Bruce K. Dixon

INDIANAPOLIS – Parents of children with inflammatory bowel disease perceive the effects of their children's illness more intensely than do the children themselves, according to Carin L. Cunningham, Ph.D.

“Treating physicians need to be aware of how the parents of children with inflammatory bowel disease are managing, because parental anxiety increases the child's anxiety,” Dr. Cunningham said during a poster session at the annual meeting of the Midwest Society for Pediatric Research.

Parents fret that their children may not lead normal lives or participate in normal activities, or that they may not be able to start a family of their own, Dr. Cunningham said in an interview.

“These concerns are most prevalent among parents who do not have IBD themselves,” explained Dr. Cunningham, a pediatric psychologist at the Rainbow Babies and Children's Hospital and Case Western Reserve University in Cleveland.

The study examined the health-related quality of life (HRQOL) of children and adolescents with inflammatory bowel disease (IBD), compared with the HRQOL of physically healthy peers, with emphasis on the effects of IBD and steroidal side effects.

The HRQOL scores of 49 children and adolescents (aged 10–18 years) with IBD and their parents, who completed the Child Health Questionnaire, were compared with those of healthy children.

“To our knowledge, this is the first study to describe the impact of IBD on HRQOL based on both a standardized measure and a controlled comparison of U.S. children and adolescents with IBD and physically healthy [peers] who were recruited from the same setting,” Dr. Cunningham and her associates said.

There are alternative interpretations of the discrepant findings between parent versus child reports of the impact of IBD on HRQOL, according to the investigators. “It is possible that children and adolescents with IBD are coping relatively well with the stressors of their condition and are not experiencing a significant impact of IBD-related problems on their HRQOL.”

Another possibility is that young people may deny or minimize the impact of IBD.

The study also found that:

▸ Caregivers of children with IBD reported that their children's physical and psychological health was more limited and that they experienced more worry and greater interference with their personal time, compared with caregivers of healthy children.

▸ Children and adolescents with IBD reported worse HRQOL than physically healthy children in only one domain, that of general health.

▸ Limitations in HRQOL were greatest in children who experienced more frequent IBD-related symptoms together with symptoms of steroidal side effects.

This suggests that children on steroids suffer the most, Dr. Cunningham said. “They become cushingoid, they gain weight, and often there's acne or stretch marks. This results in a lot of teasing from other kids, and these patients tell me they would rather have the pain of the illness than deal with the side effects of steroid medications.”

“Guidance counselors in Cleveland-area schools told me that kids will talk about their sex lives and drug use, but they won't open up about IBD, which is a bathroom issue,” she added.

INDIANAPOLIS – Parents of children with inflammatory bowel disease perceive the effects of their children's illness more intensely than do the children themselves, according to Carin L. Cunningham, Ph.D.

“Treating physicians need to be aware of how the parents of children with inflammatory bowel disease are managing, because parental anxiety increases the child's anxiety,” Dr. Cunningham said during a poster session at the annual meeting of the Midwest Society for Pediatric Research.

Parents fret that their children may not lead normal lives or participate in normal activities, or that they may not be able to start a family of their own, Dr. Cunningham said in an interview.

“These concerns are most prevalent among parents who do not have IBD themselves,” explained Dr. Cunningham, a pediatric psychologist at the Rainbow Babies and Children's Hospital and Case Western Reserve University in Cleveland.

The study examined the health-related quality of life (HRQOL) of children and adolescents with inflammatory bowel disease (IBD), compared with the HRQOL of physically healthy peers, with emphasis on the effects of IBD and steroidal side effects.

The HRQOL scores of 49 children and adolescents (aged 10–18 years) with IBD and their parents, who completed the Child Health Questionnaire, were compared with those of healthy children.

“To our knowledge, this is the first study to describe the impact of IBD on HRQOL based on both a standardized measure and a controlled comparison of U.S. children and adolescents with IBD and physically healthy [peers] who were recruited from the same setting,” Dr. Cunningham and her associates said.

There are alternative interpretations of the discrepant findings between parent versus child reports of the impact of IBD on HRQOL, according to the investigators. “It is possible that children and adolescents with IBD are coping relatively well with the stressors of their condition and are not experiencing a significant impact of IBD-related problems on their HRQOL.”

Another possibility is that young people may deny or minimize the impact of IBD.

The study also found that:

▸ Caregivers of children with IBD reported that their children's physical and psychological health was more limited and that they experienced more worry and greater interference with their personal time, compared with caregivers of healthy children.

▸ Children and adolescents with IBD reported worse HRQOL than physically healthy children in only one domain, that of general health.

▸ Limitations in HRQOL were greatest in children who experienced more frequent IBD-related symptoms together with symptoms of steroidal side effects.

