideal situation. It is better to give the patient information about the potential for operative vaginal delivery before labor starts, said Mr. Sinclitico, who is a defense attorney in Long Beach, Calif.

▸ An inexperienced operator wields the forceps or vacuum. It is okay to have a resident perform the operative vaginal delivery as long as an experienced teacher is present, Dr. Gilstrap said.

With trends toward increased numbers of cesarean sections and fewer forceps deliveries over the last 2 decades, skill levels with forceps are dropping, Mr. Sinclitico added.

▸ Forceps or the vacuum are applied incorrectly. Forceps should be placed halfway between the eyes and ears and down on the face, not the skull, Dr. Gilstrap said. Position the center of a vacuum cup 3 cm from the posterior fontanel, which puts the leading part of the cup about 3 cm from the anterior fontanel.

▸ Precautions are inadequate. If the fetus has “considerable evidence of nonreassuring heart tones,” it may be appropriate to attempt forceps or vacuum delivery, but start setting up for a C-section at the same time, James S. Bostwick, J.D., advised in a separate commentary. Or move the patient to the operating room before trying the forceps or vacuum, said Mr. Bostwick, a plaintiff's attorney in San Francisco, Calif.

▸ There is inadequate documentation. A lack of a written description of what happened, and when, leads to reliance on potentially conflicting oral accounts by physicians, nurses, and the baby's parents.

Be sure to document why you acted as you did, Mr. Sinclitico stressed. “These cases are easier to defend when my client has done something and has exercised his or her clinical judgment” rather than standing by or waiting for something to happen, he said.

SAN FRANCISCO — Use of forceps or vacuum extractor during a vaginal delivery seldom is the sole cause of litigation, but you can reduce that risk even more, several speakers said at a conference on ob.gyn., perinatal medicine, neonatology, and the law.

Operative vaginal delivery can invite litigation when one of the following happens, according to Larry C. Gilstrap III, M.D., professor and chair of ob.gyn. and reproductive services at the University of Texas at Houston:

▸ Forceps or vacuum are used for an inappropriate indication, and the baby is damaged. Indications include a prolonged second stage of labor, fetal compromise, or a need to shorten the second stage for maternal health reasons. A prolonged second stage for nulliparous women is defined as 2 hours of labor, or 3 hours with regional anesthesia. In multiparous women, a prolonged second stage is 1 hour of labor, or 2 hours with regional anesthesia.

▸ Forceps or vacuum are used for convenience. Labor and delivery are going well, but the physician grabs the forceps or vacuum to speed things along to get to a party or a tee time. “That sounds kind of ridiculous, but I've been asked to look at [such] cases. You can't defend that case,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ The mother doesn't know what to expect. Inform her of the indications, the procedure, and what to expect, Dr. Gilstrap said. “The residents and nurses are amazed sometimes at how much time I take when I go up to the head of the table and I explain to the patient why I'm going to use forceps, for example.”

He shows the mother the instrument and describes how it is going to fit on the baby's cheek, not the top of the head. He explains that the forceps will make an indentation on the cheeks that may be coded as trauma by the pediatrician and emphasizes that it is not trauma and will go away.

“I explain to them that several of my daughters and several grandchildren were delivered by forceps,” he added.

“I think this is a problem of public perception,” agreed Dennis J. Sinclitico, J.D., in a commentary on Dr. Gilstrap's presentation. Many childbirth classes don't mention operative vaginal deliveries. Trying to educate the woman and obtain informed consent in the midst of a delivery is not an ideal situation. It is better to give the patient information about the potential for operative vaginal delivery before labor starts, said Mr. Sinclitico, who is a defense attorney in Long Beach, Calif.

▸ An inexperienced operator wields the forceps or vacuum. It is okay to have a resident perform the operative vaginal delivery as long as an experienced teacher is present, Dr. Gilstrap said.

With trends toward increased numbers of cesarean sections and fewer forceps deliveries over the last 2 decades, skill levels with forceps are dropping, Mr. Sinclitico added.

▸ Forceps or the vacuum are applied incorrectly. Forceps should be placed halfway between the eyes and ears and down on the face, not the skull, Dr. Gilstrap said. Position the center of a vacuum cup 3 cm from the posterior fontanel, which puts the leading part of the cup about 3 cm from the anterior fontanel.

