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Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

Pediatricians can play an essential role in diagnosis, counseling, and management of atopic eczema. Your decision to treat these children and adolescents in your practice largely depends on your comfort level and the progression of their condition over time. In general, referral to a dermatology colleague is not warranted unless you are unsure about some aspect of the condition, or the eczema fails to improve.

To diagnose atopic eczema, look for the telltale signs, especially the cracking and fissuring of the skin on the flexural folds of the arms and legs. Besides the flexural areas of arms and legs, atopic eczema often presents on the cheeks, but can manifest anywhere on the body.

Counseling is paramount because eczema is not an individual patient disease; it affects the entire family. Parents must spend an inordinate amount of time taking care of the affected child, thereby reducing time with siblings. In addition, the condition is very, very itchy. The extreme pruritus that characterizes atopic eczema often keeps the child and parent awake at night, which can, in turn, negatively affect the next day for children at school and parents at work.

Provide information on eczema to educate everyone in the family, extended family, and anyone who participates in the child’s care. From the outset, they need to understand that optimal outcome will require a long-term commitment. Atopic eczema needs to be managed and controlled for years because there is no magic bullet or cure.

Realistic expectations, therefore, are important. I tell families that I do not want "perfection to be the enemy of very good." An acceptable goal, for example, is a child who still has minor areas of involvement that do not interfere with the child’s or the family’s normal activities.

The good news is that the majority of eczema patients will improve over time. For young children, this can take many years, usually into adolescence. Even so, I explain that the child’s skin will always be more sensitive than the skin of an unaffected person.

When I speak with a parent who is learning for the first time that their child has atopic eczema, I say that it’s as if your child were having "asthma of the skin." Most parents can relate because either they or someone in the family has asthma. The analogy also works because symptoms will wax and wane, certain triggers can worsen the eczema, and there is a shared genetic etiology. When the genes are expressed in the lungs, asthma is the result; when the genes are expressed in the nasal passages, we call it hay fever or allergic rhinitis; and when the genes manifest in the skin, we call it atopic eczema. Some children have a combination of these disorders.

Stress the importance of keeping the skin hydrated to minimize flare-ups. I recommend liberal application of a moisturizing emollient twice daily, including immediately following once-daily bathing. Instruct patients to dry themselves gently with a cotton towel. Parents often ask how much moisturizer to apply. Sometimes I jokingly tell parents that if they give their child a hug and the child has is covered with so much moisturizing cream that she squirts up out of the parent’s arms, then enough moisturizer has been applied.

This regimen also can help repair the skin barrier to optimize control of the atopic eczema. I recommend use of a newer emollient cream rich in lipids and ceramides, such as Coria Laboratories’ CeraVe. I also suggest nondetergent cleansers like Pharmaceutical Specialties’ Vanicream cleansing bar, Galderma’s Cetaphil, Unilever’s Dove cleanser, and the like. These products cleanse without harsh detergents that take away the skin’s natural moisturizing oils.

Winter can be a particularly challenging time for eczema patients because of illness and dry skin. Although a meticulous skin care program is always important, it is especially so when the child is fighting an upper respiratory infection or other illness because it can help prevent a tremendous flare in the atopic eczema.

Maintenance of skin hydration also decreases the ability of protease enzymes (produced by bacteria in the skin) to enter the microcracks and fissures and exacerbate the eczema. In more severe presentations, consider an anti-Staphylococcus antibiotic such as Keflex for 7-10 days to decrease the bacterial skin load.

A dilute bleach bath once a week also can help decrease this bacterial load and prevent flare-ups. Emphasize that only a small amount of bleach (add 1/8 cup to a full bath) is necessary; it should not smell as strong as a swimming pool. On the same day, bed linens and pajamas should be washed with bleach as well.

You as a pediatrician can help to dispel an overemphasis on food and other allergens as eczema triggers. Instruct parents that if they notice a consistent flare-up after certain exposures, these may be triggers for their child’s eczema My philosophy is to "test and adjust," but not to eliminate things across the board just because families read on the Internet that a food or substance causes atopic eczema. In my experience, fewer than 20% of patients with atopic eczema actually have true allergies and/or triggers for their condition. I also provide a prescription for a mild (group VI) steroid and moderate (group IV) steroid to use twice daily for 7 days with mild and moderate flare-ups.