This suggests that children on steroids suffer the most, Dr. Cunningham said. “They become cushingoid, they gain weight, and often there's acne or stretch marks. This results in a lot of teasing from other kids, and these patients tell me they would rather have the pain of the illness than deal with the side effects of steroid medications.”

“Guidance counselors in Cleveland-area schools told me that kids will talk about their sex lives and drug use, but they won't open up about IBD, which is a bathroom issue,” she added.

INDIANAPOLIS – Parents of children with inflammatory bowel disease perceive the effects of their children's illness more intensely than do the children themselves, according to Carin L. Cunningham, Ph.D.

“Treating physicians need to be aware of how the parents of children with inflammatory bowel disease are managing, because parental anxiety increases the child's anxiety,” Dr. Cunningham said during a poster session at the annual meeting of the Midwest Society for Pediatric Research.

Parents fret that their children may not lead normal lives or participate in normal activities, or that they may not be able to start a family of their own, Dr. Cunningham said in an interview.

“These concerns are most prevalent among parents who do not have IBD themselves,” explained Dr. Cunningham, a pediatric psychologist at the Rainbow Babies and Children's Hospital and Case Western Reserve University in Cleveland.

The study examined the health-related quality of life (HRQOL) of children and adolescents with inflammatory bowel disease (IBD), compared with the HRQOL of physically healthy peers, with emphasis on the effects of IBD and steroidal side effects.

The HRQOL scores of 49 children and adolescents (aged 10–18 years) with IBD and their parents, who completed the Child Health Questionnaire, were compared with those of healthy children.

“To our knowledge, this is the first study to describe the impact of IBD on HRQOL based on both a standardized measure and a controlled comparison of U.S. children and adolescents with IBD and physically healthy [peers] who were recruited from the same setting,” Dr. Cunningham and her associates said.

There are alternative interpretations of the discrepant findings between parent versus child reports of the impact of IBD on HRQOL, according to the investigators. “It is possible that children and adolescents with IBD are coping relatively well with the stressors of their condition and are not experiencing a significant impact of IBD-related problems on their HRQOL.”

Another possibility is that young people may deny or minimize the impact of IBD.

The study also found that:

▸ Caregivers of children with IBD reported that their children's physical and psychological health was more limited and that they experienced more worry and greater interference with their personal time, compared with caregivers of healthy children.

▸ Children and adolescents with IBD reported worse HRQOL than physically healthy children in only one domain, that of general health.

▸ Limitations in HRQOL were greatest in children who experienced more frequent IBD-related symptoms together with symptoms of steroidal side effects.

This suggests that children on steroids suffer the most, Dr. Cunningham said. “They become cushingoid, they gain weight, and often there's acne or stretch marks. This results in a lot of teasing from other kids, and these patients tell me they would rather have the pain of the illness than deal with the side effects of steroid medications.”

“Guidance counselors in Cleveland-area schools told me that kids will talk about their sex lives and drug use, but they won't open up about IBD, which is a bathroom issue,” she added.

SCOTTSDALE, ARIZ. – Monitor patients' headache frequency and disability to guide the pharamacologic prevention of migraine, Dr. Stewart J. Tepper said at a symposium sponsored by the American Headache Society.

“The goal should be to decrease migraine frequency by half and decrease duration and intensity, and comorbid illnesses are the critical aspect in picking the correct drug,” said Dr. Tepper, director of the New England Center for Headache, New Haven, Conn.

Disability is as important in daily pharmacologic prevention as it is in acute treatment, and is the key to assessing therapeutic need, said Dr. Tepper, who is also with Yale University.

Circumstances that might warrant preventive treatment include:

▸ Frequent or infrequent migraine that significantly interferes with the patient's daily routine despite acute treatment.

▸ Failure of, contraindication to, or troublesome side effects from acute medications.

▸ Special circumstances, including hemiplegic migraine and attacks with a risk of permanent neurologic injury.

▸ Pattern of increasing attacks over time, with the risk of developing rebound headache with medicines for acute attack.

▸ Patient preference (the desire to have as few acute attacks as possible).

▸ Pregnancy with severe, disabling attacks accompanied by nausea, vomiting, and possibly dehydration.

Before choosing your approach, ask about family clinical response to specific medications. “If you have family members with success using propranolol, that's helpful because they're chips off the old block genetically,” Dr. Tepper said.

He also emphasized the importance of using the lowest dose possible of a long-acting formulation and giving each treatment an adequate trial.

“It's critically important that you look for a pharmacologic twofer. … You want to treat comorbid illnesses while avoiding contraindicated medications,” he said. “And the patient diary is a must if you want to make sure your outcomes are met.”

