pdnews@elsevier.com

General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

pdnews@elsevier.com

General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

pdnews@elsevier.com

General pediatricians can take care of a great number of children with reflux disease. I recommend a step-up approach employing lifestyle modifications and/or medication prior to specialist referral in most cases. When symptoms become more troublesome or there is no response to therapeutic interventions, consultation with a pediatric gastroenterologist may be appropriate.

Begin with a thorough patient history, which is instrumental to distinguishing gastroesophageal reflux disease (GERD) from other conditions. Family medical and medication history also are important because of compelling evidence demonstrating a family link with GERD.

Advise school-age children with GERD to eat smaller meals throughout the day and not to eat too close to bedtime. Tomato-containing products, caffeine-containing products, citrus, and—believe it or not—chocolate are commonly implicated as evoking or exacerbating symptoms of GERD. Foods with high-fat content also are associated with the disorder, as they delay the ability of the stomach to empty quickly, thus potentially worsening GERD.

Sleep disturbances may be the sole symptom for a lot of older children with reflux. Microburps or microaspirations that occur when children are supine at night wake some; they do not wake others, so keep in mind that some children might be unaware of their GERD. A good question to ask is how many pillows they sleep on at night; some children already self-manage their symptoms by elevating their upper torso at night without realizing why.

Early morning nausea also can occur after a night of continuous reflux. Therefore, the presentation of a child who says he or she routinely does not want to eat in the morning, particularly if he or she complains of nausea, raises clinical suspicion for GERD. Also, some children can report regurgitating and re-swallowing all day as they sit in class.

In addition to lifestyle changes, a trial of acid-suppressing medication, such as an H₂ blocker or a proton pump inhibitor, can be tried. Limit initial treatment to 6-8 weeks for most children. If a child reports respiratory symptoms associated with GERD, consider a longer course of acid suppression therapy. It is important to discuss the specific GERD-related symptoms you expect the medication to resolve prior to initiation of therapy.

A referral to a pediatric gastroenterologist is warranted after lifestyle modifications and pharmacotherapy fail, or if symptoms return after therapy is discontinued. Sometimes patients do not improve with these interventions or they get better but you cannot get patients off the medication without symptoms returning. Also, other warning signs or symptoms such as anemia or occult blood in the stool or vomit require a referral.

Frequently, children, particularly those of school age, with GERD complain of a stomachache. However, GERD is more of a burning pain versus a cramping pain. Pain that is associated with GERD or due to another “organic” cause tends to be pain that localizes away from the belly button and is more epigastric, versus periumbilical pain, which tends to be more functional. In addition, abdominal pain that awakens children at night tends to be more organic in nature. Some children with GERD are misdiagnosed and actually have a functional GI disorder or vice versa. Definitions of pediatric functional GI disorders can aid in the differential diagnosis; these are outlined in Rome III criteria (www.romecriteria.org

There is no diagnostic test that is 100% accurate for the diagnosis of GERD. Thus, it is important to avoid too much testing or inappropriate treatment. For example, pediatricians tend to do an upper gastrointestinal series using barium and x-ray fluoroscopy, which is not good for ruling GERD in or out, but can be beneficial in identifying upper GI anatomic abnormalities. Nuclear scintigraphy can be employed to assess gastric emptying and aspiration of reflux contents.

Pediatricians can order a pH probe to ascertain the degree of acid exposure to the esophagus, although some centers require a GI consultation first. Endoscopic studies require a referral to a specialist. Specialists also may perform a newer modality called multichannel intraluminal impedance, which, when combined with the pH probe, can measure both acid reflux and nonacid or weakly acid reflux.

In a survey of 6,000 American Academy of Pediatrics members, 82% of the 1,245 responding pediatricians and pediatric specialists said they treat GERD based on clinical suspicion (J. Pediatr. Gastroenterol. Nutr. 2007;45:56-64). Such empiric therapy is still appropriate in the pediatric patient. However, there is a need for future research on the optimal therapy type, dose, and duration in these patients with clinically suspected GERD.

To promote a more standardized approach to pediatric GERD, I participated on an international committee that released an evidence-based set of definitions for reflux and GERD in the pediatric population (Am. J. Gastroenterol. 2009;104:1278-95). Additional guidance on GERD is available from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (www.naspghan.orgwww.cdhnf.org

John Nelson, MD, FACP, FHM, hasn't taken a medical test in more than 20 years. So when news began to spread last week that the American Board of Internal Medicine (ABIM) soon will be offering a Recognition of Focused Practice (RFP) in Hospital Medicine certification, he started to get a little nervous.

"I will lose sleep the week before I take this test," says Dr. Nelson, co-founder and past president of SHM, and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants. "This exam will help identify those who see this as a career. … Boy, there is nothing like a test to demonstrate professional centeredness."

The exam, likely to be available in the fall of 2010, will identify physicians who have "maintained their internal medicine certification focused in hospital medicine," according to the ABIM Web site.

"For those individuals [whose certificate] will be expiring in 2010 or 2011, this is a viable pathway for re-certification," says Eric Holmbloe, MD, senior vice president and chief medical officer at ABIM. "Interested diplomats should be able to begin the application process in early 2010. We are feverishly working to complete the test and build the technology infrastructure. We should have more information available in about six weeks."