Additional resources on atopic eczema are available online from the American Academy of Dermatology (www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis). I also have a video on my website called "Power Over Eczema." I encourage the patient’s parents to watch this video and to show it to anyone involved in the care of the child, including older siblings, nannies, babysitters, and grandparents.

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

The American College of Physicians Foundation (ACPF) has unveiled a quartet of new interventions aimed at improving care of atrial fibrillation (Afib) and stroke prevention.

Hospitalists are a core constituency for the tools, says Doron Schneider, MD, FACP, co-chair of the foundation's Initiative on Atrial Fibrillation and Stroke Prevention and medical director of the Center for Patient Safety and Healthcare Quality at Abington (Pa.) Health System.

"Atrial fibrillation is so common that the hospitalist is going to see it as primary diagnosis ... or as a background condition presenting with cellulitis and other conditions," Dr. Schneider says. "We want them to look at every patient, and if they have Afib, you don't want to treat the cellulitis and not treat the Afib because the Afib is not presenting. We want them to take a holistic approach."

The interventions are:

• A 20-page booklet for patients and caregivers titled “Afib: What You and Your Family Should Know.” The idea is to empower patients and their supporters with basic knowledge on how to live with their condition.
• Three patient education videos that cover basic facts, medication issues, and post-discharge tips for living a healthier lifestyle.
• A one-page physician support worksheet to help hospitalists and other physicians assess stroke risk and calculate outpatient bleeding risk.
• A guidebook on how to incorporate ACPF and other interventions into a hospital system’s practices.

Dr. Schneider adds that for "real and sustained change in quality initiatives," physicians need to improve all parts of a problem. “If you don't have systems redesigned to allow for education to be delivered or to get content to doctors, it's never going to happen," he says. "A lot of material is produced in the world that never gets to the bedside."

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: To what extent does diagnostic phlebotomy contribute to hospital-acquired anemia (HAA) during acute myocardial infarction (AMI)?

Background: During AMI, hospital-acquired HAA is associated with higher mortality and poorer health status. Moderate to severe HAA (nadir hemoglobin level <11 g/dL) has been shown to be prognostically important. The contribution of diagnostic phlebotomy blood loss on HAA is unknown and is a potentially modifiable factor.

Study design: Retrospective observational cohort study.

Setting: Fifty-seven U.S. hospitals.

Synopsis: Using Cerner Corp.'s Health Facts database, information was collected on 17,676 patients with AMI. Moderate to severe HAA developed in 3,551 (20%) patients who were not anemic upon admission. The diagnostic blood loss was estimated by assuming minimal blood volume per adult tube required to perform the lab work obtained. The mean phlebotomy volume was higher in patients with HAA compared with patients without HAA (173.8 mL vs. 83.5 mL; P<0.001). There was significant variation of diagnostic blood loss between hospitals. The risk of HAA increased by 18% (RR 1.18; 95% CI, 1.13-1.22) for every 50 mL of diagnostic blood loss.

Patients with HAA were noted to have greater disease severity and comorbidities. No causal inference can be made given the observational nature of the study. Randomized trials are needed to evaluate if strategies to reduce diagnostic blood loss can reduce HAA and improve clinical outcomes for patients with AMI.

Bottom line: Diagnostic blood loss is associated with development of hospital-acquired anemia in patients with acute myocardial infarction.

Citation: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011;171:1646-1653.

For more physician reviews of HM-relevant research, visit our website.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

These are hard times for the United States. Our economy is floundering. Unemployment is high. Bankers and financiers seem to be getting away with immoral and even illegal actions. People are disgruntled and dissatisfied. Our government seems to be unable or unwilling to right the obvious wrongs or to get us out of the morass. There is general malaise.

I believe there is a common thread that underlies our present situation. It is the overarching attitude that behavior in our society is primarily determined by the WIIFM principle or ‘What’s in it for me’.

Let us look at some specific examples. Elected politicians in the executive and legislative branches of our federal government should make decisions on the basis of what is best for society and our country. Unfortunately this consideration is a minor motivation.

Uniformly our President and Congress do what is most likely to get themselves re-elected, i.e., what is best for them personally, not what is best for our country. They are constantly campaigning rather than governing. As a result, actions to support entrepreneurship and private job creation are not taken, and class warfare is encouraged because more votes will be gained than lost.

