Betsy Bates

BEVERLY HILLS, CALIF. — Sympathectomy may become rare as a treatment for Raynaud's phenomenon, even in severe cases, if early success with botulinum toxin type A injections proves lasting and replicable, Dr. Michael Neumeister said at the annual meeting of the American Association for Hand Surgery.

“These days, fewer and fewer people are candidates for surgery,” remarked Dr. Neumeister, professor and chair of the division of plastic surgery at Southern Illinois University, Springfield.

Sympathectomy produces benefit in approximately half of people who undergo the complex procedure, he noted, and many Raynaud's symptoms recur, requiring reoperation.

Botox (botulinum toxin type A), meanwhile, has sharply reduced pain, improved blood flow, and fostered healing of ischemic fingertip ulcerations in every patient he has treated—16 to date—said Dr. Neumeister.

Ranging in age from 23 to 64 years, all patients treated by Dr. Neumeister had failed medical therapy; three had undergone prior sympathectomies.

The first patient he injected was a 53-year-old man who was desperate for relief from painful ulcerations, which persisted despite surgery and hospitalization for administration of intravenous morphine.

“Cut my fingers off,” Dr. Neumeister recalled the patient saying.

Instead, within minutes of palmar injections, the patient's pain had disappeared and has not recurred in more than 3 years.

Color sometimes returns to the fingertips of some patients quite soon after injections into the neurovascular bundles and web space of the palms.

Laser Doppler scans show that blood flow improves by 300% in some patients within 30 minutes after injection.

Within 24 hours, patients report full pain relief.

Dr. Neumeister said he has begun administering a wrist block prior to the procedure, because the injections can be painful.

Grip strength is affected for several months; however, intrinsic function returns after 2-3 months.

In most patients, Raynaud's pain and other symptoms do not recur; however, five patients required repeat injections 4, 6, 12, 13, and 24 months following initial palmar injections of 30-200 U of Botox. In four cases, revision amputations were required for preexisting, bone-exposing ulcers.

Dr. Neumeister is studying possible mechanisms of action that would explain the near-instantaneous pain relief achieved by Botox injections, a contrast to the 2- to 4-day time of onset of the agent's paralytic impact on muscles.

“Botox works right away [in Raynaud's phenomenon patients],” he said. “It's got to be a different mechanism.”

Thus far, he has determined that the effect on Raynaud's phenomenon is not at the vascular level, but in the sympathetic nervous system. It may be that patients with the vasospastic disease develop ectopic sodium channels not seen in normal nerves and that Botox is acting directly on those.

It is known that Botox is taken up by nerve terminals and then by vesicles containing acetylcholine. These vesicles are surrounded by SNAP-25 proteins, which Botox blocks.

“The vesicle can't migrate to the end of the nerve terminal and can't release acetylcholine that causes contraction of the muscle,” Dr. Neumeister said at the meeting.

Botox also may block stimulation of C fibers, the agents of secondary pain experienced a few seconds after one's hands are pulled out of very hot water.

“I think Botox is working against those C fibers and also working on sympathetics directly and on the cross talk between nerves in chronic pain,” he said.

Allergan Inc., the company that makes Botox, is funding Dr. Neumeister's research on the agent's mechanisms of action in Raynaud's disease and phenomenon.

However, the company does not underwrite patient treatments, and many insurance companies have refused to pay.

“There's no problem with reimbursement; you just don't get paid,” he quipped.

He has been able to convince several insurance companies that the cost of Botox injections, which run less than $1,000, are much preferable—“if they work”—to the $25,000 price tag of a sympathectomy.

Dr. Neumeister did not report any disclosures related to his presentation.

BEVERLY HILLS, CALIF. — Sympathectomy may become rare as a treatment for Raynaud's phenomenon, even in severe cases, if early success with botulinum toxin type A injections proves lasting and replicable, Dr. Michael Neumeister said at the annual meeting of the American Association for Hand Surgery.

“These days, fewer and fewer people are candidates for surgery,” remarked Dr. Neumeister, professor and chair of the division of plastic surgery at Southern Illinois University, Springfield.

Sympathectomy produces benefit in approximately half of people who undergo the complex procedure, he noted, and many Raynaud's symptoms recur, requiring reoperation.

Botox (botulinum toxin type A), meanwhile, has sharply reduced pain, improved blood flow, and fostered healing of ischemic fingertip ulcerations in every patient he has treated—16 to date—said Dr. Neumeister.

Ranging in age from 23 to 64 years, all patients treated by Dr. Neumeister had failed medical therapy; three had undergone prior sympathectomies.

The first patient he injected was a 53-year-old man who was desperate for relief from painful ulcerations, which persisted despite surgery and hospitalization for administration of intravenous morphine.

“Cut my fingers off,” Dr. Neumeister recalled the patient saying.

Instead, within minutes of palmar injections, the patient's pain had disappeared and has not recurred in more than 3 years.

Color sometimes returns to the fingertips of some patients quite soon after injections into the neurovascular bundles and web space of the palms.

Laser Doppler scans show that blood flow improves by 300% in some patients within 30 minutes after injection.

Within 24 hours, patients report full pain relief.

Dr. Neumeister said he has begun administering a wrist block prior to the procedure, because the injections can be painful.

Grip strength is affected for several months; however, intrinsic function returns after 2-3 months.

In most patients, Raynaud's pain and other symptoms do not recur; however, five patients required repeat injections 4, 6, 12, 13, and 24 months following initial palmar injections of 30-200 U of Botox. In four cases, revision amputations were required for preexisting, bone-exposing ulcers.

Dr. Neumeister is studying possible mechanisms of action that would explain the near-instantaneous pain relief achieved by Botox injections, a contrast to the 2- to 4-day time of onset of the agent's paralytic impact on muscles.

“Botox works right away [in Raynaud's phenomenon patients],” he said. “It's got to be a different mechanism.”

Thus far, he has determined that the effect on Raynaud's phenomenon is not at the vascular level, but in the sympathetic nervous system. It may be that patients with the vasospastic disease develop ectopic sodium channels not seen in normal nerves and that Botox is acting directly on those.

It is known that Botox is taken up by nerve terminals and then by vesicles containing acetylcholine. These vesicles are surrounded by SNAP-25 proteins, which Botox blocks.

“The vesicle can't migrate to the end of the nerve terminal and can't release acetylcholine that causes contraction of the muscle,” Dr. Neumeister said at the meeting.

Botox also may block stimulation of C fibers, the agents of secondary pain experienced a few seconds after one's hands are pulled out of very hot water.

“I think Botox is working against those C fibers and also working on sympathetics directly and on the cross talk between nerves in chronic pain,” he said.

Allergan Inc., the company that makes Botox, is funding Dr. Neumeister's research on the agent's mechanisms of action in Raynaud's disease and phenomenon.

However, the company does not underwrite patient treatments, and many insurance companies have refused to pay.

“There's no problem with reimbursement; you just don't get paid,” he quipped.

He has been able to convince several insurance companies that the cost of Botox injections, which run less than $1,000, are much preferable—“if they work”—to the $25,000 price tag of a sympathectomy.

Dr. Neumeister did not report any disclosures related to his presentation.

BEVERLY HILLS, CALIF. — Sympathectomy may become rare as a treatment for Raynaud's phenomenon, even in severe cases, if early success with botulinum toxin type A injections proves lasting and replicable, Dr. Michael Neumeister said at the annual meeting of the American Association for Hand Surgery.

“These days, fewer and fewer people are candidates for surgery,” remarked Dr. Neumeister, professor and chair of the division of plastic surgery at Southern Illinois University, Springfield.

Sympathectomy produces benefit in approximately half of people who undergo the complex procedure, he noted, and many Raynaud's symptoms recur, requiring reoperation.

Botox (botulinum toxin type A), meanwhile, has sharply reduced pain, improved blood flow, and fostered healing of ischemic fingertip ulcerations in every patient he has treated—16 to date—said Dr. Neumeister.

Ranging in age from 23 to 64 years, all patients treated by Dr. Neumeister had failed medical therapy; three had undergone prior sympathectomies.

The first patient he injected was a 53-year-old man who was desperate for relief from painful ulcerations, which persisted despite surgery and hospitalization for administration of intravenous morphine.

“Cut my fingers off,” Dr. Neumeister recalled the patient saying.

Instead, within minutes of palmar injections, the patient's pain had disappeared and has not recurred in more than 3 years.

Color sometimes returns to the fingertips of some patients quite soon after injections into the neurovascular bundles and web space of the palms.

Laser Doppler scans show that blood flow improves by 300% in some patients within 30 minutes after injection.

Within 24 hours, patients report full pain relief.

Dr. Neumeister said he has begun administering a wrist block prior to the procedure, because the injections can be painful.

Grip strength is affected for several months; however, intrinsic function returns after 2-3 months.

In most patients, Raynaud's pain and other symptoms do not recur; however, five patients required repeat injections 4, 6, 12, 13, and 24 months following initial palmar injections of 30-200 U of Botox. In four cases, revision amputations were required for preexisting, bone-exposing ulcers.

Dr. Neumeister is studying possible mechanisms of action that would explain the near-instantaneous pain relief achieved by Botox injections, a contrast to the 2- to 4-day time of onset of the agent's paralytic impact on muscles.

“Botox works right away [in Raynaud's phenomenon patients],” he said. “It's got to be a different mechanism.”

Thus far, he has determined that the effect on Raynaud's phenomenon is not at the vascular level, but in the sympathetic nervous system. It may be that patients with the vasospastic disease develop ectopic sodium channels not seen in normal nerves and that Botox is acting directly on those.