The U.S. Headache Consortium guidelines, now in the process of revision, classify preventive migraine medications on the strength of scientific evidence from randomized, controlled trials in descending order from most evidence to least (A, B, or C) and by groups of effectiveness, 1 being most efficacious and 3 the least.

In group 1, class A drugs include the antiepilepsy drugs divalproex sodium and topiramate. Both drugs are associated with significant side effects, and divalproex use is limited by its propensity to cause birth defects and polycystic ovaries.

“We should not be using divalproex as first-line therapy in women of childbearing age,” Dr. Tepper said, adding that patients offered topiramate should be warned about the risk of paresthesias and of reversible angle-closure glaucoma. “When patients develop paresthesias, I find that potassium supplementation is helpful.”

The group 2 antiepilepsy drug gabapentin is class B but has not received Food and Drug Administration approval for migraine prevention. All three medications in this class produced modest reductions in migraine attacks in clinical trials. Gabapentin, which produced its best results at a dose of 2,400 mg, had a high dropout rate due to dizziness and drowsiness, he said.

Included on the consortium's group 1 list are five alternative medications, of which three–chelated magnesium, riboflavin, and feverfew–are listed as class B. However, feverfew may be dropped from class B in the revision because of bad showings in two randomized, controlled trials.

The revision is also expected to include butterbur root and coenzyme Q10 in class B, Dr. Tepper noted.

Tricyclic antidepressants are clearly the standard when there are such comorbid illnesses as insomnia, neck pain, and depression, he said.

“Amitriptyline is a class A drug in group 1 but is not FDA approved for this indication. The other tricyclics are all class C in the guidelines, but since the guidelines were released there have been two small randomized, controlled trials of venlafaxine showing effectiveness in episodic migraine at a dose of 150 mg.”

Dr. Tepper predicts that selective serotonin reuptake inhibitors, currently listed as class B and C medications, will be demoted in the revised guidelines.

“And I don't list botulinum neurotoxin type A because the evidence has shown ineffectiveness in episodic migraine, and studies are pending in chronic migraine,” he added.

Two β-blockers, which Dr. Tepper prescribes for comorbid anxiety and hypertension, have been approved for episodic migraine prevention: Propranolol and timolol both have class A evidence and lie in group 1.

All of the calcium channel blocking agents available in the United States have class B scientific evidence. Calcium channel blockers are the drugs of choice for hemiplegic migraine and basilar-type migraine, Dr. Tepper explained.

Dr. Tepper disclosed significant relationships with Valeant Pharmaceuticals, Pfizer, Alexa, AstraZeneca, Endo Pharmaceuticals, and Eisai as the recipient of research grants; with Allergan Inc. as a consultant, lecturer, and recipient of research grants; with Johnson and Johnson as a lecturer and recipient of research grants; and with Merck U.S. Human Health as a consultant and recipient of research grants.

SCOTTSDALE, ARIZ. – Monitor patients' headache frequency and disability to guide the pharamacologic prevention of migraine, Dr. Stewart J. Tepper said at a symposium sponsored by the American Headache Society.

“The goal should be to decrease migraine frequency by half and decrease duration and intensity, and comorbid illnesses are the critical aspect in picking the correct drug,” said Dr. Tepper, director of the New England Center for Headache, New Haven, Conn.

Disability is as important in daily pharmacologic prevention as it is in acute treatment, and is the key to assessing therapeutic need, said Dr. Tepper, who is also with Yale University.

Circumstances that might warrant preventive treatment include:

▸ Frequent or infrequent migraine that significantly interferes with the patient's daily routine despite acute treatment.

▸ Failure of, contraindication to, or troublesome side effects from acute medications.

▸ Special circumstances, including hemiplegic migraine and attacks with a risk of permanent neurologic injury.

▸ Pattern of increasing attacks over time, with the risk of developing rebound headache with medicines for acute attack.

▸ Patient preference (the desire to have as few acute attacks as possible).

▸ Pregnancy with severe, disabling attacks accompanied by nausea, vomiting, and possibly dehydration.

Before choosing your approach, ask about family clinical response to specific medications. “If you have family members with success using propranolol, that's helpful because they're chips off the old block genetically,” Dr. Tepper said.

He also emphasized the importance of using the lowest dose possible of a long-acting formulation and giving each treatment an adequate trial.

“It's critically important that you look for a pharmacologic twofer. … You want to treat comorbid illnesses while avoiding contraindicated medications,” he said. “And the patient diary is a must if you want to make sure your outcomes are met.”

The U.S. Headache Consortium guidelines, now in the process of revision, classify preventive migraine medications on the strength of scientific evidence from randomized, controlled trials in descending order from most evidence to least (A, B, or C) and by groups of effectiveness, 1 being most efficacious and 3 the least.