Attorneys who block tort reform are another example of the WIIFM principle. They must know that the present system is imperfect and costing our society billions of dollars, at least some of which are unjustified. Yet they spend millions supporting the re-election campaigns of legislators to block even a wisp of reform. Both the attorneys and the legislators who are influenced by this legal form of bribery are clearly guided by WIIFM. Society pays and suffers.

Similarly, bankers and others in the financial community, known collectively as Wall Street, guided by the WIIFM principle expend great efforts to preserve a system riddled with opaque derivative securities and other practices which benefit a few clever manipulators and harm our financial system and our society. Financial donations to politicians, again legalized bribery, and unfair executive compensation help to sustain a system in which rewards are far in excess of the value contributed to society.

Labor unions and their leaders are also substantially motivated by WIIFM. Otherwise they might compromise on demands to preserve unsustainable pension and benefit systems that are bankrupting our state and federal governments. The promise of votes and again contribution-associated influence over elected leaders are part of the toxic mix. Once again WIIFM triumphs over what is good for our overall economy and our country. The effort to close the job-creating Boeing plant in South Carolina and the pension preserving battles in Wisconsin and Ohio are glaring examples of the evils of WIIFM.

So also are the efforts of some to block any tax increase. If government waste, spending excesses, and unfair tax loopholes can be sharply diminished, reasonable tax increases can be considered part of a shared sacrifice for the common good of deficit reduction. All must acknowledge that our economic problems can only be solved by the compromise of such shared sacrifice. We will be better off in the long run and so will our progeny.

Physicians can also be motivated by the WIIFM principle. There is the temptation to maintain diminishing incomes at all costs – even by performing procedures that may not be fully indicated or justified, or by spending less than adequate time with individual patients. Our health care system is imperfect in many ways, but physicians too must resist the urge to be guided predominantly by WIIFM.

Finally there is the public at large. Are we guided in our voting by short-term WIIFM? Should we vote for the candidate who will lower our personal taxes the most in the next few years? Or should we vote for the individual who we believe will act in the best interests of our country at-large and its future long-term well-being?

We must all recognize the intrinsic dangers of being motivated excessively by WIIFM. Our country cannot survive and prosper if everyone pursues that motivation. We do not have the resources to do so. We must all display some of the courage, restraint, and spirit of compromise of our forefathers who took huge political and physical risks to found our country. They were motivated by a desire to do what was best for the country at large, to work for the greater good, to do what was right for the whole society. It often required self-denial, shared sacrifice, compromise, altruism, and the responsibility to act for the common good. The WIIFM principle had to be suppressed. The result was a United States of unparalleled greatness.

Today we are drifting away from that greatness. Aside from our military and a few other rare exceptions, the WIIFM principle seems to underlie that drift. Although some self-interest is acceptable and part of the human nature, we must all resist the temptation to make that our predominant motivation. Otherwise our country will decline, and we are doomed to failure.

Clearly, this recognition and movement away from WIIFM, this ‘me-first attitude’, this idea of ‘let someone else sacrifice’ should begin with our key political leaders. They must find the courage to do what is right for our country, and give up their WIIFM motivation of acting solely to get re-elected. If they can start the ball rolling in the right direction, surely other segments of society and indeed all of us should be able to follow.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is also an associate medical editor for Vascular Specialist.

The ideas and opinions expresssed in Vascular Specialist do not necessarily reflect those of the Society or the Publisher.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.

ORLANDO – The ACE inhibitor ramipril boosted both walking ability and quality of life in patients with peripheral arterial disease in a double-blind, randomized trial.

"The magnitude of these effects is greater than that reported for conventional medical therapies," Dr. Anna A. Ahimastos observed when presenting the study findings at the annual meeting of the American Heart Association.

She reported on 343 patients with peripheral arterial disease (PAD) who were randomized to 24 weeks of ramipril at 10 mg once daily or placebo. They averaged 65 years of age, 80% were men, the baseline ankle-brachial index was 0.56, and 36% had diabetes.

At 24 weeks, the average pain-free walking time (PFWT) in the ramipril group had increased by 87%, compared with a baseline of 131 seconds. The maximum walk time (MWT) improved by 139% from a baseline of 229 seconds. This corresponded to a clinically meaningful 172-meter increase in walking distance on a standardized treadmill test conducted at a speed of 3.2 km/hr and a 12% gradient, according to Dr. Ahimastos of the Baker IDI Heart and Diabetes Institute at Alfred Hospital in Melbourne. In contrast, both PFWT and MWT decreased modestly over the course of 24 weeks in the control group.