▸ Precautions are inadequate. If the fetus has “considerable evidence of nonreassuring heart tones,” it may be appropriate to attempt forceps or vacuum delivery, but start setting up for a C-section at the same time, James S. Bostwick, J.D., advised in a separate commentary. Or move the patient to the operating room before trying the forceps or vacuum, said Mr. Bostwick, a plaintiff's attorney in San Francisco, Calif.

▸ There is inadequate documentation. A lack of a written description of what happened, and when, leads to reliance on potentially conflicting oral accounts by physicians, nurses, and the baby's parents.

Be sure to document why you acted as you did, Mr. Sinclitico stressed. “These cases are easier to defend when my client has done something and has exercised his or her clinical judgment” rather than standing by or waiting for something to happen, he said.

SAN FRANCISCO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., advised.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital protocol for Pitocin use, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it's not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin wasn't ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

SAN FRANCISCO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., advised.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital protocol for Pitocin use, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it's not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin wasn't ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

SAN FRANCISCO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., advised.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital protocol for Pitocin use, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it's not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin wasn't ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

SAN FRANCISCO — Seventeen children under the age of 6 who underwent occipital cervical fusion using transarticular screws showed normal growth and alignment of the spine an average of 28 months later, Richard C.E. Anderson, M.D., said at a meeting on pediatric neurologic surgery.

Children with atlantoaxial or occipitocervical instability often need surgery to stabilize the spine, but not much is known about the long-term effects of spinal fusion in children younger than 9 years, whose spines are still growing. Patients in this retrospective study averaged 5 years in age at the time of atlantoaxial (C1-C2) or occipitocervical fusion and have been followed for 13-54 months so far. The study compared plain radiographic and CT images taken immediately after surgery with images from both modalities taken at the most recent follow-up.

All patients fused successfully and maintained straight or lordotic spinal shapes, with most spines staying the same or evolving from straight to a lordotic curvature. One went from lordotic to straight, said Dr. Anderson of Columbia University, New York.

The degree of lordosis in a neutral position increased by 12 degrees, from 15 degrees postoperatively to 27 degrees, a nonsignificant increase that trended toward statistical significance, he said. Of the overall spinal growth, an average of approximately 34% occurred within the fusion construct, suggesting normal growth of the spine.

The follow-up imaging showed no kyphosis, osteophyte formation, or long-term instability. “Some previous papers have commented on an unusually high incidence of unintended fusion to adjacent spinal segments,” but this study found no evidence of this, he said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A subset analysis of five patients with longer follow-up—more than 48 months each—found similar results. These patients averaged 4 years in age at the time of surgery and were followed for a mean of 50 months.

The preliminary long-term results suggest that there's no increased risk for spinal deformity in children under age 6 undergoing C1-C2 or occipital-C2 fusion. Longer follow-up is needed until their spines reach maturity, and better CT data would be helpful, Dr. Anderson said.

“Really, we want to know how the spinal canal grows,” among other things, he said.

Lateral plain x-ray immediately after C1-C2 fusion (left). After 4 years and 28% vertical growth, there is no deformity to cervical alignment (right). Photos courtesy Dr. Richard C.E. Anderson

SAN FRANCISCO — Seventeen children under the age of 6 who underwent occipital cervical fusion using transarticular screws showed normal growth and alignment of the spine an average of 28 months later, Richard C.E. Anderson, M.D., said at a meeting on pediatric neurologic surgery.

Children with atlantoaxial or occipitocervical instability often need surgery to stabilize the spine, but not much is known about the long-term effects of spinal fusion in children younger than 9 years, whose spines are still growing. Patients in this retrospective study averaged 5 years in age at the time of atlantoaxial (C1-C2) or occipitocervical fusion and have been followed for 13-54 months so far. The study compared plain radiographic and CT images taken immediately after surgery with images from both modalities taken at the most recent follow-up.

All patients fused successfully and maintained straight or lordotic spinal shapes, with most spines staying the same or evolving from straight to a lordotic curvature. One went from lordotic to straight, said Dr. Anderson of Columbia University, New York.