It is known that Botox is taken up by nerve terminals and then by vesicles containing acetylcholine. These vesicles are surrounded by SNAP-25 proteins, which Botox blocks.

“The vesicle can't migrate to the end of the nerve terminal and can't release acetylcholine that causes contraction of the muscle,” Dr. Neumeister said at the meeting.

Botox also may block stimulation of C fibers, the agents of secondary pain experienced a few seconds after one's hands are pulled out of very hot water.

“I think Botox is working against those C fibers and also working on sympathetics directly and on the cross talk between nerves in chronic pain,” he said.

Allergan Inc., the company that makes Botox, is funding Dr. Neumeister's research on the agent's mechanisms of action in Raynaud's disease and phenomenon.

However, the company does not underwrite patient treatments, and many insurance companies have refused to pay.

“There's no problem with reimbursement; you just don't get paid,” he quipped.

He has been able to convince several insurance companies that the cost of Botox injections, which run less than $1,000, are much preferable—“if they work”—to the $25,000 price tag of a sympathectomy.

Dr. Neumeister did not report any disclosures related to his presentation.

VANCOUVER, B.C. — Primary care physicians in community health centers say they are practicing “reluctant psychiatry” because mentally ill patients with chronic diseases often have nowhere else to turn for care, Dr. Carol Darr reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

“They hate it. They're dealing with many, many things beyond the scope of their knowledge,” said Dr. Darr of the Colorado health outcomes program at the University of Colorado Health Science Center in Denver.

Dr. Darr and her associates conducted 71 semistructured interviews with primary care physicians and staff members and observed 198 hours of clinical care and practice processes at seven community health care centers that serve uninsured or underinsured working poor families in the Denver region.

They found that mental health issues significantly complicated the care of chronically ill patients served by the clinics, but that a combination of spending cuts and a shortage of mental health professionals created barriers in referral.

The physicians said they felt they were often “on their own,” either consciously ignoring clues to mental health issues or practicing “reluctant psychiatry” outside of their scope of expertise, said Dr. Darr in an interview at the meeting.

Statements by the respondents illustrated their high level of frustration as their clinics are increasingly forced to manage chronically ill patients with mental health problems. In many cases, specialty clinics have closed or cut back their services because of funding cuts. Other times, families lose access to care through the loss of Medicaid or other insurance programs.

“This is beyond me,” one physician said of a particular patient. “I don't know what to do with the man. I've adjusted his meds as much as I can do [as] a primary care person. But he needs a little bit more than that—he's still hearing voices.”

Another physician described a patient who saw a psychiatrist and received psychotropic medications while hospitalized but did not receive them after her release.

“She's 100% in-house managed now,” the physician said. “And this woman truly does need to see a psychiatrist … somebody who understands psychosis and … all the antipsychotics and all the medications that she's on. As family practitioners, we do the best we can, but we're not psychiatrists. She's pretty poorly controlled.”

Yet another physician said, “If you feel you don't have a lot of tools at hand to deal with the mental health side of things, that tends to be the last thing you get to … why open that can of worms if you don't know [how] to solve the problem?”

Respondents described trying to obtain more psychiatric training “on their own or on the job” and said they sometimes have to “curb side” a psychiatrist to obtain an informal consultation about some of these cases, said Dr. Darr.

One physician recalled getting a telephone consultation with a psychiatrist who vowed never to speak to him again after he learned that his name would appear in the patient's chart.

Dr. Darr said the findings suggest that those compiling medical education models and drawing up clinical guidelines may need to rethink their assumptions that primary care physicians have the option of referring patients with serious mental health disorders to psychiatrists. Risks and liability issues are elevated whether primary care physicians ignore mental health issues or treat complex disorders outside of their scope of practice, she added.

“Reluctant psychiatry exacts a toll on the individuals forced to practice it, on the patients whose care is compromised for lack of appropriate specialty care, and on the society that absorbs the cost of supporting increasing numbers of individuals whose physical and mental health are poorly controlled,” she concluded.

VANCOUVER, B.C. — Primary care physicians in community health centers say they are practicing “reluctant psychiatry” because mentally ill patients with chronic diseases often have nowhere else to turn for care, Dr. Carol Darr reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

“They hate it. They're dealing with many, many things beyond the scope of their knowledge,” said Dr. Darr of the Colorado health outcomes program at the University of Colorado Health Science Center in Denver.

Dr. Darr and her associates conducted 71 semistructured interviews with primary care physicians and staff members and observed 198 hours of clinical care and practice processes at seven community health care centers that serve uninsured or underinsured working poor families in the Denver region.

They found that mental health issues significantly complicated the care of chronically ill patients served by the clinics, but that a combination of spending cuts and a shortage of mental health professionals created barriers in referral.

The physicians said they felt they were often “on their own,” either consciously ignoring clues to mental health issues or practicing “reluctant psychiatry” outside of their scope of expertise, said Dr. Darr in an interview at the meeting.

Statements by the respondents illustrated their high level of frustration as their clinics are increasingly forced to manage chronically ill patients with mental health problems. In many cases, specialty clinics have closed or cut back their services because of funding cuts. Other times, families lose access to care through the loss of Medicaid or other insurance programs.

“This is beyond me,” one physician said of a particular patient. “I don't know what to do with the man. I've adjusted his meds as much as I can do [as] a primary care person. But he needs a little bit more than that—he's still hearing voices.”

Another physician described a patient who saw a psychiatrist and received psychotropic medications while hospitalized but did not receive them after her release.

“She's 100% in-house managed now,” the physician said. “And this woman truly does need to see a psychiatrist … somebody who understands psychosis and … all the antipsychotics and all the medications that she's on. As family practitioners, we do the best we can, but we're not psychiatrists. She's pretty poorly controlled.”

Yet another physician said, “If you feel you don't have a lot of tools at hand to deal with the mental health side of things, that tends to be the last thing you get to … why open that can of worms if you don't know [how] to solve the problem?”

Respondents described trying to obtain more psychiatric training “on their own or on the job” and said they sometimes have to “curb side” a psychiatrist to obtain an informal consultation about some of these cases, said Dr. Darr.

One physician recalled getting a telephone consultation with a psychiatrist who vowed never to speak to him again after he learned that his name would appear in the patient's chart.

Dr. Darr said the findings suggest that those compiling medical education models and drawing up clinical guidelines may need to rethink their assumptions that primary care physicians have the option of referring patients with serious mental health disorders to psychiatrists. Risks and liability issues are elevated whether primary care physicians ignore mental health issues or treat complex disorders outside of their scope of practice, she added.

“Reluctant psychiatry exacts a toll on the individuals forced to practice it, on the patients whose care is compromised for lack of appropriate specialty care, and on the society that absorbs the cost of supporting increasing numbers of individuals whose physical and mental health are poorly controlled,” she concluded.

VANCOUVER, B.C. — Primary care physicians in community health centers say they are practicing “reluctant psychiatry” because mentally ill patients with chronic diseases often have nowhere else to turn for care, Dr. Carol Darr reported in a poster presentation at the annual meeting of the North American Primary Care Research Group.

“They hate it. They're dealing with many, many things beyond the scope of their knowledge,” said Dr. Darr of the Colorado health outcomes program at the University of Colorado Health Science Center in Denver.

Dr. Darr and her associates conducted 71 semistructured interviews with primary care physicians and staff members and observed 198 hours of clinical care and practice processes at seven community health care centers that serve uninsured or underinsured working poor families in the Denver region.

They found that mental health issues significantly complicated the care of chronically ill patients served by the clinics, but that a combination of spending cuts and a shortage of mental health professionals created barriers in referral.

The physicians said they felt they were often “on their own,” either consciously ignoring clues to mental health issues or practicing “reluctant psychiatry” outside of their scope of expertise, said Dr. Darr in an interview at the meeting.

Statements by the respondents illustrated their high level of frustration as their clinics are increasingly forced to manage chronically ill patients with mental health problems. In many cases, specialty clinics have closed or cut back their services because of funding cuts. Other times, families lose access to care through the loss of Medicaid or other insurance programs.

“This is beyond me,” one physician said of a particular patient. “I don't know what to do with the man. I've adjusted his meds as much as I can do [as] a primary care person. But he needs a little bit more than that—he's still hearing voices.”

Another physician described a patient who saw a psychiatrist and received psychotropic medications while hospitalized but did not receive them after her release.

“She's 100% in-house managed now,” the physician said. “And this woman truly does need to see a psychiatrist … somebody who understands psychosis and … all the antipsychotics and all the medications that she's on. As family practitioners, we do the best we can, but we're not psychiatrists. She's pretty poorly controlled.”

Yet another physician said, “If you feel you don't have a lot of tools at hand to deal with the mental health side of things, that tends to be the last thing you get to … why open that can of worms if you don't know [how] to solve the problem?”

Respondents described trying to obtain more psychiatric training “on their own or on the job” and said they sometimes have to “curb side” a psychiatrist to obtain an informal consultation about some of these cases, said Dr. Darr.

One physician recalled getting a telephone consultation with a psychiatrist who vowed never to speak to him again after he learned that his name would appear in the patient's chart.

Dr. Darr said the findings suggest that those compiling medical education models and drawing up clinical guidelines may need to rethink their assumptions that primary care physicians have the option of referring patients with serious mental health disorders to psychiatrists. Risks and liability issues are elevated whether primary care physicians ignore mental health issues or treat complex disorders outside of their scope of practice, she added.