A finding of particular importance in this impaired population was the documented improvement in quality of life that accompanied 24 weeks of ramipril, she continued. Daily functional capacity as measured by the WIQ (Walking Impairment Questionnaire) score domains of walking distance, speed, and stair climbing improved by 184%-213%. Scores on the SF-36 (36-Item Short Form) physical function component showed a significant 7% improvement from a baseline average of 38.5.

Results of this study are consistent with those of an earlier randomized, double-blind pilot study that Dr. Ahimastos and coworkers conducted in 40 patients (Ann. Intern. Med. 2006;144:660-4).

The pilot study showed average gains of 164% in PFWT and 243% in MWT with 24 weeks of ramipril, a magnitude of benefit roughly twice that seen in the new, much larger trial. This is probably because the pilot study employed quite restrictive inclusion criteria, whereas the new study included a broader spectrum of PAD patients, including those with diabetes and with aortoiliac or infrainguinal disease.

Outcomes in the two randomized trials of ramipril for PAD – gains of 87%-164% in PFWT and 139%-243% in MWT – compare favorably with the results of placebo-controlled studies of conventional therapies. The phosphodiesterase-3 inhibitor cilostazol has shown 32%-82% improvements in PFWT and MWT. Pentoxifylline, another phosphodiesterase inhibitor, produced a 12% gain in MWT. And exercise training has shown a 150% improvement in both MWT and PFWT. However, the compliance rate with exercise is quite low in the PAD population, she noted.

Audience members who have grown accustomed to negative clinical trials being reported for PAD were enthusiastic at the prospect of finally gaining an additional effective medical therapy for this difficult condition. And they were curious as to Dr. Ahimastos’s thoughts on the mechanism of benefit.

She replied that at this point she can only speculate, since clinical trials don’t provide answers regarding mechanisms and the data from the new study were unblinded only the week prior to her presentation. She noted that ACE inhibitors have antiangiogenic and vasodilatory effects. The enhanced nitric oxide release and the drugs’ effects on bradykinin might also be relevant.

The improvement in walking doesn’t appear to stem from ramipril’s blood pressure–lowering effect, however, as the blood pressure reductions were minimal – less than 3 mm Hg in both systolic and diastolic blood pressure – and the degree of blood pressure reduction in individual patients didn’t correlate with their magnitude of walking improvement.

She and her colleagues don’t know whether angiotensin-receptor blockers would have similar clinical benefits on walking in PAD patients. That will prove difficult to study. For ethical reasons, future clinical trials are unlikely, as there is now evidence-based agreement among experts that patients with PAD should be on an ACE inhibitor or ARB anyway for cardiovascular protection.

The study was funded by Australia’s National Heart Foundation. Dr. Ahimastos declared having no financial conflicts.

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Welcome to the debut of the EHR Report Podcast!

Starting this month, the authors of the EHR Report column, Dr. Neil Skolnik and Dr. Chris Notte, will deliver even more of their EHR know-how via their new podcast. Tune in regularly for candid analyses of EHR strategies, advanced tips on best practices, and one-on-one interviews with innovators in the field of EHRs.

In this, the first of a two-part series, Dr. Skolnik and Dr. Notte offer listeners an in-depth discussion of exactly what it takes for physicians to achieve meaningful use of their electronic health records software and earn federal incentives.

To download the podcast, click here.

To read the related column, click here.

To listen via this Web page, click on the player below:

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic

Julie Totten was 24 years old when her brother Mark took his life. Shortly after, she helped her father, who had been suffering from undiagnosed depression all his life, get treated for the illness. In dealing with the depression that afflicted her father and brother, she felt alone, lost, and responsible. She thought there must be a lot of other families like hers.

So, 10 years after Mark’s death, Julie founded Families for Depression Awareness, a nonprofit organization to help families, including family caregivers like her, recognize and cope with depressive disorders to get people well and prevent suicides. The organization’s website, helps families recognize and cope with depression, and focuses on getting people into treatment to prevent suicide.

Dr. Bill Beardslee, chairman of psychiatry at Children’s Hospital Boston, lost an older sister to suicide when he was in medical school. "The depression took her over and after a valiant struggle against it, she took her own life some years later.