HM pioneers like Dr. Nelson consider the RFP designation a validation of decades-long efforts to carve a niche in medicine. The test will symbolize dedication to the specialty and provide HM physicians with professional self-regulation.

Scott Flanders, MD, FHM, president of SHM, terms the announcement a "watershed moment" for the field.

"I think this is a major, major moment for HM," says Dr. Flanders, who practices at the University of Michigan Medical Center in Ann Arbor. "We've been looking at this for a long time. This validates the field, and the belief that HM is a positive [for the field of medicine]."

Dr. Nelson couldn't agree more. "This test is the first way hospitalists will be able to show their competence," he says. "I think it's a great opportunity. This will help people take our field more seriously."

John Nelson, MD, FACP, FHM, hasn't taken a medical test in more than 20 years. So when news began to spread last week that the American Board of Internal Medicine (ABIM) soon will be offering a Recognition of Focused Practice (RFP) in Hospital Medicine certification, he started to get a little nervous.

"I will lose sleep the week before I take this test," says Dr. Nelson, co-founder and past president of SHM, and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants. "This exam will help identify those who see this as a career. … Boy, there is nothing like a test to demonstrate professional centeredness."

The exam, likely to be available in the fall of 2010, will identify physicians who have "maintained their internal medicine certification focused in hospital medicine," according to the ABIM Web site.

"For those individuals [whose certificate] will be expiring in 2010 or 2011, this is a viable pathway for re-certification," says Eric Holmbloe, MD, senior vice president and chief medical officer at ABIM. "Interested diplomats should be able to begin the application process in early 2010. We are feverishly working to complete the test and build the technology infrastructure. We should have more information available in about six weeks."

HM pioneers like Dr. Nelson consider the RFP designation a validation of decades-long efforts to carve a niche in medicine. The test will symbolize dedication to the specialty and provide HM physicians with professional self-regulation.

Scott Flanders, MD, FHM, president of SHM, terms the announcement a "watershed moment" for the field.

"I think this is a major, major moment for HM," says Dr. Flanders, who practices at the University of Michigan Medical Center in Ann Arbor. "We've been looking at this for a long time. This validates the field, and the belief that HM is a positive [for the field of medicine]."

Dr. Nelson couldn't agree more. "This test is the first way hospitalists will be able to show their competence," he says. "I think it's a great opportunity. This will help people take our field more seriously."

John Nelson, MD, FACP, FHM, hasn't taken a medical test in more than 20 years. So when news began to spread last week that the American Board of Internal Medicine (ABIM) soon will be offering a Recognition of Focused Practice (RFP) in Hospital Medicine certification, he started to get a little nervous.

"I will lose sleep the week before I take this test," says Dr. Nelson, co-founder and past president of SHM, and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants. "This exam will help identify those who see this as a career. … Boy, there is nothing like a test to demonstrate professional centeredness."

The exam, likely to be available in the fall of 2010, will identify physicians who have "maintained their internal medicine certification focused in hospital medicine," according to the ABIM Web site.

"For those individuals [whose certificate] will be expiring in 2010 or 2011, this is a viable pathway for re-certification," says Eric Holmbloe, MD, senior vice president and chief medical officer at ABIM. "Interested diplomats should be able to begin the application process in early 2010. We are feverishly working to complete the test and build the technology infrastructure. We should have more information available in about six weeks."

HM pioneers like Dr. Nelson consider the RFP designation a validation of decades-long efforts to carve a niche in medicine. The test will symbolize dedication to the specialty and provide HM physicians with professional self-regulation.

Scott Flanders, MD, FHM, president of SHM, terms the announcement a "watershed moment" for the field.

"I think this is a major, major moment for HM," says Dr. Flanders, who practices at the University of Michigan Medical Center in Ann Arbor. "We've been looking at this for a long time. This validates the field, and the belief that HM is a positive [for the field of medicine]."

Dr. Nelson couldn't agree more. "This test is the first way hospitalists will be able to show their competence," he says. "I think it's a great opportunity. This will help people take our field more seriously."

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."

Last week’s release of the “chairman’s mark” of the America’s Healthy Future Act from Senate Finance Committee Chairman Max Baucus (D-Mont.) opened the latest chapter in the debate over healthcare reform. Beyond the hot-button issues, several Medicare-related proposals could directly impact hospitalists. Here’s a look at four of them, with observations from Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee.

Addition of a hospital value-based purchasing (VBP) program to Medicare beginning in 2012. The program would tie incentive payments to performance on quality measures related to such conditions as heart failure, pneumonia, surgical care, and patient perceptions of care. So far, the program’s rough outlines have been well received. “We fundamentally support hospital value-based purchasing,” Dr. Siegal says. “We think it’s a necessary step in the evolution to higher-value health care in general.”

Expansion of the Physician’s Quality Reporting Initiative, with a 1% payment penalty by 2012 for nonparticipants. The bill also would direct the Centers for Medicare and Medicaid Services (CMS) to improve the appeals process and feedback mechanism. Although the Baucus plan’s “mark” doesn’t discuss transitioning to pay-for-performance, Dr. Siegal says the shift likely is inevitable. In the meantime, pay-for-reporting can encourage better outcomes through a public reporting mechanism and “grease the skids” for a pay-for-performance initiative.