The degree of lordosis in a neutral position increased by 12 degrees, from 15 degrees postoperatively to 27 degrees, a nonsignificant increase that trended toward statistical significance, he said. Of the overall spinal growth, an average of approximately 34% occurred within the fusion construct, suggesting normal growth of the spine.

The follow-up imaging showed no kyphosis, osteophyte formation, or long-term instability. “Some previous papers have commented on an unusually high incidence of unintended fusion to adjacent spinal segments,” but this study found no evidence of this, he said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A subset analysis of five patients with longer follow-up—more than 48 months each—found similar results. These patients averaged 4 years in age at the time of surgery and were followed for a mean of 50 months.

The preliminary long-term results suggest that there's no increased risk for spinal deformity in children under age 6 undergoing C1-C2 or occipital-C2 fusion. Longer follow-up is needed until their spines reach maturity, and better CT data would be helpful, Dr. Anderson said.

“Really, we want to know how the spinal canal grows,” among other things, he said.

Lateral plain x-ray immediately after C1-C2 fusion (left). After 4 years and 28% vertical growth, there is no deformity to cervical alignment (right). Photos courtesy Dr. Richard C.E. Anderson

SAN FRANCISCO — Seventeen children under the age of 6 who underwent occipital cervical fusion using transarticular screws showed normal growth and alignment of the spine an average of 28 months later, Richard C.E. Anderson, M.D., said at a meeting on pediatric neurologic surgery.

Children with atlantoaxial or occipitocervical instability often need surgery to stabilize the spine, but not much is known about the long-term effects of spinal fusion in children younger than 9 years, whose spines are still growing. Patients in this retrospective study averaged 5 years in age at the time of atlantoaxial (C1-C2) or occipitocervical fusion and have been followed for 13-54 months so far. The study compared plain radiographic and CT images taken immediately after surgery with images from both modalities taken at the most recent follow-up.

All patients fused successfully and maintained straight or lordotic spinal shapes, with most spines staying the same or evolving from straight to a lordotic curvature. One went from lordotic to straight, said Dr. Anderson of Columbia University, New York.

The degree of lordosis in a neutral position increased by 12 degrees, from 15 degrees postoperatively to 27 degrees, a nonsignificant increase that trended toward statistical significance, he said. Of the overall spinal growth, an average of approximately 34% occurred within the fusion construct, suggesting normal growth of the spine.

The follow-up imaging showed no kyphosis, osteophyte formation, or long-term instability. “Some previous papers have commented on an unusually high incidence of unintended fusion to adjacent spinal segments,” but this study found no evidence of this, he said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

A subset analysis of five patients with longer follow-up—more than 48 months each—found similar results. These patients averaged 4 years in age at the time of surgery and were followed for a mean of 50 months.

The preliminary long-term results suggest that there's no increased risk for spinal deformity in children under age 6 undergoing C1-C2 or occipital-C2 fusion. Longer follow-up is needed until their spines reach maturity, and better CT data would be helpful, Dr. Anderson said.

“Really, we want to know how the spinal canal grows,” among other things, he said.

Lateral plain x-ray immediately after C1-C2 fusion (left). After 4 years and 28% vertical growth, there is no deformity to cervical alignment (right). Photos courtesy Dr. Richard C.E. Anderson

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation. Nine patients had more than one herniated disk.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires completed an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to the findings of an informal comparison with patients in the literature who were treated prior to the era of microsurgery and MRI.

Children in the current study were more likely to present with low back pain, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Approximately 1%-3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation. Nine patients had more than one herniated disk.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires completed an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to the findings of an informal comparison with patients in the literature who were treated prior to the era of microsurgery and MRI.

Children in the current study were more likely to present with low back pain, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Approximately 1%-3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation. Nine patients had more than one herniated disk.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires completed an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to the findings of an informal comparison with patients in the literature who were treated prior to the era of microsurgery and MRI.

Children in the current study were more likely to present with low back pain, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Approximately 1%-3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four.

“Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

They rated the EHR impact on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the participating physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after the implementation of EHR.

Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four.

“Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

They rated the EHR impact on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the participating physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after the implementation of EHR.

Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four.

“Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

They rated the EHR impact on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the participating physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after the implementation of EHR.

Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. Nine patients had more than one herniated disk.

The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to an informal comparison with patients in the literature who were treated prior to the era of microsurgery.

Children in the current study were more likely to complain of low back pain at presentation, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Disk disease is uncommon in children. Approximately 1%–3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. Nine patients had more than one herniated disk.

The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to an informal comparison with patients in the literature who were treated prior to the era of microsurgery.

Children in the current study were more likely to complain of low back pain at presentation, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Disk disease is uncommon in children. Approximately 1%–3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — Children with herniated spinal disks fared better after microdiskectomy, compared with conservative management, in a study of 52 patients treated from 2000 to 2004.

The series is not the largest in the medical literature, but it is the only one to include pediatric diskectomies performed solely in the era of microsurgery and MRI, Kevin L. Stevenson, M.D., said at a meeting on pediatric neurologic surgery.

Physicians' decisions about management of children with disk herniation “are often based on literature that's 40-plus years old,” Dr. Stevenson said at the meeting, jointly sponsored by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

In collaboration with his colleagues at Children's Healthcare of Atlanta at Scottish Rite, Dr. Stevenson reviewed the charts of all children seen for disk herniation at the center during the study period and obtained further follow-up information by phone interviews. All patients underwent 7 weeks of conservative management, defined as a complete cessation of strenuous activity, ongoing NSAID therapy, and a course of physical therapy after the initial disk flare-up. Nine patients had more than one herniated disk.

The study excluded patients with only a disk bulge. The study's 52 patients had 62 herniated disks—1 in the cervical spine, 2 in the thoracic spine, and 59 in the lumbar spine. The injuries comprised 39 central herniations, 22 lateral herniations, and 1 far lateral herniation.

Conservative management continued in 28 patients. The other 24 had surgery, consisting of 37 unilateral laminotomies and microdiskectomies, 1 complete laminectomy, 1 thoracotomy, and 5 multilevel laminectomies.

Telephone questionnaires an average of 38 months after presentation found that none of 19 patients in the surgery group who originally complained of radiculopathy had an active radiculopathy at follow-up. Of 20 control group patients, 8 with initial radiculopathies had active disease at follow-up, said Dr. Stevenson.

Of 22 patients in the surgical group who originally complained of back pain, 2 reported at follow-up that they had back pain only upon exertion. In the control group, all 28 patients complained of back pain at presentation, and the pain persisted in 16 patients at follow-up, with approximately one-third of these reporting pain only upon exertion.

Objective neurologic deficits found at presentation in 12 patients in the surgical group and 6 in the control group persisted in the control patients at follow-up but had cleared in the surgical group. Dr. Stevenson noted that the modern surgical cohort had fewer symptoms and were more likely to show improved function, according to an informal comparison with patients in the literature who were treated prior to the era of microsurgery.

Children in the current study were more likely to complain of low back pain at presentation, compared with those in the literature (92% vs. 86%). The modern surgery was more successful at eliminating radiculopathies, compared with reports of conservative management outcomes in the literature (100% vs. 89%). The average hospitalization stay after surgery fell from 4 days for cases in the literature to 2 days for the modern cohort.

Patients in the modern cohort had fewer complications, returned to school quicker, and were less likely to need reoperation, compared with patients in the literature, Dr. Stevenson added.

“The existing literature does not appear to accurately reflect modern surgical outcomes after pediatric diskectomy. In carefully selected patients, it's a safe and effective treatment for pediatric disk disease after failed conservative management,” he said.

Disk disease is uncommon in children. Approximately 1%–3% of diskectomies each year are done in children. In adults, an estimated 85% of disk herniations improve with conservative management.

SAN FRANCISCO — A child with fever of unexplained origin and an abscess in the right thigh ultimately was diagnosed with systemic juvenile idiopathic arthritis after tests showed the abscess was sterile, Sara Fitzpatrick said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

The English medical literature contains no previous reports of systemic juvenile idiopathic arthritis (JIA) presenting with a sterile abscess, said Ms. Fitzpatrick, who worked on the report with Elizabeth C. Chalom, M.D., director of pediatric rheumatology, and other associates at St. Barnabas Medical Center, Livingston, N.J.