"It has taken me many years to deal with that and many conversations with my father, my mother and my wife, my friends, and, more recently, my children. Above all, it has given me a sense of how awful this illness can be for families," he wrote on the Hachette Book Group website. In his book, Out of the Darkened Room (New York: Little, Brown & Co., 2002), he describes the experiences of families with depression and strategies that families find helpful. It is highly recommended to psychiatrists to share with their patients and families.

Parents with depression worry that their children are suffering. Dr. Beardslee, who also is the Gardner-Monks Professor of Child Psychiatry at Harvard Medical School, Boston, has developed interventions with his colleagues aimed at helping these families. A major goal is "breaking the silence and helping the family talk together about depression." He conceptualizes depression as a chronic medical illness but also a family calamity and has developed an intervention to help families talk together and make meaning together.

His website, Families Preventing and Overcoming Depression provides details on the Family Talk Preventive Intervention. This is a public health, strength-based, and family-centered intervention designed to support families in which one or both parents have depression. This evidence-based practice partners with families to improve relationships and functioning by educating families on depression risk factors and understanding the benefits of applying protective factors to promote resilience.

Dr. Beardslee has many international collaborators in many different countries: Australia, Finland, the Netherlands, Norway, Sweden, Columbia, Costa Rica, and Iceland. Family interventions in these countries are supported by government, and in the public health, and medical and mental health systems. Interventions in these countries are more widespread and systematically available than they are in the United States.

A symposium on this topic will be held at the American Psychiatric Association’s annual meeting in Philadelphia, moderated by Dr. Ellen Berman. It is called "When Your Patient Is a Parent: Supporting the Family and Addressing the Needs of Children." As part of that symposium, Dr. Beardslee will present "Clinical Implications of Evidence-Based Preventive Interventions for Families With Parental Depression." Finally, Ms. Totten will present "A Family Perspective," and I will present "Overview of Needs of the Children of Parents With Mental Illness." See you there!

Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic

A little more than a year after the new anticoagulant dabigatran (Pradaxa) was approved for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients, the FDA is evaluating post-marketing reports of serious bleeds in patients taking the drug.

The FDA is trying to determine if patients on Pradaxa are experiencing severe bleeding more than expected based on results of the clinical trial that led to Pradaxa’s approval, according to FDA spokeswoman Sandy Walsh.

“At this time, FDA continues to believe that Pradaxa provides an important health benefit when used as directed and recommends that healthcare professionals who prescribe Pradaxa follow the recommendations in the approved drug label,” Walsh tells The Hospitalist.

It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin.

—Robert Pendleton, MD, director of the hospitalist program, University of Utah Healthcare; medical director, University Healthcare Thrombosis Service

Patients should not stop taking dabigatran without first talking to their doctors, the FDA announcement cautions. While “serious, even fatal events have been reported,” according to the FDA’s announcement, Walsh says the FDA isn’t prepared to say how many reports of serious bleeding events have been received because they’re still being reviewed.

“We often put out ‘early’ communications when we learn of drug safety issues,” she says. “We want to be transparent and make [the] public [aware of] what we do know, but our analysis is not final. At this point, the FDA is still evaluating this issue.”

Bleeding that leads to serious or fatal outcomes is a well-recognized complication of all anticoagulant therapies.

Dabigatran, a direct thrombin inhibitor, was approved in October 2010, becoming the first new oral anticoagulant approved in 50 years. It was the first approved among several new anti-coagulants that are poised to enter the market and are expected to challenge warfarin (Coumadin), the longtime standard of care.

The new drugs—including rivaroxaban (Xarelto), a Factor Xa-inhibitor that was approved in 2011—have been eagerly anticipated because they don’t require frequent blood draws for monitoring, as warfarin does. Hospitalists are especially interested in the new anticoagulant therapies because they treat numerous patients at an increased risk of clotting.

In the RE-LY trial, the 18,000-patient clinical trial comparing dabigatran and warfarin, major bleeding events occurred at similar rates with the two drugs.

Dabigatran manufacturer Boehringer Ingelheim is working with the FDA to evaluate the major bleeding reports, but spokeswoman Anna Moses says the drug has been performing according to expectations.