Creation of a CMS Payment Innovation Center “authorized to test, evaluate, and expand different payment structures and methodologies,” with a goal of improving quality and reducing Medicare costs. Dr. Siegal says the proposal is consistent with SHM’s aims. “We have for a long time advocated for a robust capability to test new payment models and to figure out what works better than what we have right now,” he says.

Establishment of a three-year Medicare pilot called the Community Care Transitions Program. The program would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations. SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify. “We’re very positive about that,” Dr. Siegal says. “I think there is a huge amount of scrutiny now on avoidable rehospitalizations. We think BOOST is a step in the right direction, and we’d love to see greater funding to roll this out on a much larger basis.”

For more information on the current healthcare reform debate, visit SHM’s advocacy portal.

Last week’s release of the “chairman’s mark” of the America’s Healthy Future Act from Senate Finance Committee Chairman Max Baucus (D-Mont.) opened the latest chapter in the debate over healthcare reform. Beyond the hot-button issues, several Medicare-related proposals could directly impact hospitalists. Here’s a look at four of them, with observations from Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee.

Addition of a hospital value-based purchasing (VBP) program to Medicare beginning in 2012. The program would tie incentive payments to performance on quality measures related to such conditions as heart failure, pneumonia, surgical care, and patient perceptions of care. So far, the program’s rough outlines have been well received. “We fundamentally support hospital value-based purchasing,” Dr. Siegal says. “We think it’s a necessary step in the evolution to higher-value health care in general.”

Expansion of the Physician’s Quality Reporting Initiative, with a 1% payment penalty by 2012 for nonparticipants. The bill also would direct the Centers for Medicare and Medicaid Services (CMS) to improve the appeals process and feedback mechanism. Although the Baucus plan’s “mark” doesn’t discuss transitioning to pay-for-performance, Dr. Siegal says the shift likely is inevitable. In the meantime, pay-for-reporting can encourage better outcomes through a public reporting mechanism and “grease the skids” for a pay-for-performance initiative.

Creation of a CMS Payment Innovation Center “authorized to test, evaluate, and expand different payment structures and methodologies,” with a goal of improving quality and reducing Medicare costs. Dr. Siegal says the proposal is consistent with SHM’s aims. “We have for a long time advocated for a robust capability to test new payment models and to figure out what works better than what we have right now,” he says.

Establishment of a three-year Medicare pilot called the Community Care Transitions Program. The program would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations. SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify. “We’re very positive about that,” Dr. Siegal says. “I think there is a huge amount of scrutiny now on avoidable rehospitalizations. We think BOOST is a step in the right direction, and we’d love to see greater funding to roll this out on a much larger basis.”

For more information on the current healthcare reform debate, visit SHM’s advocacy portal.

Last week’s release of the “chairman’s mark” of the America’s Healthy Future Act from Senate Finance Committee Chairman Max Baucus (D-Mont.) opened the latest chapter in the debate over healthcare reform. Beyond the hot-button issues, several Medicare-related proposals could directly impact hospitalists. Here’s a look at four of them, with observations from Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee.

Addition of a hospital value-based purchasing (VBP) program to Medicare beginning in 2012. The program would tie incentive payments to performance on quality measures related to such conditions as heart failure, pneumonia, surgical care, and patient perceptions of care. So far, the program’s rough outlines have been well received. “We fundamentally support hospital value-based purchasing,” Dr. Siegal says. “We think it’s a necessary step in the evolution to higher-value health care in general.”

Expansion of the Physician’s Quality Reporting Initiative, with a 1% payment penalty by 2012 for nonparticipants. The bill also would direct the Centers for Medicare and Medicaid Services (CMS) to improve the appeals process and feedback mechanism. Although the Baucus plan’s “mark” doesn’t discuss transitioning to pay-for-performance, Dr. Siegal says the shift likely is inevitable. In the meantime, pay-for-reporting can encourage better outcomes through a public reporting mechanism and “grease the skids” for a pay-for-performance initiative.

Creation of a CMS Payment Innovation Center “authorized to test, evaluate, and expand different payment structures and methodologies,” with a goal of improving quality and reducing Medicare costs. Dr. Siegal says the proposal is consistent with SHM’s aims. “We have for a long time advocated for a robust capability to test new payment models and to figure out what works better than what we have right now,” he says.

Establishment of a three-year Medicare pilot called the Community Care Transitions Program. The program would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations. SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify. “We’re very positive about that,” Dr. Siegal says. “I think there is a huge amount of scrutiny now on avoidable rehospitalizations. We think BOOST is a step in the right direction, and we’d love to see greater funding to roll this out on a much larger basis.”

For more information on the current healthcare reform debate, visit SHM’s advocacy portal.

Another SHM Leadership Academy just ended, with introductory and advanced courses presented at the Fontainebleau resort, complete with the backdrop of Miami Beach. These four-day courses are aimed at hospitalist leaders, and have trained more than 1,200 participants to date. The faculty includes nationally recognized experts in their respective fields, as well as experienced HM leaders.