“Reluctant psychiatry exacts a toll on the individuals forced to practice it, on the patients whose care is compromised for lack of appropriate specialty care, and on the society that absorbs the cost of supporting increasing numbers of individuals whose physical and mental health are poorly controlled,” she concluded.

HONOLULU — Fewer than half of critically ill patients received a physical examination from their primary intensive care unit physicians each day, Canadian researchers have found.

Patients seen first during rounds, those with higher Sequential Organ Failure Assessment (SOFA) scores, and those not in isolation were more likely to be examined by their lead physicians during surreptitious line-of-sight observations of 195 patient/physician encounters, according to the findings of a study presented at the annual congress of the Society of Critical Care Medicine.

During multidisciplinary rounds, time spent at each ICU patient's bedside averaged 8 minutes, with progressively less time spent on each subsequent patient in the rounding order. Time spent at the bedside increased with higher SOFA scores and with the number of health professionals attending medical rounds.

Dr. Adel Al-Sarraf led the study at Sunnybrook Health Sciences Centre in Toronto, in which an impartial observer with critical care experience timed patient encounters and noted whether each ICU patient received a physical examination each day.

The busy academic medical center ICU had a mean 95.6% occupancy during the study, with a ratio of medical to surgical patients of 31:69. Nearly half of patients were mechanically ventilated, and 9% were in isolation. The mean Acute Physiology and Chronic Health Evaluation (APACHE) score for the study population was 19.6.

Lead physicians physically examined their patients in 87 of 195 daily encounters, or 46.5%.

The duration of the primary ICU physician's time at the bedside averaged 11 minutes, with 69 seconds spent on physical examination.

The first patient seen by the lead physician was 2.5 times more likely to receive a physical examination than was the last patient seen. Patients in isolation were almost four times less likely to be examined, while higher SOFA scores slightly but significantly increased the likelihood of an examination.

As clinical experience increased, the likelihood of a lead physician conducting a physical examination decreased, with fellows being most lax, said Dr. Al-Sarraf. During briefer multidisciplinary rounds, just 8% of patients were physically examined.

Each patient seen during multidisciplinary rounds was seen for a shorter time than the previous patient was. When more health care professionals attended rounds, time spent at a patient's bedside increased, as was also true with a higher SOFA score.

Dr. Al-Sarraf concluded that “patient, caregiver, and ICU organization factors significantly influence bedside clinical examination and assessment practices.”

During the discussion following his talk, Dr. Al-Sarraf acknowledged that the study did not include any measures that would determine whether physical examinations correlated with improved outcome. He said that this might be a fruitful avenue for future research, particularly because technology has taken physicians increasingly away from patients' bedsides.

HONOLULU — Fewer than half of critically ill patients received a physical examination from their primary intensive care unit physicians each day, Canadian researchers have found.

Patients seen first during rounds, those with higher Sequential Organ Failure Assessment (SOFA) scores, and those not in isolation were more likely to be examined by their lead physicians during surreptitious line-of-sight observations of 195 patient/physician encounters, according to the findings of a study presented at the annual congress of the Society of Critical Care Medicine.

During multidisciplinary rounds, time spent at each ICU patient's bedside averaged 8 minutes, with progressively less time spent on each subsequent patient in the rounding order. Time spent at the bedside increased with higher SOFA scores and with the number of health professionals attending medical rounds.

Dr. Adel Al-Sarraf led the study at Sunnybrook Health Sciences Centre in Toronto, in which an impartial observer with critical care experience timed patient encounters and noted whether each ICU patient received a physical examination each day.

The busy academic medical center ICU had a mean 95.6% occupancy during the study, with a ratio of medical to surgical patients of 31:69. Nearly half of patients were mechanically ventilated, and 9% were in isolation. The mean Acute Physiology and Chronic Health Evaluation (APACHE) score for the study population was 19.6.

Lead physicians physically examined their patients in 87 of 195 daily encounters, or 46.5%.

The duration of the primary ICU physician's time at the bedside averaged 11 minutes, with 69 seconds spent on physical examination.

The first patient seen by the lead physician was 2.5 times more likely to receive a physical examination than was the last patient seen. Patients in isolation were almost four times less likely to be examined, while higher SOFA scores slightly but significantly increased the likelihood of an examination.

As clinical experience increased, the likelihood of a lead physician conducting a physical examination decreased, with fellows being most lax, said Dr. Al-Sarraf. During briefer multidisciplinary rounds, just 8% of patients were physically examined.

Each patient seen during multidisciplinary rounds was seen for a shorter time than the previous patient was. When more health care professionals attended rounds, time spent at a patient's bedside increased, as was also true with a higher SOFA score.

Dr. Al-Sarraf concluded that “patient, caregiver, and ICU organization factors significantly influence bedside clinical examination and assessment practices.”

During the discussion following his talk, Dr. Al-Sarraf acknowledged that the study did not include any measures that would determine whether physical examinations correlated with improved outcome. He said that this might be a fruitful avenue for future research, particularly because technology has taken physicians increasingly away from patients' bedsides.

HONOLULU — Fewer than half of critically ill patients received a physical examination from their primary intensive care unit physicians each day, Canadian researchers have found.

Patients seen first during rounds, those with higher Sequential Organ Failure Assessment (SOFA) scores, and those not in isolation were more likely to be examined by their lead physicians during surreptitious line-of-sight observations of 195 patient/physician encounters, according to the findings of a study presented at the annual congress of the Society of Critical Care Medicine.

During multidisciplinary rounds, time spent at each ICU patient's bedside averaged 8 minutes, with progressively less time spent on each subsequent patient in the rounding order. Time spent at the bedside increased with higher SOFA scores and with the number of health professionals attending medical rounds.

Dr. Adel Al-Sarraf led the study at Sunnybrook Health Sciences Centre in Toronto, in which an impartial observer with critical care experience timed patient encounters and noted whether each ICU patient received a physical examination each day.

The busy academic medical center ICU had a mean 95.6% occupancy during the study, with a ratio of medical to surgical patients of 31:69. Nearly half of patients were mechanically ventilated, and 9% were in isolation. The mean Acute Physiology and Chronic Health Evaluation (APACHE) score for the study population was 19.6.

Lead physicians physically examined their patients in 87 of 195 daily encounters, or 46.5%.

The duration of the primary ICU physician's time at the bedside averaged 11 minutes, with 69 seconds spent on physical examination.

The first patient seen by the lead physician was 2.5 times more likely to receive a physical examination than was the last patient seen. Patients in isolation were almost four times less likely to be examined, while higher SOFA scores slightly but significantly increased the likelihood of an examination.

As clinical experience increased, the likelihood of a lead physician conducting a physical examination decreased, with fellows being most lax, said Dr. Al-Sarraf. During briefer multidisciplinary rounds, just 8% of patients were physically examined.

Each patient seen during multidisciplinary rounds was seen for a shorter time than the previous patient was. When more health care professionals attended rounds, time spent at a patient's bedside increased, as was also true with a higher SOFA score.

Dr. Al-Sarraf concluded that “patient, caregiver, and ICU organization factors significantly influence bedside clinical examination and assessment practices.”

During the discussion following his talk, Dr. Al-Sarraf acknowledged that the study did not include any measures that would determine whether physical examinations correlated with improved outcome. He said that this might be a fruitful avenue for future research, particularly because technology has taken physicians increasingly away from patients' bedsides.

VANCOUVER, B.C. – Men live longer when a “watchful waiting” prostate cancer strategy is followed by treatment later in the course of the disease, compared with aggressive initial treatment, Dr. Li Li said at the annual meeting of the North American Primary Care Research Group.

Dr. Li and his associates from Case Western Reserve University, Cleveland, conducted a survival analysis using 1991-2001 Medicare-Surveillance, Epidemiology, and End Results (SEER) linked data, reviewing the disease course of 138,670 men diagnosed with prostate cancer. A follow-up analysis was performed in 2004. Survival was analyzed based on whether patients were followed by various cancer management strategies, including:

▸ Watchful waiting, in which patients received no initial treatment, but follow-up examinations after their diagnosis.

▸ Watchful waiting with delayed treatment, in which active hormone treatments were instituted during some follow-up point based on disease course.

▸ No treatment, in which patients did not receive any subsequent examinations or active treatments after the initial cancer diagnosis.

Overall survival and prostate-cancer specific survival rates were adjusted for age, ethnicity, comorbidity, screening, socioeconomic status, and cancer stage/grade.

Opting for no treatment or follow-up was associated with a “huge, almost fourfold increase in dying,” even among men who were older than 80 years, in all likelihood because the strategy prevented identification and treatment of competing causes of mortality, said Dr. Li.

However, even prostate-specific survival was strongly adversely affected by a lack of treatment or follow-up in men of all ages.

Watchful waiting with no subsequent treatment led to nearly 25% higher overall mortality than did aggressive treatment for men who were younger than 80 years, with a hazard ratio of 1.24 (1.19-1.28), whereas the strategy did not significantly increase mortality over aggressive treatment in older men (hazard ratio 1.04 (0.99-1.09).

Watchful waiting followed by treatment if necessary conferred a survival benefit regardless of mens' ages at diagnosis, said Dr. Li during an oral presentation at the meeting.

Men followed by watchful waiting who did eventually receive treatment for prostate cancer had lower all-cause mortality than any other strategy: watchful waiting without treatment, hormone therapy only, or no treatment or follow-up.

In men under age 80, the relative risk for survival with this strategy was 0.88 (0.85-0.92); in men 80 and older, it was 0.72 (0.68-0.77), representing a 12% and 28% survival advantage, respectively.