“Global data collected to date on major bleeding are consistent with our expectations based on the RE-LY trial and are in alignment with the U.S. Prescribing Information, which clearly state the benefits and risks associated with Pradaxa,” Moses says. “Overall, the positive-benefit-risk ratio of Pradaxa in NVAF remains unchanged.” (Visit the manufacturer website for prescribing information [PDF].)

Robert Pendleton, MD, director of the hospitalist program at the University of Utah Healthcare and Medical Director of the University Healthcare Thrombosis Service, expressed no surprise at the FDA’s statement.

“Although the data with new anticoagulants like Pradaxa is very favorable in a clinical trial setting, there’s great risk of enhanced demonstration of harm in the real-world setting if it’s not used optimally,” Dr. Pendleton says. “There will be more liberal sort of prescribing in a less-pure patient population.

So if people are not particularly cognizant of a patient’s renal function, their body weight, prior history of bleeding, etc., then you’re sort of applying new drugs in patients who are even more prone to bleed.”

Dr. Pendleton notes that in subgroup analyses, the slight benefits of the new drugs have come in patients with poor warfarin control, so if patients with good warfarin control are switched, outcomes could generally be expected not to be better, and could be worse.

“It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin,” he says, “but part of that is [that] here, in our healthcare system, we’re pretty cautious in who gets put on one of the new agents. And so those that do are patients who are most like those in the clinical trial.”

Tom Collins is a freelance writer in Florida.

A little more than a year after the new anticoagulant dabigatran (Pradaxa) was approved for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients, the FDA is evaluating post-marketing reports of serious bleeds in patients taking the drug.

The FDA is trying to determine if patients on Pradaxa are experiencing severe bleeding more than expected based on results of the clinical trial that led to Pradaxa’s approval, according to FDA spokeswoman Sandy Walsh.

“At this time, FDA continues to believe that Pradaxa provides an important health benefit when used as directed and recommends that healthcare professionals who prescribe Pradaxa follow the recommendations in the approved drug label,” Walsh tells The Hospitalist.

It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin.

—Robert Pendleton, MD, director of the hospitalist program, University of Utah Healthcare; medical director, University Healthcare Thrombosis Service

Patients should not stop taking dabigatran without first talking to their doctors, the FDA announcement cautions. While “serious, even fatal events have been reported,” according to the FDA’s announcement, Walsh says the FDA isn’t prepared to say how many reports of serious bleeding events have been received because they’re still being reviewed.

“We often put out ‘early’ communications when we learn of drug safety issues,” she says. “We want to be transparent and make [the] public [aware of] what we do know, but our analysis is not final. At this point, the FDA is still evaluating this issue.”

Bleeding that leads to serious or fatal outcomes is a well-recognized complication of all anticoagulant therapies.

Dabigatran, a direct thrombin inhibitor, was approved in October 2010, becoming the first new oral anticoagulant approved in 50 years. It was the first approved among several new anti-coagulants that are poised to enter the market and are expected to challenge warfarin (Coumadin), the longtime standard of care.

The new drugs—including rivaroxaban (Xarelto), a Factor Xa-inhibitor that was approved in 2011—have been eagerly anticipated because they don’t require frequent blood draws for monitoring, as warfarin does. Hospitalists are especially interested in the new anticoagulant therapies because they treat numerous patients at an increased risk of clotting.

In the RE-LY trial, the 18,000-patient clinical trial comparing dabigatran and warfarin, major bleeding events occurred at similar rates with the two drugs.

Dabigatran manufacturer Boehringer Ingelheim is working with the FDA to evaluate the major bleeding reports, but spokeswoman Anna Moses says the drug has been performing according to expectations.

“Global data collected to date on major bleeding are consistent with our expectations based on the RE-LY trial and are in alignment with the U.S. Prescribing Information, which clearly state the benefits and risks associated with Pradaxa,” Moses says. “Overall, the positive-benefit-risk ratio of Pradaxa in NVAF remains unchanged.” (Visit the manufacturer website for prescribing information [PDF].)

Robert Pendleton, MD, director of the hospitalist program at the University of Utah Healthcare and Medical Director of the University Healthcare Thrombosis Service, expressed no surprise at the FDA’s statement.

“Although the data with new anticoagulants like Pradaxa is very favorable in a clinical trial setting, there’s great risk of enhanced demonstration of harm in the real-world setting if it’s not used optimally,” Dr. Pendleton says. “There will be more liberal sort of prescribing in a less-pure patient population.