Level I courses are designed to help new leaders in HM, and focus on communication skills, hospital business drivers, leadership, strategic planning, and conflict resolution. Harjit Bhogal, MD, a hospitalist at Johns Hopkins University School of Medicine in Baltimore, found the Level I course addressed many of the roles she has as a new hospitalist. “The session on strategic planning was interactive and extremely informative,” Dr. Bhogal says. She also says the academy is an ideal place for networking, as attendees have access to more than 100 practicing hospitalist leaders with whom to connect.

Level II takes concepts introduced in Level I and refines them. Communication and negotiation, “meta-leadership,” financial storytelling, and a leadership roundtable help more advanced leaders tackle more complex issues. The session on meta-leadership was “terrific,” according to hospitalist Darlene Tad-y, MD, of Johns Hopkins. “One of the best days I have spent as an adult learner,” she says. “Lenny [Marcus] was absolutely amazing; his walk-in-the-woods approach was a terrific method to discuss leadership.”

Many see hospitalists as the future leaders of the hospital and throughout healthcare. “In addition to helping train leaders for hospital medicine, we believe that SHM has the obligation to train hospitalists to be the next hospital CMOs and CEOs,” says Larry Wellikson, MD, FHM, CEO of SHM.

Apparently, 1,200 academy graduates agree with him.

Another SHM Leadership Academy just ended, with introductory and advanced courses presented at the Fontainebleau resort, complete with the backdrop of Miami Beach. These four-day courses are aimed at hospitalist leaders, and have trained more than 1,200 participants to date. The faculty includes nationally recognized experts in their respective fields, as well as experienced HM leaders.

Level I courses are designed to help new leaders in HM, and focus on communication skills, hospital business drivers, leadership, strategic planning, and conflict resolution. Harjit Bhogal, MD, a hospitalist at Johns Hopkins University School of Medicine in Baltimore, found the Level I course addressed many of the roles she has as a new hospitalist. “The session on strategic planning was interactive and extremely informative,” Dr. Bhogal says. She also says the academy is an ideal place for networking, as attendees have access to more than 100 practicing hospitalist leaders with whom to connect.

Level II takes concepts introduced in Level I and refines them. Communication and negotiation, “meta-leadership,” financial storytelling, and a leadership roundtable help more advanced leaders tackle more complex issues. The session on meta-leadership was “terrific,” according to hospitalist Darlene Tad-y, MD, of Johns Hopkins. “One of the best days I have spent as an adult learner,” she says. “Lenny [Marcus] was absolutely amazing; his walk-in-the-woods approach was a terrific method to discuss leadership.”

Many see hospitalists as the future leaders of the hospital and throughout healthcare. “In addition to helping train leaders for hospital medicine, we believe that SHM has the obligation to train hospitalists to be the next hospital CMOs and CEOs,” says Larry Wellikson, MD, FHM, CEO of SHM.

Apparently, 1,200 academy graduates agree with him.

Another SHM Leadership Academy just ended, with introductory and advanced courses presented at the Fontainebleau resort, complete with the backdrop of Miami Beach. These four-day courses are aimed at hospitalist leaders, and have trained more than 1,200 participants to date. The faculty includes nationally recognized experts in their respective fields, as well as experienced HM leaders.

Level I courses are designed to help new leaders in HM, and focus on communication skills, hospital business drivers, leadership, strategic planning, and conflict resolution. Harjit Bhogal, MD, a hospitalist at Johns Hopkins University School of Medicine in Baltimore, found the Level I course addressed many of the roles she has as a new hospitalist. “The session on strategic planning was interactive and extremely informative,” Dr. Bhogal says. She also says the academy is an ideal place for networking, as attendees have access to more than 100 practicing hospitalist leaders with whom to connect.

Level II takes concepts introduced in Level I and refines them. Communication and negotiation, “meta-leadership,” financial storytelling, and a leadership roundtable help more advanced leaders tackle more complex issues. The session on meta-leadership was “terrific,” according to hospitalist Darlene Tad-y, MD, of Johns Hopkins. “One of the best days I have spent as an adult learner,” she says. “Lenny [Marcus] was absolutely amazing; his walk-in-the-woods approach was a terrific method to discuss leadership.”

Many see hospitalists as the future leaders of the hospital and throughout healthcare. “In addition to helping train leaders for hospital medicine, we believe that SHM has the obligation to train hospitalists to be the next hospital CMOs and CEOs,” says Larry Wellikson, MD, FHM, CEO of SHM.

Apparently, 1,200 academy graduates agree with him.

A landmark New Jersey law that increases public disclosure of major preventable medical errors and prohibits charges for certain medical expenses related to those mistakes has hospitalists poised to take a leadership role in patient-safety efforts.

The legislation allows the state to release hospital-specific data on 14 medical mistakes considered by the federal government to be most preventable. It also bans hospitals from charging patients or insurers for follow-up medical costs related to the errors, including pressure ulcers, DVT, and catheter-associated urinary tract infections.

“It’s hard to argue the New Jersey legislation doesn’t make sense,” says hospitalist Niraj Sehgal, MD, MPH, associate chair for quality and safety in the Department of Medicine at the University of California at San Francisco. “After all, if I had the wrong limb operated on, I certainly wouldn’t expect to pay for the subsequent care needs, and nor should our system.”