When Dr. Li and his associates studied the 64% of men in the cohort who had low to intermediate risk prostate cancer, age became a factor as a strategic consideration.

In this group, watchful waiting without subsequent treatment led to slightly lower overall survival rates than did aggressive treatment in men over age 80, with a relative risk of 1.13 (1.06-1.22). The survival difference was greater for men aged 80 or younger, with a relative risk of 1.28 (1.22-1.33).

In both age groups of men at low to intermediate risk, watchful waiting followed by treatment led to higher survival rates than any other strategy. Prostate cancer-specific survival was highest in low to intermediate-risk men who were followed by watchful waiting without subsequent treatment.

Among the oldest men (over age 80) in this risk group, watchful waiting with delayed treatment prolonged disease-specific survival at about the same rates as aggressive treatment.

However, men under age 80 had diminished prostate-specific survival rates of nearly 40% when their treatment was delayed compared with initial aggressive treatment.

VANCOUVER, B.C. – Men live longer when a “watchful waiting” prostate cancer strategy is followed by treatment later in the course of the disease, compared with aggressive initial treatment, Dr. Li Li said at the annual meeting of the North American Primary Care Research Group.

Dr. Li and his associates from Case Western Reserve University, Cleveland, conducted a survival analysis using 1991-2001 Medicare-Surveillance, Epidemiology, and End Results (SEER) linked data, reviewing the disease course of 138,670 men diagnosed with prostate cancer. A follow-up analysis was performed in 2004. Survival was analyzed based on whether patients were followed by various cancer management strategies, including:

▸ Watchful waiting, in which patients received no initial treatment, but follow-up examinations after their diagnosis.

▸ Watchful waiting with delayed treatment, in which active hormone treatments were instituted during some follow-up point based on disease course.

▸ No treatment, in which patients did not receive any subsequent examinations or active treatments after the initial cancer diagnosis.

Overall survival and prostate-cancer specific survival rates were adjusted for age, ethnicity, comorbidity, screening, socioeconomic status, and cancer stage/grade.

Opting for no treatment or follow-up was associated with a “huge, almost fourfold increase in dying,” even among men who were older than 80 years, in all likelihood because the strategy prevented identification and treatment of competing causes of mortality, said Dr. Li.

However, even prostate-specific survival was strongly adversely affected by a lack of treatment or follow-up in men of all ages.

Watchful waiting with no subsequent treatment led to nearly 25% higher overall mortality than did aggressive treatment for men who were younger than 80 years, with a hazard ratio of 1.24 (1.19-1.28), whereas the strategy did not significantly increase mortality over aggressive treatment in older men (hazard ratio 1.04 (0.99-1.09).

Watchful waiting followed by treatment if necessary conferred a survival benefit regardless of mens' ages at diagnosis, said Dr. Li during an oral presentation at the meeting.

Men followed by watchful waiting who did eventually receive treatment for prostate cancer had lower all-cause mortality than any other strategy: watchful waiting without treatment, hormone therapy only, or no treatment or follow-up.

In men under age 80, the relative risk for survival with this strategy was 0.88 (0.85-0.92); in men 80 and older, it was 0.72 (0.68-0.77), representing a 12% and 28% survival advantage, respectively.

When Dr. Li and his associates studied the 64% of men in the cohort who had low to intermediate risk prostate cancer, age became a factor as a strategic consideration.

In this group, watchful waiting without subsequent treatment led to slightly lower overall survival rates than did aggressive treatment in men over age 80, with a relative risk of 1.13 (1.06-1.22). The survival difference was greater for men aged 80 or younger, with a relative risk of 1.28 (1.22-1.33).

In both age groups of men at low to intermediate risk, watchful waiting followed by treatment led to higher survival rates than any other strategy. Prostate cancer-specific survival was highest in low to intermediate-risk men who were followed by watchful waiting without subsequent treatment.

Among the oldest men (over age 80) in this risk group, watchful waiting with delayed treatment prolonged disease-specific survival at about the same rates as aggressive treatment.

However, men under age 80 had diminished prostate-specific survival rates of nearly 40% when their treatment was delayed compared with initial aggressive treatment.

VANCOUVER, B.C. – Men live longer when a “watchful waiting” prostate cancer strategy is followed by treatment later in the course of the disease, compared with aggressive initial treatment, Dr. Li Li said at the annual meeting of the North American Primary Care Research Group.

Dr. Li and his associates from Case Western Reserve University, Cleveland, conducted a survival analysis using 1991-2001 Medicare-Surveillance, Epidemiology, and End Results (SEER) linked data, reviewing the disease course of 138,670 men diagnosed with prostate cancer. A follow-up analysis was performed in 2004. Survival was analyzed based on whether patients were followed by various cancer management strategies, including:

▸ Watchful waiting, in which patients received no initial treatment, but follow-up examinations after their diagnosis.

▸ Watchful waiting with delayed treatment, in which active hormone treatments were instituted during some follow-up point based on disease course.

▸ No treatment, in which patients did not receive any subsequent examinations or active treatments after the initial cancer diagnosis.

Overall survival and prostate-cancer specific survival rates were adjusted for age, ethnicity, comorbidity, screening, socioeconomic status, and cancer stage/grade.

Opting for no treatment or follow-up was associated with a “huge, almost fourfold increase in dying,” even among men who were older than 80 years, in all likelihood because the strategy prevented identification and treatment of competing causes of mortality, said Dr. Li.

However, even prostate-specific survival was strongly adversely affected by a lack of treatment or follow-up in men of all ages.

Watchful waiting with no subsequent treatment led to nearly 25% higher overall mortality than did aggressive treatment for men who were younger than 80 years, with a hazard ratio of 1.24 (1.19-1.28), whereas the strategy did not significantly increase mortality over aggressive treatment in older men (hazard ratio 1.04 (0.99-1.09).

Watchful waiting followed by treatment if necessary conferred a survival benefit regardless of mens' ages at diagnosis, said Dr. Li during an oral presentation at the meeting.

Men followed by watchful waiting who did eventually receive treatment for prostate cancer had lower all-cause mortality than any other strategy: watchful waiting without treatment, hormone therapy only, or no treatment or follow-up.

In men under age 80, the relative risk for survival with this strategy was 0.88 (0.85-0.92); in men 80 and older, it was 0.72 (0.68-0.77), representing a 12% and 28% survival advantage, respectively.

When Dr. Li and his associates studied the 64% of men in the cohort who had low to intermediate risk prostate cancer, age became a factor as a strategic consideration.

In this group, watchful waiting without subsequent treatment led to slightly lower overall survival rates than did aggressive treatment in men over age 80, with a relative risk of 1.13 (1.06-1.22). The survival difference was greater for men aged 80 or younger, with a relative risk of 1.28 (1.22-1.33).

In both age groups of men at low to intermediate risk, watchful waiting followed by treatment led to higher survival rates than any other strategy. Prostate cancer-specific survival was highest in low to intermediate-risk men who were followed by watchful waiting without subsequent treatment.

Among the oldest men (over age 80) in this risk group, watchful waiting with delayed treatment prolonged disease-specific survival at about the same rates as aggressive treatment.

However, men under age 80 had diminished prostate-specific survival rates of nearly 40% when their treatment was delayed compared with initial aggressive treatment.

STANFORD, CALIF. – Picture a 15-year-old Hispanic girl who is 152.5 cm tall, weighs 88.7 kg, and has a body mass index of 38 kg/m

Her father has hyperlipidemia, but she has no family history of a premature coronary artery event (such as a myocardial infarction in a family member less than 55 years old) and no physical signs of hypercholesterolemia such as xanthomas under the skin.

Her fasting lipid profile is the following: total cholesterol, 267 mg/dL; triglycerides, 255 mg/dL; HDL cholesterol, 51 mg/dL; and LDL cholesterol, 164 mg/dL.

When would Dr. Clifford Chin consider initiating cholestyramine or a statin medication?

“The short answer is never,” said Dr. Chin, a pediatric cardiologist and codirector of the pediatric heart transplant program at the Lucile Packard Children's Hospital at Stanford (Calif.) University.

“I feel fairly strongly we should not give an individual with obesity a pill. I think it sends a message: 'It's not up to me. It doesn't matter what I do. I'll take this pill and I'll be fine,' “he said at a recent pediatric update sponsored by Stanford University. “[Patients with] hyperlipidemia induced by obesity [in childhood] should have obesity treatment as their primary therapy.”

Children who have genetic abnormalities at the root of their dyslipidemia may well require medical therapy, even at a young age.

But in today's children, dubbed “Generation XXL” by some, hyperlipidemia is far more likely to be caused by obesity.

In this scenario, the evidence favoring drug therapy is far from clear, according to Dr. Chin.

Most obese children do not have significant elevations in LDL cholesterol. “It's triglycerides [that drive up their total cholesterol], and we don't have much evidence that lowering triglycerides has an impact on premature coronary artery disease,” said Dr. Chin.

Indeed, no study to date has demonstrated that lowering lipids in general during childhood has any effect on the end point of preventing coronary events in adults.

The long-term impact of cholesterol-lowering drugs has not been studied in children and “no one knows the optimal timing of when to initiate drug therapy,” he stressed.

Given the dearth of evidence of benefit, Dr. Chin's policy is to focus on dietary therapy and lifestyle changes in obese adolescents and reserve medications for those with such conditions as familial hypercholesterolemia caused by genetic mutations.

At Stanford, obese children can be referred to a specialized teen weight clinic or be seen by a pediatric nutritionist.