So if people are not particularly cognizant of a patient’s renal function, their body weight, prior history of bleeding, etc., then you’re sort of applying new drugs in patients who are even more prone to bleed.”

Dr. Pendleton notes that in subgroup analyses, the slight benefits of the new drugs have come in patients with poor warfarin control, so if patients with good warfarin control are switched, outcomes could generally be expected not to be better, and could be worse.

“It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin,” he says, “but part of that is [that] here, in our healthcare system, we’re pretty cautious in who gets put on one of the new agents. And so those that do are patients who are most like those in the clinical trial.”

Tom Collins is a freelance writer in Florida.

A little more than a year after the new anticoagulant dabigatran (Pradaxa) was approved for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients, the FDA is evaluating post-marketing reports of serious bleeds in patients taking the drug.

The FDA is trying to determine if patients on Pradaxa are experiencing severe bleeding more than expected based on results of the clinical trial that led to Pradaxa’s approval, according to FDA spokeswoman Sandy Walsh.

“At this time, FDA continues to believe that Pradaxa provides an important health benefit when used as directed and recommends that healthcare professionals who prescribe Pradaxa follow the recommendations in the approved drug label,” Walsh tells The Hospitalist.

It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin.

—Robert Pendleton, MD, director of the hospitalist program, University of Utah Healthcare; medical director, University Healthcare Thrombosis Service

Patients should not stop taking dabigatran without first talking to their doctors, the FDA announcement cautions. While “serious, even fatal events have been reported,” according to the FDA’s announcement, Walsh says the FDA isn’t prepared to say how many reports of serious bleeding events have been received because they’re still being reviewed.

“We often put out ‘early’ communications when we learn of drug safety issues,” she says. “We want to be transparent and make [the] public [aware of] what we do know, but our analysis is not final. At this point, the FDA is still evaluating this issue.”

Bleeding that leads to serious or fatal outcomes is a well-recognized complication of all anticoagulant therapies.

Dabigatran, a direct thrombin inhibitor, was approved in October 2010, becoming the first new oral anticoagulant approved in 50 years. It was the first approved among several new anti-coagulants that are poised to enter the market and are expected to challenge warfarin (Coumadin), the longtime standard of care.

The new drugs—including rivaroxaban (Xarelto), a Factor Xa-inhibitor that was approved in 2011—have been eagerly anticipated because they don’t require frequent blood draws for monitoring, as warfarin does. Hospitalists are especially interested in the new anticoagulant therapies because they treat numerous patients at an increased risk of clotting.

In the RE-LY trial, the 18,000-patient clinical trial comparing dabigatran and warfarin, major bleeding events occurred at similar rates with the two drugs.

Dabigatran manufacturer Boehringer Ingelheim is working with the FDA to evaluate the major bleeding reports, but spokeswoman Anna Moses says the drug has been performing according to expectations.

“Global data collected to date on major bleeding are consistent with our expectations based on the RE-LY trial and are in alignment with the U.S. Prescribing Information, which clearly state the benefits and risks associated with Pradaxa,” Moses says. “Overall, the positive-benefit-risk ratio of Pradaxa in NVAF remains unchanged.” (Visit the manufacturer website for prescribing information [PDF].)

Robert Pendleton, MD, director of the hospitalist program at the University of Utah Healthcare and Medical Director of the University Healthcare Thrombosis Service, expressed no surprise at the FDA’s statement.

“Although the data with new anticoagulants like Pradaxa is very favorable in a clinical trial setting, there’s great risk of enhanced demonstration of harm in the real-world setting if it’s not used optimally,” Dr. Pendleton says. “There will be more liberal sort of prescribing in a less-pure patient population.

So if people are not particularly cognizant of a patient’s renal function, their body weight, prior history of bleeding, etc., then you’re sort of applying new drugs in patients who are even more prone to bleed.”

Dr. Pendleton notes that in subgroup analyses, the slight benefits of the new drugs have come in patients with poor warfarin control, so if patients with good warfarin control are switched, outcomes could generally be expected not to be better, and could be worse.

“It won’t cause me to take people who I have prescribed Pradaxa and switch them back to warfarin,” he says, “but part of that is [that] here, in our healthcare system, we’re pretty cautious in who gets put on one of the new agents. And so those that do are patients who are most like those in the clinical trial.”

Tom Collins is a freelance writer in Florida.