The most common cause of fever of unknown origin in childhood is infection, she noted, and the abscess and other findings initially misled clinicians into thinking that was the case with this child.

The 21-month-old boy entered the hospital with a 3-week history of spiking diurnal fevers ranging from 101.7° to 104.5° F. He was alert but irritable and refused to walk. His past history was unremarkable, he had not traveled, and his immunizations were up to date.

Physical exam findings were normal except for shoddy inguinal lymphadenopathy bilaterally, mild synovitis bilaterally in the ankles, slightly decreased extension of the left wrist, and pain with motion of the left ankle or wrist. He had a faint macular rash over his chest,

MRI of both ankles showed mild effusion with no significant synovial thickening. Bone marrow aspiration results suggested an acute inflammatory process. Clinicians could find no neoplastic lesions. A gallium scan showed increased uptake in the right distal thigh above the knee joint.

A multicystic, loculated lesion consistent with a formed abscess was seen on an MRI of the thigh. Physicians opened and drained the abscess, and the child was treated with antibiotics.

The abscess exudates were negative on Gram stain, culture, and acid-fast stain. The pathology specimen was consistent with a simple abscess and reactive inflammation in the muscle and periosteum. There was no direct evidence of infection in either the bone or muscle.

Despite extensive antibiotic therapy, the child continued to spike fevers up to 104°F. Viral studies and tuberculosis tests were negative. The persistent fevers, lack of an infectious process, and evidence of joint involvement led clinicians to consider systemic JIA more closely. The child's serum ferritin level increased from 500 ng/mL to 1,583 ng/mL; markedly elevated serum ferritin is a common finding in systemic JIA.

When physicians started the NSAID naproxen (Naprosyn), the fevers decreased to around 101°F. Subsequent steroid treatment significantly reduced symptoms, and the fevers resolved. A repeat gallium scan showed mild residual uptake in the right thigh and periosteum, and symmetrical uptake in both ankles. Repeat surgical exploration of the abscess found reaccumulation of purulent material.

The patient went home with a diagnosis of systemic JIA and a lower regimen of steroids, and the fevers returned. He currently is being treated with methotrexate and a weaning dose of prednisone.

MRI showed a multicystic, loculated lesion along the left side of the bone that was consistent with a formed abscess. The exudates were negative for infection. Photos courtesy Dr. Elizabeth C. Chalom

SAN FRANCISCO — A child with fever of unexplained origin and an abscess in the right thigh ultimately was diagnosed with systemic juvenile idiopathic arthritis after tests showed the abscess was sterile, Sara Fitzpatrick said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

The English medical literature contains no previous reports of systemic juvenile idiopathic arthritis (JIA) presenting with a sterile abscess, said Ms. Fitzpatrick, who worked on the report with Elizabeth C. Chalom, M.D., director of pediatric rheumatology, and other associates at St. Barnabas Medical Center, Livingston, N.J.

The most common cause of fever of unknown origin in childhood is infection, she noted, and the abscess and other findings initially misled clinicians into thinking that was the case with this child.

The 21-month-old boy entered the hospital with a 3-week history of spiking diurnal fevers ranging from 101.7° to 104.5° F. He was alert but irritable and refused to walk. His past history was unremarkable, he had not traveled, and his immunizations were up to date.

Physical exam findings were normal except for shoddy inguinal lymphadenopathy bilaterally, mild synovitis bilaterally in the ankles, slightly decreased extension of the left wrist, and pain with motion of the left ankle or wrist. He had a faint macular rash over his chest,

MRI of both ankles showed mild effusion with no significant synovial thickening. Bone marrow aspiration results suggested an acute inflammatory process. Clinicians could find no neoplastic lesions. A gallium scan showed increased uptake in the right distal thigh above the knee joint.

A multicystic, loculated lesion consistent with a formed abscess was seen on an MRI of the thigh. Physicians opened and drained the abscess, and the child was treated with antibiotics.