Dr. Chin counsels families to follow the American Heart Association Step I diet, which emphasizes a daily intake of no more than 30% of total calories from fat and less than 10% of total calories from saturated fat.

An easy way to begin is to cut starch intake by half in each meal and make up the difference in vegetables, he said.

Close monitoring and encouragement can help, but medication actually may interfere with lifestyle adaptation by making it seem unnecessary, he said.

Even children with a strong family history of premature coronary disease deserve a full lipoprotein profile rather than a simple total cholesterol screen before any decision is reached about initiating cholesterol-lowering therapy, he said.

In a typical cholesterol panel, the LDL cholesterol is not measured directly, but calculated according to a formula based on total cholesterol.

A full lipoprotein profile offered reassuring news to the parents of a 7-year-old Asian American boy who had three relatives who suffered premature coronary events (myocardial infarction, angina pectoris, and established coronary atherosclerosis by imaging, sudden cardiac death, or peripheral or cerebrovascular disease before the age of 55 years).

This child's height was 120 cm; weight, 23 kg; and BMI, normal at 16 kg/m

His total fasting cholesterol was 220 mg/dL, but his triglycerides were in the normal range at 100 mg/dL, his HDL cholesterol 80 mg/dL, and LDL cholesterol 120 mg/dL.

“Although he comes from a family with premature coronary disease, he seems somewhat protected,” said Dr. Chin.

He would follow the child and order a repeat lipoprotein profile at age 12, but for now, this child does not require medical therapy, he concluded.

STANFORD, CALIF. – Picture a 15-year-old Hispanic girl who is 152.5 cm tall, weighs 88.7 kg, and has a body mass index of 38 kg/m

Her father has hyperlipidemia, but she has no family history of a premature coronary artery event (such as a myocardial infarction in a family member less than 55 years old) and no physical signs of hypercholesterolemia such as xanthomas under the skin.

Her fasting lipid profile is the following: total cholesterol, 267 mg/dL; triglycerides, 255 mg/dL; HDL cholesterol, 51 mg/dL; and LDL cholesterol, 164 mg/dL.

When would Dr. Clifford Chin consider initiating cholestyramine or a statin medication?

“The short answer is never,” said Dr. Chin, a pediatric cardiologist and codirector of the pediatric heart transplant program at the Lucile Packard Children's Hospital at Stanford (Calif.) University.

“I feel fairly strongly we should not give an individual with obesity a pill. I think it sends a message: 'It's not up to me. It doesn't matter what I do. I'll take this pill and I'll be fine,' “he said at a recent pediatric update sponsored by Stanford University. “[Patients with] hyperlipidemia induced by obesity [in childhood] should have obesity treatment as their primary therapy.”

Children who have genetic abnormalities at the root of their dyslipidemia may well require medical therapy, even at a young age.

But in today's children, dubbed “Generation XXL” by some, hyperlipidemia is far more likely to be caused by obesity.

In this scenario, the evidence favoring drug therapy is far from clear, according to Dr. Chin.

Most obese children do not have significant elevations in LDL cholesterol. “It's triglycerides [that drive up their total cholesterol], and we don't have much evidence that lowering triglycerides has an impact on premature coronary artery disease,” said Dr. Chin.

Indeed, no study to date has demonstrated that lowering lipids in general during childhood has any effect on the end point of preventing coronary events in adults.

The long-term impact of cholesterol-lowering drugs has not been studied in children and “no one knows the optimal timing of when to initiate drug therapy,” he stressed.

Given the dearth of evidence of benefit, Dr. Chin's policy is to focus on dietary therapy and lifestyle changes in obese adolescents and reserve medications for those with such conditions as familial hypercholesterolemia caused by genetic mutations.

At Stanford, obese children can be referred to a specialized teen weight clinic or be seen by a pediatric nutritionist.

Dr. Chin counsels families to follow the American Heart Association Step I diet, which emphasizes a daily intake of no more than 30% of total calories from fat and less than 10% of total calories from saturated fat.

An easy way to begin is to cut starch intake by half in each meal and make up the difference in vegetables, he said.

Close monitoring and encouragement can help, but medication actually may interfere with lifestyle adaptation by making it seem unnecessary, he said.

Even children with a strong family history of premature coronary disease deserve a full lipoprotein profile rather than a simple total cholesterol screen before any decision is reached about initiating cholesterol-lowering therapy, he said.

In a typical cholesterol panel, the LDL cholesterol is not measured directly, but calculated according to a formula based on total cholesterol.

A full lipoprotein profile offered reassuring news to the parents of a 7-year-old Asian American boy who had three relatives who suffered premature coronary events (myocardial infarction, angina pectoris, and established coronary atherosclerosis by imaging, sudden cardiac death, or peripheral or cerebrovascular disease before the age of 55 years).

This child's height was 120 cm; weight, 23 kg; and BMI, normal at 16 kg/m

His total fasting cholesterol was 220 mg/dL, but his triglycerides were in the normal range at 100 mg/dL, his HDL cholesterol 80 mg/dL, and LDL cholesterol 120 mg/dL.

“Although he comes from a family with premature coronary disease, he seems somewhat protected,” said Dr. Chin.

He would follow the child and order a repeat lipoprotein profile at age 12, but for now, this child does not require medical therapy, he concluded.

STANFORD, CALIF. – Picture a 15-year-old Hispanic girl who is 152.5 cm tall, weighs 88.7 kg, and has a body mass index of 38 kg/m

Her father has hyperlipidemia, but she has no family history of a premature coronary artery event (such as a myocardial infarction in a family member less than 55 years old) and no physical signs of hypercholesterolemia such as xanthomas under the skin.

Her fasting lipid profile is the following: total cholesterol, 267 mg/dL; triglycerides, 255 mg/dL; HDL cholesterol, 51 mg/dL; and LDL cholesterol, 164 mg/dL.

When would Dr. Clifford Chin consider initiating cholestyramine or a statin medication?

“The short answer is never,” said Dr. Chin, a pediatric cardiologist and codirector of the pediatric heart transplant program at the Lucile Packard Children's Hospital at Stanford (Calif.) University.

“I feel fairly strongly we should not give an individual with obesity a pill. I think it sends a message: 'It's not up to me. It doesn't matter what I do. I'll take this pill and I'll be fine,' “he said at a recent pediatric update sponsored by Stanford University. “[Patients with] hyperlipidemia induced by obesity [in childhood] should have obesity treatment as their primary therapy.”

Children who have genetic abnormalities at the root of their dyslipidemia may well require medical therapy, even at a young age.

But in today's children, dubbed “Generation XXL” by some, hyperlipidemia is far more likely to be caused by obesity.

In this scenario, the evidence favoring drug therapy is far from clear, according to Dr. Chin.

Most obese children do not have significant elevations in LDL cholesterol. “It's triglycerides [that drive up their total cholesterol], and we don't have much evidence that lowering triglycerides has an impact on premature coronary artery disease,” said Dr. Chin.

Indeed, no study to date has demonstrated that lowering lipids in general during childhood has any effect on the end point of preventing coronary events in adults.

The long-term impact of cholesterol-lowering drugs has not been studied in children and “no one knows the optimal timing of when to initiate drug therapy,” he stressed.

Given the dearth of evidence of benefit, Dr. Chin's policy is to focus on dietary therapy and lifestyle changes in obese adolescents and reserve medications for those with such conditions as familial hypercholesterolemia caused by genetic mutations.

At Stanford, obese children can be referred to a specialized teen weight clinic or be seen by a pediatric nutritionist.

Dr. Chin counsels families to follow the American Heart Association Step I diet, which emphasizes a daily intake of no more than 30% of total calories from fat and less than 10% of total calories from saturated fat.

An easy way to begin is to cut starch intake by half in each meal and make up the difference in vegetables, he said.

Close monitoring and encouragement can help, but medication actually may interfere with lifestyle adaptation by making it seem unnecessary, he said.

Even children with a strong family history of premature coronary disease deserve a full lipoprotein profile rather than a simple total cholesterol screen before any decision is reached about initiating cholesterol-lowering therapy, he said.

In a typical cholesterol panel, the LDL cholesterol is not measured directly, but calculated according to a formula based on total cholesterol.

A full lipoprotein profile offered reassuring news to the parents of a 7-year-old Asian American boy who had three relatives who suffered premature coronary events (myocardial infarction, angina pectoris, and established coronary atherosclerosis by imaging, sudden cardiac death, or peripheral or cerebrovascular disease before the age of 55 years).

This child's height was 120 cm; weight, 23 kg; and BMI, normal at 16 kg/m

His total fasting cholesterol was 220 mg/dL, but his triglycerides were in the normal range at 100 mg/dL, his HDL cholesterol 80 mg/dL, and LDL cholesterol 120 mg/dL.

“Although he comes from a family with premature coronary disease, he seems somewhat protected,” said Dr. Chin.

He would follow the child and order a repeat lipoprotein profile at age 12, but for now, this child does not require medical therapy, he concluded.

STANFORD, CALIF. — California's kindergartners speak 100 different dialects, in what may offer a preview for the rest of the changing nation, Dr. Fernando S. Mendoza said during a pediatric update sponsored by Stanford University.

“Just try to be culturally competent with 100 different languages,” said Dr. Mendoza, professor and chief of the division of general pediatrics at the university.

Culture, he explained, involves not only language but also thoughts, communication, actions, customs, beliefs, values, and institutions reflecting racial, ethnic, religious, or social groups.

In our diverse society, ignoring such differences risks alienating and confusing families and delivering substandard medical care through misunderstanding and misinterpretation.