Dr. Sehgal expects more states to follow New Jersey’s lead, a likely outcome given the fact the AARP is calling the Garden State measure “a national landmark.” The legislation also dovetails with the “no pay for errors” initiative from the Centers for Medicare & Medicaid Services.

Many hospitalists think HM groups are best positioned to spearhead quality and patient-safety efforts tied to the legislation. Hospitalist Vincent Barba, MD, FACP, FHM, medical director for quality improvement with University of Medicine and Dentistry of New Jersey in Newark, says HM leaders just have to seize the opportunity.

“Be the home team,” Dr. Barba says. “Step up. Take a leading role.”

A landmark New Jersey law that increases public disclosure of major preventable medical errors and prohibits charges for certain medical expenses related to those mistakes has hospitalists poised to take a leadership role in patient-safety efforts.

The legislation allows the state to release hospital-specific data on 14 medical mistakes considered by the federal government to be most preventable. It also bans hospitals from charging patients or insurers for follow-up medical costs related to the errors, including pressure ulcers, DVT, and catheter-associated urinary tract infections.

“It’s hard to argue the New Jersey legislation doesn’t make sense,” says hospitalist Niraj Sehgal, MD, MPH, associate chair for quality and safety in the Department of Medicine at the University of California at San Francisco. “After all, if I had the wrong limb operated on, I certainly wouldn’t expect to pay for the subsequent care needs, and nor should our system.”

Dr. Sehgal expects more states to follow New Jersey’s lead, a likely outcome given the fact the AARP is calling the Garden State measure “a national landmark.” The legislation also dovetails with the “no pay for errors” initiative from the Centers for Medicare & Medicaid Services.

Many hospitalists think HM groups are best positioned to spearhead quality and patient-safety efforts tied to the legislation. Hospitalist Vincent Barba, MD, FACP, FHM, medical director for quality improvement with University of Medicine and Dentistry of New Jersey in Newark, says HM leaders just have to seize the opportunity.

“Be the home team,” Dr. Barba says. “Step up. Take a leading role.”

A landmark New Jersey law that increases public disclosure of major preventable medical errors and prohibits charges for certain medical expenses related to those mistakes has hospitalists poised to take a leadership role in patient-safety efforts.

The legislation allows the state to release hospital-specific data on 14 medical mistakes considered by the federal government to be most preventable. It also bans hospitals from charging patients or insurers for follow-up medical costs related to the errors, including pressure ulcers, DVT, and catheter-associated urinary tract infections.

“It’s hard to argue the New Jersey legislation doesn’t make sense,” says hospitalist Niraj Sehgal, MD, MPH, associate chair for quality and safety in the Department of Medicine at the University of California at San Francisco. “After all, if I had the wrong limb operated on, I certainly wouldn’t expect to pay for the subsequent care needs, and nor should our system.”

Dr. Sehgal expects more states to follow New Jersey’s lead, a likely outcome given the fact the AARP is calling the Garden State measure “a national landmark.” The legislation also dovetails with the “no pay for errors” initiative from the Centers for Medicare & Medicaid Services.

Many hospitalists think HM groups are best positioned to spearhead quality and patient-safety efforts tied to the legislation. Hospitalist Vincent Barba, MD, FACP, FHM, medical director for quality improvement with University of Medicine and Dentistry of New Jersey in Newark, says HM leaders just have to seize the opportunity.

“Be the home team,” Dr. Barba says. “Step up. Take a leading role.”

Clinical question: Does aspirin prevent cardiovascular events in patients with peripheral artery disease (PAD)?

Background: Evidence that aspirin decreases risk of cardiovascular events in patients with symptomatic coronary artery disease and cerebrovascular disease has led to a recommendation of aspirin as secondary prevention in PAD. Evidence for its efficacy in this context is not established.

Study design: Meta-analysis.

Setting: Multiple study sites.

Synopsis: The investigators looked at 18 randomized controlled trials involving 5,269 participants, 2,823 of whom received aspirin, including 1,516 as monotherapy and 2,446 controls. The primary endpoint investigated was cardiovascular events.

This meta-analysis did not show a statistical benefit in cardiovascular event reduction (8.9% vs. 11%) in aspirin therapy in patients with peripheral artery disease, but it did show a decrease in the secondary endpoint of nonfatal strokes. A subset analysis of aspirin monotherapy versus placebo showed a nonsignificant decrease in the primary endpoint.

The studies had a short timeline with few cardiovascular events, so conclusions cannot be drawn about longer timeframes. Furthermore, some of the included studies were not designed to measure cardiovascular events. Finally, the study was not powered to detect differences less than 25%.

Bottom line: In patients with PAD, aspirin might not decrease the incidence of cardiovascular events.

Citation: Berger JT, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301(18):1909-1919.

—Reviewed for The Hospitalist by Steven Deitelzweig, MD, MMM, FHM; Frank Wharton, MD, FACP; Renee Meadows, MD, FHM; Srinivas Vuppala, MD; Kevin Hude, MD; Doris Lin, MD; Damodar Kumbala, MD, Department of Hospital Medicine, Ochsner Medical Center, New Orleans

Clinical question: Does aspirin prevent cardiovascular events in patients with peripheral artery disease (PAD)?