The abscess exudates were negative on Gram stain, culture, and acid-fast stain. The pathology specimen was consistent with a simple abscess and reactive inflammation in the muscle and periosteum. There was no direct evidence of infection in either the bone or muscle.

Despite extensive antibiotic therapy, the child continued to spike fevers up to 104°F. Viral studies and tuberculosis tests were negative. The persistent fevers, lack of an infectious process, and evidence of joint involvement led clinicians to consider systemic JIA more closely. The child's serum ferritin level increased from 500 ng/mL to 1,583 ng/mL; markedly elevated serum ferritin is a common finding in systemic JIA.

When physicians started the NSAID naproxen (Naprosyn), the fevers decreased to around 101°F. Subsequent steroid treatment significantly reduced symptoms, and the fevers resolved. A repeat gallium scan showed mild residual uptake in the right thigh and periosteum, and symmetrical uptake in both ankles. Repeat surgical exploration of the abscess found reaccumulation of purulent material.

The patient went home with a diagnosis of systemic JIA and a lower regimen of steroids, and the fevers returned. He currently is being treated with methotrexate and a weaning dose of prednisone.

MRI showed a multicystic, loculated lesion along the left side of the bone that was consistent with a formed abscess. The exudates were negative for infection. Photos courtesy Dr. Elizabeth C. Chalom

SAN FRANCISCO — A child with fever of unexplained origin and an abscess in the right thigh ultimately was diagnosed with systemic juvenile idiopathic arthritis after tests showed the abscess was sterile, Sara Fitzpatrick said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

The English medical literature contains no previous reports of systemic juvenile idiopathic arthritis (JIA) presenting with a sterile abscess, said Ms. Fitzpatrick, who worked on the report with Elizabeth C. Chalom, M.D., director of pediatric rheumatology, and other associates at St. Barnabas Medical Center, Livingston, N.J.

The most common cause of fever of unknown origin in childhood is infection, she noted, and the abscess and other findings initially misled clinicians into thinking that was the case with this child.

The 21-month-old boy entered the hospital with a 3-week history of spiking diurnal fevers ranging from 101.7° to 104.5° F. He was alert but irritable and refused to walk. His past history was unremarkable, he had not traveled, and his immunizations were up to date.

Physical exam findings were normal except for shoddy inguinal lymphadenopathy bilaterally, mild synovitis bilaterally in the ankles, slightly decreased extension of the left wrist, and pain with motion of the left ankle or wrist. He had a faint macular rash over his chest,

MRI of both ankles showed mild effusion with no significant synovial thickening. Bone marrow aspiration results suggested an acute inflammatory process. Clinicians could find no neoplastic lesions. A gallium scan showed increased uptake in the right distal thigh above the knee joint.

A multicystic, loculated lesion consistent with a formed abscess was seen on an MRI of the thigh. Physicians opened and drained the abscess, and the child was treated with antibiotics.

The abscess exudates were negative on Gram stain, culture, and acid-fast stain. The pathology specimen was consistent with a simple abscess and reactive inflammation in the muscle and periosteum. There was no direct evidence of infection in either the bone or muscle.

Despite extensive antibiotic therapy, the child continued to spike fevers up to 104°F. Viral studies and tuberculosis tests were negative. The persistent fevers, lack of an infectious process, and evidence of joint involvement led clinicians to consider systemic JIA more closely. The child's serum ferritin level increased from 500 ng/mL to 1,583 ng/mL; markedly elevated serum ferritin is a common finding in systemic JIA.

When physicians started the NSAID naproxen (Naprosyn), the fevers decreased to around 101°F. Subsequent steroid treatment significantly reduced symptoms, and the fevers resolved. A repeat gallium scan showed mild residual uptake in the right thigh and periosteum, and symmetrical uptake in both ankles. Repeat surgical exploration of the abscess found reaccumulation of purulent material.

The patient went home with a diagnosis of systemic JIA and a lower regimen of steroids, and the fevers returned. He currently is being treated with methotrexate and a weaning dose of prednisone.

MRI showed a multicystic, loculated lesion along the left side of the bone that was consistent with a formed abscess. The exudates were negative for infection. Photos courtesy Dr. Elizabeth C. Chalom