Becoming cross-culturally effective means borrowing techniques from anthropology, counseled Dr. Mendoza as he asked pediatricians to watch, listen, and elicit family participation by asking the question, “What do you think is going on with your child?”

Paying attention to the process of interacting—body language, respect, and the human connection—will go further in building physician-family partnerships than will trying to learn details of each culture represented in one's practice, particularly as the U.S. pediatric population becomes less and less white.

In California, half of the babies born today are Hispanic and 70% are Hispanic, African American, or Asian American or Pacific Islander, according to Kidsdata from the Lucile Packard Foundation for Children's Health in Palo Alto.

Nationwide, there is a parallel trend, with non-Hispanic whites expected to constitute less than half of the country's population by the year 2050, the U.S. Census Bureau predicts.

Unless pediatric residency programs become far more diverse, it means fewer and fewer pediatricians will share a culture with the majority of their patients, said Dr. Mendoza.

In 2006, the American Academy of Pediatrics reported that 61% of residents and 71% of postresidents were non-Hispanic whites, compared with 2% and 6% who were Hispanics, respectively; 29% and 17%, Asian Americans; and 5% and 6%, blacks. These data are from the 2006 AAP Periodic Survey of Fellows to which 859 U.S. nonretired AAP members responded; a national random sample of members was mailed the survey.

Already, many Hispanic children are unlikely to be served by physicians who look like them and speak the language they hear at home, yet they are particularly in need of competent care. Hispanic children lead the nation in tuberculosis and obesity prevalence, incomplete immunizations, poor dental health, and poor health perception. Bridging the language gap would be a start toward meeting the urgent health needs of these children, according to Dr. Mendoza.

Although 31% of California's residents are Hispanic (12% with limited English proficiency), just 4% of California's physicians are Hispanic, according to American Medical Association Physician Masterfile and the California Department of Finance. Spanish fluency among pediatricians is highly variable, leading to inevitable errors in communication.

One study found that 68% of pediatric residents in one program had limited or no fluency in Spanish, yet half tried to use their limited language skills to communicate with Spanish-speaking patients on a daily basis. Professional interpreters rarely were used, the study said.

Another study, this one done outside of California, found an average of 31 errors in taped pediatric encounters involving limited English proficiency families, with 63% of these errors considered medically consequential. Even official medical interpreters made numerous errors during the study, and 53% of their errors were consequential.

Dr. Mendoza mentioned two nonprofit association Web sites that offer interpreter training and assistance, http://cms.chiaonline.orgwww.mmia.org/resources/links.aspwww.languageline.com

STANFORD, CALIF. — California's kindergartners speak 100 different dialects, in what may offer a preview for the rest of the changing nation, Dr. Fernando S. Mendoza said during a pediatric update sponsored by Stanford University.

“Just try to be culturally competent with 100 different languages,” said Dr. Mendoza, professor and chief of the division of general pediatrics at the university.

Culture, he explained, involves not only language but also thoughts, communication, actions, customs, beliefs, values, and institutions reflecting racial, ethnic, religious, or social groups.

In our diverse society, ignoring such differences risks alienating and confusing families and delivering substandard medical care through misunderstanding and misinterpretation.

Becoming cross-culturally effective means borrowing techniques from anthropology, counseled Dr. Mendoza as he asked pediatricians to watch, listen, and elicit family participation by asking the question, “What do you think is going on with your child?”

Paying attention to the process of interacting—body language, respect, and the human connection—will go further in building physician-family partnerships than will trying to learn details of each culture represented in one's practice, particularly as the U.S. pediatric population becomes less and less white.

In California, half of the babies born today are Hispanic and 70% are Hispanic, African American, or Asian American or Pacific Islander, according to Kidsdata from the Lucile Packard Foundation for Children's Health in Palo Alto.

Nationwide, there is a parallel trend, with non-Hispanic whites expected to constitute less than half of the country's population by the year 2050, the U.S. Census Bureau predicts.

Unless pediatric residency programs become far more diverse, it means fewer and fewer pediatricians will share a culture with the majority of their patients, said Dr. Mendoza.

In 2006, the American Academy of Pediatrics reported that 61% of residents and 71% of postresidents were non-Hispanic whites, compared with 2% and 6% who were Hispanics, respectively; 29% and 17%, Asian Americans; and 5% and 6%, blacks. These data are from the 2006 AAP Periodic Survey of Fellows to which 859 U.S. nonretired AAP members responded; a national random sample of members was mailed the survey.

Already, many Hispanic children are unlikely to be served by physicians who look like them and speak the language they hear at home, yet they are particularly in need of competent care. Hispanic children lead the nation in tuberculosis and obesity prevalence, incomplete immunizations, poor dental health, and poor health perception. Bridging the language gap would be a start toward meeting the urgent health needs of these children, according to Dr. Mendoza.

Although 31% of California's residents are Hispanic (12% with limited English proficiency), just 4% of California's physicians are Hispanic, according to American Medical Association Physician Masterfile and the California Department of Finance. Spanish fluency among pediatricians is highly variable, leading to inevitable errors in communication.

One study found that 68% of pediatric residents in one program had limited or no fluency in Spanish, yet half tried to use their limited language skills to communicate with Spanish-speaking patients on a daily basis. Professional interpreters rarely were used, the study said.

Another study, this one done outside of California, found an average of 31 errors in taped pediatric encounters involving limited English proficiency families, with 63% of these errors considered medically consequential. Even official medical interpreters made numerous errors during the study, and 53% of their errors were consequential.

Dr. Mendoza mentioned two nonprofit association Web sites that offer interpreter training and assistance, http://cms.chiaonline.orgwww.mmia.org/resources/links.aspwww.languageline.com

STANFORD, CALIF. — California's kindergartners speak 100 different dialects, in what may offer a preview for the rest of the changing nation, Dr. Fernando S. Mendoza said during a pediatric update sponsored by Stanford University.

“Just try to be culturally competent with 100 different languages,” said Dr. Mendoza, professor and chief of the division of general pediatrics at the university.

Culture, he explained, involves not only language but also thoughts, communication, actions, customs, beliefs, values, and institutions reflecting racial, ethnic, religious, or social groups.

In our diverse society, ignoring such differences risks alienating and confusing families and delivering substandard medical care through misunderstanding and misinterpretation.

Becoming cross-culturally effective means borrowing techniques from anthropology, counseled Dr. Mendoza as he asked pediatricians to watch, listen, and elicit family participation by asking the question, “What do you think is going on with your child?”

Paying attention to the process of interacting—body language, respect, and the human connection—will go further in building physician-family partnerships than will trying to learn details of each culture represented in one's practice, particularly as the U.S. pediatric population becomes less and less white.

In California, half of the babies born today are Hispanic and 70% are Hispanic, African American, or Asian American or Pacific Islander, according to Kidsdata from the Lucile Packard Foundation for Children's Health in Palo Alto.

Nationwide, there is a parallel trend, with non-Hispanic whites expected to constitute less than half of the country's population by the year 2050, the U.S. Census Bureau predicts.

Unless pediatric residency programs become far more diverse, it means fewer and fewer pediatricians will share a culture with the majority of their patients, said Dr. Mendoza.

In 2006, the American Academy of Pediatrics reported that 61% of residents and 71% of postresidents were non-Hispanic whites, compared with 2% and 6% who were Hispanics, respectively; 29% and 17%, Asian Americans; and 5% and 6%, blacks. These data are from the 2006 AAP Periodic Survey of Fellows to which 859 U.S. nonretired AAP members responded; a national random sample of members was mailed the survey.

Already, many Hispanic children are unlikely to be served by physicians who look like them and speak the language they hear at home, yet they are particularly in need of competent care. Hispanic children lead the nation in tuberculosis and obesity prevalence, incomplete immunizations, poor dental health, and poor health perception. Bridging the language gap would be a start toward meeting the urgent health needs of these children, according to Dr. Mendoza.

Although 31% of California's residents are Hispanic (12% with limited English proficiency), just 4% of California's physicians are Hispanic, according to American Medical Association Physician Masterfile and the California Department of Finance. Spanish fluency among pediatricians is highly variable, leading to inevitable errors in communication.

One study found that 68% of pediatric residents in one program had limited or no fluency in Spanish, yet half tried to use their limited language skills to communicate with Spanish-speaking patients on a daily basis. Professional interpreters rarely were used, the study said.

Another study, this one done outside of California, found an average of 31 errors in taped pediatric encounters involving limited English proficiency families, with 63% of these errors considered medically consequential. Even official medical interpreters made numerous errors during the study, and 53% of their errors were consequential.

Dr. Mendoza mentioned two nonprofit association Web sites that offer interpreter training and assistance, http://cms.chiaonline.orgwww.mmia.org/resources/links.aspwww.languageline.com

VANCOUVER, B.C. — Family physicians provide ambulatory care to a higher proportion of disadvantaged adults than do other specialists, including general internists, according to a study presented at the annual meeting of the North American Primary Care Research Group.

Dr. Robert Ferrer of the University of Texas Health Science Center, San Antonio, analyzed 2004 data from the Medical Expenditure Panel Survey of that year by comparing proportional access to physicians and midlevel practitioners by people disadvantaged by income, health insurance status, race or ethnicity, and rural or urban status. He presented his findings during a Distinguished Paper session at the meeting.

Adults with at least three markers of disadvantaged status received just under 46% of their ambulatory care from family physicians, said Dr. Ferrer, whereas adults with no markers of disadvantage received about 31% of their care from family physicians.

Family physicians provided a higher proportional level of care to poor, near-poor, low-income, and publicly insured patients than did general internists, surgical specialists, other medical specialists, nurse practitioners, or physician assistants.