Background: Evidence that aspirin decreases risk of cardiovascular events in patients with symptomatic coronary artery disease and cerebrovascular disease has led to a recommendation of aspirin as secondary prevention in PAD. Evidence for its efficacy in this context is not established.

Study design: Meta-analysis.

Setting: Multiple study sites.

Synopsis: The investigators looked at 18 randomized controlled trials involving 5,269 participants, 2,823 of whom received aspirin, including 1,516 as monotherapy and 2,446 controls. The primary endpoint investigated was cardiovascular events.

This meta-analysis did not show a statistical benefit in cardiovascular event reduction (8.9% vs. 11%) in aspirin therapy in patients with peripheral artery disease, but it did show a decrease in the secondary endpoint of nonfatal strokes. A subset analysis of aspirin monotherapy versus placebo showed a nonsignificant decrease in the primary endpoint.

The studies had a short timeline with few cardiovascular events, so conclusions cannot be drawn about longer timeframes. Furthermore, some of the included studies were not designed to measure cardiovascular events. Finally, the study was not powered to detect differences less than 25%.

Bottom line: In patients with PAD, aspirin might not decrease the incidence of cardiovascular events.

Citation: Berger JT, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301(18):1909-1919.

—Reviewed for The Hospitalist by Steven Deitelzweig, MD, MMM, FHM; Frank Wharton, MD, FACP; Renee Meadows, MD, FHM; Srinivas Vuppala, MD; Kevin Hude, MD; Doris Lin, MD; Damodar Kumbala, MD, Department of Hospital Medicine, Ochsner Medical Center, New Orleans

Clinical question: Does aspirin prevent cardiovascular events in patients with peripheral artery disease (PAD)?

Background: Evidence that aspirin decreases risk of cardiovascular events in patients with symptomatic coronary artery disease and cerebrovascular disease has led to a recommendation of aspirin as secondary prevention in PAD. Evidence for its efficacy in this context is not established.

Study design: Meta-analysis.

Setting: Multiple study sites.

Synopsis: The investigators looked at 18 randomized controlled trials involving 5,269 participants, 2,823 of whom received aspirin, including 1,516 as monotherapy and 2,446 controls. The primary endpoint investigated was cardiovascular events.

This meta-analysis did not show a statistical benefit in cardiovascular event reduction (8.9% vs. 11%) in aspirin therapy in patients with peripheral artery disease, but it did show a decrease in the secondary endpoint of nonfatal strokes. A subset analysis of aspirin monotherapy versus placebo showed a nonsignificant decrease in the primary endpoint.

The studies had a short timeline with few cardiovascular events, so conclusions cannot be drawn about longer timeframes. Furthermore, some of the included studies were not designed to measure cardiovascular events. Finally, the study was not powered to detect differences less than 25%.

Bottom line: In patients with PAD, aspirin might not decrease the incidence of cardiovascular events.

Citation: Berger JT, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301(18):1909-1919.

—Reviewed for The Hospitalist by Steven Deitelzweig, MD, MMM, FHM; Frank Wharton, MD, FACP; Renee Meadows, MD, FHM; Srinivas Vuppala, MD; Kevin Hude, MD; Doris Lin, MD; Damodar Kumbala, MD, Department of Hospital Medicine, Ochsner Medical Center, New Orleans

An e-newsletter focusing on challenging case studies

Progesterone use in management of secondary amenorrhea

Read the following case study and earn

FREE 0.5 CME/CE CREDIT

Expiration date: July 31, 2009

Estimated time to complete activity: 0.5 hour

Target: Physicians, physician assistants and nurse practitioners

Supported by an educational grant from Solvay Pharmaceuticals, Inc.

Sponsored by the American Society for Reproductive Medicine.

Click here to take the FREE CME/CE test online for 0.5 credits

Nicole is 27 years old, gravida 0, with a long history of obesity and great difficulty losing weight. She reports having irregular menstrual cycles ranging from 45 days to 6 months apart. Her last menstrual period was 5 months ago, when she had a heavy menses that lasted 2 weeks. Her body mass index is 42 kg/m2, which is considered morbid obesity. Nicole has a large abdominal pannus and normal blood pressure. She has scattered acne lesions on her face and upper back and acanthosis nigricans, a dark pigmentation around the neck and the axilla. Acanthosis nigricans is a biomarker for insulin resistance and high circulating insulin levels.

Nicole’s pelvic exam showed a normal vagina and cervix, but it was not possible to palpate her uterus or ovaries because of her abdominal girth. Transvaginal ultrasound found an endometrial thickness of 22 mm. Her ovaries appeared to be multicystic but had normal ovarian volumes. We performed an endometrial biopsy because of concerns about the long duration of unopposed estrogen exposure. The biopsy revealed complex hyperplasia with no atypia.

A lipid profile demonstrated cholesterol 245 mg/dL low-density lipoprotein cholesterol of 180 mg/dL and triglyceride levels of 259 mg/dL. This patient demonstrates many features we see with increasing frequency in reproductive-aged women as we deal with the obesity epidemic.

A complicated diagnosis

Nicole’s abdominal obesity, high triglycerides, and evidence of insulin-resistance constituted metabolic syndrome. Although there are many different criteria for this, we used those of the National Cholesterol Education Program (TABLE).¹

Long-term prognosis?

If she is not treated, Nicole would be unable to achieve pregnancy because she does not ovulate and she may have an increased risk of endometrial cancer. Her obesity would eventually cause increasing insulin levels, exhaustion of her pancreatic insulin secretion, and type 2 diabetes. Her obesity might also result in osteoarthritis and difficulty with mobility. Her lipid levels confer increased risk of hypertension and cardiovascular events.

Selecting a treatment strategy: Considerations

If this patient does not desire pregnancy, short-term treatment for endometrial hyperplasia involves administration of progesterone or progestins for at least 2 weeks per month for 3 months, with a follow-up endometrial biopsy.

Nicole also needs protection against endometrial hyperplasia even after this episode is addressed. Oral contraceptives are frequently used for long-term treatment, although there might be concern about the risk of deep vein thrombosis (DVT), particularly in obese or morbidly obese patients and older patients who smoke.

If this patient were not a candidate for oral contraceptives, progesterone or a progestin would typically be administered for approximately 2 weeks each month to prevent recurrence of the hyperplasia. Patients who do not desire a monthly withdrawal bleed can take progesterone every 2 to 3 months. Patients who are being treated with a progestogen for amenorrhea and hyperplasia may occasionally ovulate. They should be counseled that an alternative form of contraception, such as condoms, is needed to avoid pregnancy.

An intrauterine device (IUD) for this patient could also be considered for this patient. We have individual patients using a levonorgestrel-containing IUD. One challenge we have faced with some of our obese patients is difficultly accessing the cervix for placement.

Case study follow-up

Nicole received norethindrone,²,³ 5 mg, a strong progestin, for 2 weeks and had a withdrawal flow for 3 months in a row. Her repeat endometrial biopsy showed a normal endometrium. She still did not ovulate, and since she was not sexually active at that time, she elected to use progesterone, 200 mg, for 14 days every 2 months. We treated her acne with topical clindamycin gel and she joined our supervised diet and exercise program. She is considering bariatric surgery but must participate in the lifestyle program for at least 6 months in order to qualify.

An e-newsletter focusing on challenging case studies

Progesterone use in management of secondary amenorrhea

Read the following case study and earn

FREE 0.5 CME/CE CREDIT

Expiration date: July 31, 2009

Estimated time to complete activity: 0.5 hour

Target: Physicians, physician assistants and nurse practitioners

Supported by an educational grant from Solvay Pharmaceuticals, Inc.

Sponsored by the American Society for Reproductive Medicine.

Click here to take the FREE CME/CE test online for 0.5 credits

Nicole is 27 years old, gravida 0, with a long history of obesity and great difficulty losing weight. She reports having irregular menstrual cycles ranging from 45 days to 6 months apart. Her last menstrual period was 5 months ago, when she had a heavy menses that lasted 2 weeks. Her body mass index is 42 kg/m2, which is considered morbid obesity. Nicole has a large abdominal pannus and normal blood pressure. She has scattered acne lesions on her face and upper back and acanthosis nigricans, a dark pigmentation around the neck and the axilla. Acanthosis nigricans is a biomarker for insulin resistance and high circulating insulin levels.

Nicole’s pelvic exam showed a normal vagina and cervix, but it was not possible to palpate her uterus or ovaries because of her abdominal girth. Transvaginal ultrasound found an endometrial thickness of 22 mm. Her ovaries appeared to be multicystic but had normal ovarian volumes. We performed an endometrial biopsy because of concerns about the long duration of unopposed estrogen exposure. The biopsy revealed complex hyperplasia with no atypia.

A lipid profile demonstrated cholesterol 245 mg/dL low-density lipoprotein cholesterol of 180 mg/dL and triglyceride levels of 259 mg/dL. This patient demonstrates many features we see with increasing frequency in reproductive-aged women as we deal with the obesity epidemic.

A complicated diagnosis

Nicole’s abdominal obesity, high triglycerides, and evidence of insulin-resistance constituted metabolic syndrome. Although there are many different criteria for this, we used those of the National Cholesterol Education Program (TABLE).¹

Long-term prognosis?

If she is not treated, Nicole would be unable to achieve pregnancy because she does not ovulate and she may have an increased risk of endometrial cancer. Her obesity would eventually cause increasing insulin levels, exhaustion of her pancreatic insulin secretion, and type 2 diabetes. Her obesity might also result in osteoarthritis and difficulty with mobility. Her lipid levels confer increased risk of hypertension and cardiovascular events.

Selecting a treatment strategy: Considerations

If this patient does not desire pregnancy, short-term treatment for endometrial hyperplasia involves administration of progesterone or progestins for at least 2 weeks per month for 3 months, with a follow-up endometrial biopsy.

Nicole also needs protection against endometrial hyperplasia even after this episode is addressed. Oral contraceptives are frequently used for long-term treatment, although there might be concern about the risk of deep vein thrombosis (DVT), particularly in obese or morbidly obese patients and older patients who smoke.