Internists provided a higher proportion of care to blacks than did other specialists, which may be explained by the presence of major hospitals and residency programs in urban areas, noted Dr. Ferrer.

Midlevel providers, including physician assistants and nurse practitioners, followed by family physicians, provided the highest proportion of care to rural adults.

In addition, family physicians even provided a disproportionate share of care to poor, near-poor, and low- and medium-income children, compared with pediatricians or nurse practitioners.

Pediatricians saw many more children overall than did family physicians, but more than 30% of children with at least three markers of disadvantage saw a family physician for ambulatory care, compared with just under 17% of children with no markers of disadvantage.

“[FPs] are the only clinician group that does not demonstrate income disparities in access to care,” Dr. Ferrer concluded.

VANCOUVER, B.C. — Family physicians provide ambulatory care to a higher proportion of disadvantaged adults than do other specialists, including general internists, according to a study presented at the annual meeting of the North American Primary Care Research Group.

Dr. Robert Ferrer of the University of Texas Health Science Center, San Antonio, analyzed 2004 data from the Medical Expenditure Panel Survey of that year by comparing proportional access to physicians and midlevel practitioners by people disadvantaged by income, health insurance status, race or ethnicity, and rural or urban status. He presented his findings during a Distinguished Paper session at the meeting.

Adults with at least three markers of disadvantaged status received just under 46% of their ambulatory care from family physicians, said Dr. Ferrer, whereas adults with no markers of disadvantage received about 31% of their care from family physicians.

Family physicians provided a higher proportional level of care to poor, near-poor, low-income, and publicly insured patients than did general internists, surgical specialists, other medical specialists, nurse practitioners, or physician assistants.

Internists provided a higher proportion of care to blacks than did other specialists, which may be explained by the presence of major hospitals and residency programs in urban areas, noted Dr. Ferrer.

Midlevel providers, including physician assistants and nurse practitioners, followed by family physicians, provided the highest proportion of care to rural adults.

In addition, family physicians even provided a disproportionate share of care to poor, near-poor, and low- and medium-income children, compared with pediatricians or nurse practitioners.

Pediatricians saw many more children overall than did family physicians, but more than 30% of children with at least three markers of disadvantage saw a family physician for ambulatory care, compared with just under 17% of children with no markers of disadvantage.

“[FPs] are the only clinician group that does not demonstrate income disparities in access to care,” Dr. Ferrer concluded.

VANCOUVER, B.C. — Family physicians provide ambulatory care to a higher proportion of disadvantaged adults than do other specialists, including general internists, according to a study presented at the annual meeting of the North American Primary Care Research Group.

Dr. Robert Ferrer of the University of Texas Health Science Center, San Antonio, analyzed 2004 data from the Medical Expenditure Panel Survey of that year by comparing proportional access to physicians and midlevel practitioners by people disadvantaged by income, health insurance status, race or ethnicity, and rural or urban status. He presented his findings during a Distinguished Paper session at the meeting.

Adults with at least three markers of disadvantaged status received just under 46% of their ambulatory care from family physicians, said Dr. Ferrer, whereas adults with no markers of disadvantage received about 31% of their care from family physicians.

Family physicians provided a higher proportional level of care to poor, near-poor, low-income, and publicly insured patients than did general internists, surgical specialists, other medical specialists, nurse practitioners, or physician assistants.

Internists provided a higher proportion of care to blacks than did other specialists, which may be explained by the presence of major hospitals and residency programs in urban areas, noted Dr. Ferrer.

Midlevel providers, including physician assistants and nurse practitioners, followed by family physicians, provided the highest proportion of care to rural adults.

In addition, family physicians even provided a disproportionate share of care to poor, near-poor, and low- and medium-income children, compared with pediatricians or nurse practitioners.

Pediatricians saw many more children overall than did family physicians, but more than 30% of children with at least three markers of disadvantage saw a family physician for ambulatory care, compared with just under 17% of children with no markers of disadvantage.

“[FPs] are the only clinician group that does not demonstrate income disparities in access to care,” Dr. Ferrer concluded.

VICTORIA, B.C. — More than midway through the family medicine TransforMED National Demonstration Project, organizers have learned to focus on relationships, systems, and technology in converting offices into places where teams deliver efficient, patient-centered, prevention-focused care.

That was the message from Elizabeth Stewart, Ph.D., an analyst for the American Academy of Family Physicians, as she described some of the hurdles and successes experienced by 36 practices selected to test new models of care in the real world.

The task, she said, has proved daunting to the 18 facilitated and 18 self-directed practices from Scottsdale, Ariz., to Harlan, Iowa, chosen to begin to implement goals set out in the Future of Family Medicine collaborative project completed in 2004.

The TransforMED practice redesign initiative fosters a focus on the personal medical home, patient-centered care, the continuous care relationship, and a whole-person orientation.

“Implementation is an absolutely monumental undertaking,” Dr. Stewart said during a paper presentation session at the annual meeting of the North American Primary Care Research Group.

“A family medicine practice [adjusting to the TransforMED model of care] in today's world is like a 1950s DC3 trying to transform in midair to the Starship Enterprise. They have to keep seeing patients.”

One of the most difficult challenges has been the shift from individual leadership and individualistic performance goals to shared leadership systems in which everyone in an office works together in synchrony. Sometimes this requires a personal transformation by a physician who is used to making all the decisions, or by staff members who might be comfortable with the status quo and not altogether enthusiastic about being empowered to do more, said Dr. Stewart.

The most successful demonstration practices have distributed leadership among three individuals: one focused on vision, one on operations (“making it happen”), and one on finance, she explained.

As part of the TransforMED project, facilitators were assigned to help half of the practices implement changes through site visits, learning sessions, conference calls, Web seminars, referrals to national consultants, and nearly constant phone and e-mail communication.

They soon learned that some practices had “serious dysfunctional problems at baseline,” despite a high degree of motivation, evident by their willingness to participate as early adopters of the new model of care delivery, Dr. Stewart said.

Technology, initially envisioned by some participants as a “plug and play” ticket to better office efficiency, proved to be one of the most frustrating challenges for practices. One practice, for example, spent 14 months trying to integrate a disease registry into its existing electronic health record system.

“Frustration with some of these technological elements have been so difficult it tends to cloud [satisfaction with] other parts of the transformation process,” she said.

TransforMED facilitators also learned that physicians' visions for the new model varied considerably. Some practices most hoped to cultivate a proactive, population-based approach to care, rather than focusing exclusively on individual patients. Others voiced a desire to create a “joyful practice, where people like to come to work.” A few hoped the new model would mean, “I can push a button and technology does everything we want.”

At a midpoint in implementation, Dr. Stewart concluded that certain key elements seem critical to success. One is cohesive facilitation, meaning that practices have access to technical and structural guidance in adapting to goals of the future.

Perhaps more importantly, however, are lessons about how to shift from individualistic office styles to a systems approach in which staff members cooperate and perform to their highest abilities.

Some physicians started out wary of the “warm and fuzzy stuff” such as relationship building and power sharing, but most tended to give high marks to the new office equilibrium once it evolves. One skeptic, for example, said that he felt for the first time in 10 years that he was coming to work at a “real practice that works.”

Even highly motivated, highly successful practices suffer from “change fatigue,” when many new model transformations are attempted at once.

VICTORIA, B.C. — More than midway through the family medicine TransforMED National Demonstration Project, organizers have learned to focus on relationships, systems, and technology in converting offices into places where teams deliver efficient, patient-centered, prevention-focused care.

That was the message from Elizabeth Stewart, Ph.D., an analyst for the American Academy of Family Physicians, as she described some of the hurdles and successes experienced by 36 practices selected to test new models of care in the real world.

The task, she said, has proved daunting to the 18 facilitated and 18 self-directed practices from Scottsdale, Ariz., to Harlan, Iowa, chosen to begin to implement goals set out in the Future of Family Medicine collaborative project completed in 2004.

The TransforMED practice redesign initiative fosters a focus on the personal medical home, patient-centered care, the continuous care relationship, and a whole-person orientation.

“Implementation is an absolutely monumental undertaking,” Dr. Stewart said during a paper presentation session at the annual meeting of the North American Primary Care Research Group.

“A family medicine practice [adjusting to the TransforMED model of care] in today's world is like a 1950s DC3 trying to transform in midair to the Starship Enterprise. They have to keep seeing patients.”

One of the most difficult challenges has been the shift from individual leadership and individualistic performance goals to shared leadership systems in which everyone in an office works together in synchrony. Sometimes this requires a personal transformation by a physician who is used to making all the decisions, or by staff members who might be comfortable with the status quo and not altogether enthusiastic about being empowered to do more, said Dr. Stewart.

The most successful demonstration practices have distributed leadership among three individuals: one focused on vision, one on operations (“making it happen”), and one on finance, she explained.

As part of the TransforMED project, facilitators were assigned to help half of the practices implement changes through site visits, learning sessions, conference calls, Web seminars, referrals to national consultants, and nearly constant phone and e-mail communication.

They soon learned that some practices had “serious dysfunctional problems at baseline,” despite a high degree of motivation, evident by their willingness to participate as early adopters of the new model of care delivery, Dr. Stewart said.

Technology, initially envisioned by some participants as a “plug and play” ticket to better office efficiency, proved to be one of the most frustrating challenges for practices. One practice, for example, spent 14 months trying to integrate a disease registry into its existing electronic health record system.

“Frustration with some of these technological elements have been so difficult it tends to cloud [satisfaction with] other parts of the transformation process,” she said.