If this patient were not a candidate for oral contraceptives, progesterone or a progestin would typically be administered for approximately 2 weeks each month to prevent recurrence of the hyperplasia. Patients who do not desire a monthly withdrawal bleed can take progesterone every 2 to 3 months. Patients who are being treated with a progestogen for amenorrhea and hyperplasia may occasionally ovulate. They should be counseled that an alternative form of contraception, such as condoms, is needed to avoid pregnancy.

An intrauterine device (IUD) for this patient could also be considered for this patient. We have individual patients using a levonorgestrel-containing IUD. One challenge we have faced with some of our obese patients is difficultly accessing the cervix for placement.

Case study follow-up

Nicole received norethindrone,²,³ 5 mg, a strong progestin, for 2 weeks and had a withdrawal flow for 3 months in a row. Her repeat endometrial biopsy showed a normal endometrium. She still did not ovulate, and since she was not sexually active at that time, she elected to use progesterone, 200 mg, for 14 days every 2 months. We treated her acne with topical clindamycin gel and she joined our supervised diet and exercise program. She is considering bariatric surgery but must participate in the lifestyle program for at least 6 months in order to qualify.

An e-newsletter focusing on challenging case studies

Progesterone use in management of secondary amenorrhea

Read the following case study and earn

FREE 0.5 CME/CE CREDIT

Expiration date: July 31, 2009

Estimated time to complete activity: 0.5 hour

Target: Physicians, physician assistants and nurse practitioners

Supported by an educational grant from Solvay Pharmaceuticals, Inc.

Sponsored by the American Society for Reproductive Medicine.

Click here to take the FREE CME/CE test online for 0.5 credits

Nicole is 27 years old, gravida 0, with a long history of obesity and great difficulty losing weight. She reports having irregular menstrual cycles ranging from 45 days to 6 months apart. Her last menstrual period was 5 months ago, when she had a heavy menses that lasted 2 weeks. Her body mass index is 42 kg/m2, which is considered morbid obesity. Nicole has a large abdominal pannus and normal blood pressure. She has scattered acne lesions on her face and upper back and acanthosis nigricans, a dark pigmentation around the neck and the axilla. Acanthosis nigricans is a biomarker for insulin resistance and high circulating insulin levels.

Nicole’s pelvic exam showed a normal vagina and cervix, but it was not possible to palpate her uterus or ovaries because of her abdominal girth. Transvaginal ultrasound found an endometrial thickness of 22 mm. Her ovaries appeared to be multicystic but had normal ovarian volumes. We performed an endometrial biopsy because of concerns about the long duration of unopposed estrogen exposure. The biopsy revealed complex hyperplasia with no atypia.

A lipid profile demonstrated cholesterol 245 mg/dL low-density lipoprotein cholesterol of 180 mg/dL and triglyceride levels of 259 mg/dL. This patient demonstrates many features we see with increasing frequency in reproductive-aged women as we deal with the obesity epidemic.

A complicated diagnosis

Nicole’s abdominal obesity, high triglycerides, and evidence of insulin-resistance constituted metabolic syndrome. Although there are many different criteria for this, we used those of the National Cholesterol Education Program (TABLE).¹

Long-term prognosis?

If she is not treated, Nicole would be unable to achieve pregnancy because she does not ovulate and she may have an increased risk of endometrial cancer. Her obesity would eventually cause increasing insulin levels, exhaustion of her pancreatic insulin secretion, and type 2 diabetes. Her obesity might also result in osteoarthritis and difficulty with mobility. Her lipid levels confer increased risk of hypertension and cardiovascular events.

Selecting a treatment strategy: Considerations

If this patient does not desire pregnancy, short-term treatment for endometrial hyperplasia involves administration of progesterone or progestins for at least 2 weeks per month for 3 months, with a follow-up endometrial biopsy.

Nicole also needs protection against endometrial hyperplasia even after this episode is addressed. Oral contraceptives are frequently used for long-term treatment, although there might be concern about the risk of deep vein thrombosis (DVT), particularly in obese or morbidly obese patients and older patients who smoke.

If this patient were not a candidate for oral contraceptives, progesterone or a progestin would typically be administered for approximately 2 weeks each month to prevent recurrence of the hyperplasia. Patients who do not desire a monthly withdrawal bleed can take progesterone every 2 to 3 months. Patients who are being treated with a progestogen for amenorrhea and hyperplasia may occasionally ovulate. They should be counseled that an alternative form of contraception, such as condoms, is needed to avoid pregnancy.

An intrauterine device (IUD) for this patient could also be considered for this patient. We have individual patients using a levonorgestrel-containing IUD. One challenge we have faced with some of our obese patients is difficultly accessing the cervix for placement.

Case study follow-up

Nicole received norethindrone,²,³ 5 mg, a strong progestin, for 2 weeks and had a withdrawal flow for 3 months in a row. Her repeat endometrial biopsy showed a normal endometrium. She still did not ovulate, and since she was not sexually active at that time, she elected to use progesterone, 200 mg, for 14 days every 2 months. We treated her acne with topical clindamycin gel and she joined our supervised diet and exercise program. She is considering bariatric surgery but must participate in the lifestyle program for at least 6 months in order to qualify.