TransforMED facilitators also learned that physicians' visions for the new model varied considerably. Some practices most hoped to cultivate a proactive, population-based approach to care, rather than focusing exclusively on individual patients. Others voiced a desire to create a “joyful practice, where people like to come to work.” A few hoped the new model would mean, “I can push a button and technology does everything we want.”

At a midpoint in implementation, Dr. Stewart concluded that certain key elements seem critical to success. One is cohesive facilitation, meaning that practices have access to technical and structural guidance in adapting to goals of the future.

Perhaps more importantly, however, are lessons about how to shift from individualistic office styles to a systems approach in which staff members cooperate and perform to their highest abilities.

Some physicians started out wary of the “warm and fuzzy stuff” such as relationship building and power sharing, but most tended to give high marks to the new office equilibrium once it evolves. One skeptic, for example, said that he felt for the first time in 10 years that he was coming to work at a “real practice that works.”

Even highly motivated, highly successful practices suffer from “change fatigue,” when many new model transformations are attempted at once.

VICTORIA, B.C. — More than midway through the family medicine TransforMED National Demonstration Project, organizers have learned to focus on relationships, systems, and technology in converting offices into places where teams deliver efficient, patient-centered, prevention-focused care.

That was the message from Elizabeth Stewart, Ph.D., an analyst for the American Academy of Family Physicians, as she described some of the hurdles and successes experienced by 36 practices selected to test new models of care in the real world.

The task, she said, has proved daunting to the 18 facilitated and 18 self-directed practices from Scottsdale, Ariz., to Harlan, Iowa, chosen to begin to implement goals set out in the Future of Family Medicine collaborative project completed in 2004.

The TransforMED practice redesign initiative fosters a focus on the personal medical home, patient-centered care, the continuous care relationship, and a whole-person orientation.

“Implementation is an absolutely monumental undertaking,” Dr. Stewart said during a paper presentation session at the annual meeting of the North American Primary Care Research Group.

“A family medicine practice [adjusting to the TransforMED model of care] in today's world is like a 1950s DC3 trying to transform in midair to the Starship Enterprise. They have to keep seeing patients.”

One of the most difficult challenges has been the shift from individual leadership and individualistic performance goals to shared leadership systems in which everyone in an office works together in synchrony. Sometimes this requires a personal transformation by a physician who is used to making all the decisions, or by staff members who might be comfortable with the status quo and not altogether enthusiastic about being empowered to do more, said Dr. Stewart.

The most successful demonstration practices have distributed leadership among three individuals: one focused on vision, one on operations (“making it happen”), and one on finance, she explained.

As part of the TransforMED project, facilitators were assigned to help half of the practices implement changes through site visits, learning sessions, conference calls, Web seminars, referrals to national consultants, and nearly constant phone and e-mail communication.

They soon learned that some practices had “serious dysfunctional problems at baseline,” despite a high degree of motivation, evident by their willingness to participate as early adopters of the new model of care delivery, Dr. Stewart said.

Technology, initially envisioned by some participants as a “plug and play” ticket to better office efficiency, proved to be one of the most frustrating challenges for practices. One practice, for example, spent 14 months trying to integrate a disease registry into its existing electronic health record system.

“Frustration with some of these technological elements have been so difficult it tends to cloud [satisfaction with] other parts of the transformation process,” she said.

TransforMED facilitators also learned that physicians' visions for the new model varied considerably. Some practices most hoped to cultivate a proactive, population-based approach to care, rather than focusing exclusively on individual patients. Others voiced a desire to create a “joyful practice, where people like to come to work.” A few hoped the new model would mean, “I can push a button and technology does everything we want.”

At a midpoint in implementation, Dr. Stewart concluded that certain key elements seem critical to success. One is cohesive facilitation, meaning that practices have access to technical and structural guidance in adapting to goals of the future.

Perhaps more importantly, however, are lessons about how to shift from individualistic office styles to a systems approach in which staff members cooperate and perform to their highest abilities.

Some physicians started out wary of the “warm and fuzzy stuff” such as relationship building and power sharing, but most tended to give high marks to the new office equilibrium once it evolves. One skeptic, for example, said that he felt for the first time in 10 years that he was coming to work at a “real practice that works.”

Even highly motivated, highly successful practices suffer from “change fatigue,” when many new model transformations are attempted at once.

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

VANCOUVER, B.C. — Measuring a patient's height during routine primary care visits may be one of the simplest and least expensive ways to predict osteoporosis risk and to guide screening, according to a study at Virginia Commonwealth University, Richmond.

Height loss of 1.5 inches (about 4 cm) or more over 3 years was associated with almost a doubling of osteoporosis risk in patients aged 50 years or older in the study of 1,039 primary care patients, reported Dr. Emmeline Gasink at the annual meeting of the North American Primary Care Research Group.

Mean height loss in the study population was 0.596 inches, said Dr. Gasink, a resident in the family medicine program at Riverside Healthcare System in Carrollton, Va.

Among the 16% of patients who had a height loss of at least 1.5 inches, 3% had a diagnosis of osteoporosis (odds ratio, 1.8) of developing the disease.

Some patients (13%) had significant height loss but were not diagnosed with osteoporosis. Another 8% did not have significant height loss but had osteoporosis, perhaps representing osteoporosis in a nonvertebral site, said Dr. Gasink in an interview at the meeting.

Nonetheless, a height loss of 1.5 inches or greater over 3 years provided a positive predictive value of 21% for osteoporosis, she said.

The study population was 71% female, so the risk may be slightly less for males. Also, people with low bone density tend to lose height more rapidly than do those with greater bone density.

Still, the overall conclusion of the study, together with findings from five longitudinal trials reviewed by Dr. Gasink, suggest a “strong relationship” between height loss and a new vertebral fracture, lending strength to her findings.

“Height measurement should definitely be a part of a yearly physical for patients 50 and older, as recommended by the U.S. Preventive Health Task Force,” he said after the meeting. “As a family physician who follows these people over a period of years, [I suggest that] it would be an easy piece of data to help determine early risk factors for osteoporosis.”

VANCOUVER, B.C. — Measuring a patient's height during routine primary care visits may be one of the simplest and least expensive ways to predict osteoporosis risk and to guide screening, according to a study at Virginia Commonwealth University, Richmond.

Height loss of 1.5 inches (about 4 cm) or more over 3 years was associated with almost a doubling of osteoporosis risk in patients aged 50 years or older in the study of 1,039 primary care patients, reported Dr. Emmeline Gasink at the annual meeting of the North American Primary Care Research Group.

Mean height loss in the study population was 0.596 inches, said Dr. Gasink, a resident in the family medicine program at Riverside Healthcare System in Carrollton, Va.

Among the 16% of patients who had a height loss of at least 1.5 inches, 3% had a diagnosis of osteoporosis (odds ratio, 1.8) of developing the disease.

Some patients (13%) had significant height loss but were not diagnosed with osteoporosis. Another 8% did not have significant height loss but had osteoporosis, perhaps representing osteoporosis in a nonvertebral site, said Dr. Gasink in an interview at the meeting.

Nonetheless, a height loss of 1.5 inches or greater over 3 years provided a positive predictive value of 21% for osteoporosis, she said.

The study population was 71% female, so the risk may be slightly less for males. Also, people with low bone density tend to lose height more rapidly than do those with greater bone density.

Still, the overall conclusion of the study, together with findings from five longitudinal trials reviewed by Dr. Gasink, suggest a “strong relationship” between height loss and a new vertebral fracture, lending strength to her findings.

“Height measurement should definitely be a part of a yearly physical for patients 50 and older, as recommended by the U.S. Preventive Health Task Force,” he said after the meeting. “As a family physician who follows these people over a period of years, [I suggest that] it would be an easy piece of data to help determine early risk factors for osteoporosis.”

VANCOUVER, B.C. — Measuring a patient's height during routine primary care visits may be one of the simplest and least expensive ways to predict osteoporosis risk and to guide screening, according to a study at Virginia Commonwealth University, Richmond.

Height loss of 1.5 inches (about 4 cm) or more over 3 years was associated with almost a doubling of osteoporosis risk in patients aged 50 years or older in the study of 1,039 primary care patients, reported Dr. Emmeline Gasink at the annual meeting of the North American Primary Care Research Group.

Mean height loss in the study population was 0.596 inches, said Dr. Gasink, a resident in the family medicine program at Riverside Healthcare System in Carrollton, Va.

Among the 16% of patients who had a height loss of at least 1.5 inches, 3% had a diagnosis of osteoporosis (odds ratio, 1.8) of developing the disease.

Some patients (13%) had significant height loss but were not diagnosed with osteoporosis. Another 8% did not have significant height loss but had osteoporosis, perhaps representing osteoporosis in a nonvertebral site, said Dr. Gasink in an interview at the meeting.

Nonetheless, a height loss of 1.5 inches or greater over 3 years provided a positive predictive value of 21% for osteoporosis, she said.

The study population was 71% female, so the risk may be slightly less for males. Also, people with low bone density tend to lose height more rapidly than do those with greater bone density.

Still, the overall conclusion of the study, together with findings from five longitudinal trials reviewed by Dr. Gasink, suggest a “strong relationship” between height loss and a new vertebral fracture, lending strength to her findings.

“Height measurement should definitely be a part of a yearly physical for patients 50 and older, as recommended by the U.S. Preventive Health Task Force,” he said after the meeting. “As a family physician who follows these people over a period of years, [I suggest that] it would be an easy piece of data to help determine early risk factors for osteoporosis.”