In group 1, class A drugs include the antiepilepsy drugs divalproex sodium and topiramate. Both drugs are associated with significant side effects, and divalproex use is limited by its propensity to cause birth defects and polycystic ovaries.

“We should not be using divalproex as first-line therapy in women of childbearing age,” Dr. Tepper said, adding that patients offered topiramate should be warned about the risk of paresthesias and of reversible angle-closure glaucoma. “When patients develop paresthesias, I find that potassium supplementation is helpful.”

The group 2 antiepilepsy drug gabapentin is class B but has not received Food and Drug Administration approval for migraine prevention. All three medications in this class produced modest reductions in migraine attacks in clinical trials. Gabapentin, which produced its best results at a dose of 2,400 mg, had a high dropout rate due to dizziness and drowsiness, he said.

Included on the consortium's group 1 list are five alternative medications, of which three–chelated magnesium, riboflavin, and feverfew–are listed as class B. However, feverfew may be dropped from class B in the revision because of bad showings in two randomized, controlled trials.

The revision is also expected to include butterbur root and coenzyme Q10 in class B, Dr. Tepper noted.

Tricyclic antidepressants are clearly the standard when there are such comorbid illnesses as insomnia, neck pain, and depression, he said.

“Amitriptyline is a class A drug in group 1 but is not FDA approved for this indication. The other tricyclics are all class C in the guidelines, but since the guidelines were released there have been two small randomized, controlled trials of venlafaxine showing effectiveness in episodic migraine at a dose of 150 mg.”

Dr. Tepper predicts that selective serotonin reuptake inhibitors, currently listed as class B and C medications, will be demoted in the revised guidelines.

“And I don't list botulinum neurotoxin type A because the evidence has shown ineffectiveness in episodic migraine, and studies are pending in chronic migraine,” he added.

Two β-blockers, which Dr. Tepper prescribes for comorbid anxiety and hypertension, have been approved for episodic migraine prevention: Propranolol and timolol both have class A evidence and lie in group 1.

All of the calcium channel blocking agents available in the United States have class B scientific evidence. Calcium channel blockers are the drugs of choice for hemiplegic migraine and basilar-type migraine, Dr. Tepper explained.

Dr. Tepper disclosed significant relationships with Valeant Pharmaceuticals, Pfizer, Alexa, AstraZeneca, Endo Pharmaceuticals, and Eisai as the recipient of research grants; with Allergan Inc. as a consultant, lecturer, and recipient of research grants; with Johnson and Johnson as a lecturer and recipient of research grants; and with Merck U.S. Human Health as a consultant and recipient of research grants.

SCOTTSDALE, ARIZ. – Monitor patients' headache frequency and disability to guide the pharamacologic prevention of migraine, Dr. Stewart J. Tepper said at a symposium sponsored by the American Headache Society.

“The goal should be to decrease migraine frequency by half and decrease duration and intensity, and comorbid illnesses are the critical aspect in picking the correct drug,” said Dr. Tepper, director of the New England Center for Headache, New Haven, Conn.

Disability is as important in daily pharmacologic prevention as it is in acute treatment, and is the key to assessing therapeutic need, said Dr. Tepper, who is also with Yale University.

Circumstances that might warrant preventive treatment include:

▸ Frequent or infrequent migraine that significantly interferes with the patient's daily routine despite acute treatment.

▸ Failure of, contraindication to, or troublesome side effects from acute medications.

▸ Special circumstances, including hemiplegic migraine and attacks with a risk of permanent neurologic injury.

▸ Pattern of increasing attacks over time, with the risk of developing rebound headache with medicines for acute attack.

▸ Patient preference (the desire to have as few acute attacks as possible).

▸ Pregnancy with severe, disabling attacks accompanied by nausea, vomiting, and possibly dehydration.

Before choosing your approach, ask about family clinical response to specific medications. “If you have family members with success using propranolol, that's helpful because they're chips off the old block genetically,” Dr. Tepper said.

He also emphasized the importance of using the lowest dose possible of a long-acting formulation and giving each treatment an adequate trial.

“It's critically important that you look for a pharmacologic twofer. … You want to treat comorbid illnesses while avoiding contraindicated medications,” he said. “And the patient diary is a must if you want to make sure your outcomes are met.”

The U.S. Headache Consortium guidelines, now in the process of revision, classify preventive migraine medications on the strength of scientific evidence from randomized, controlled trials in descending order from most evidence to least (A, B, or C) and by groups of effectiveness, 1 being most efficacious and 3 the least.

In group 1, class A drugs include the antiepilepsy drugs divalproex sodium and topiramate. Both drugs are associated with significant side effects, and divalproex use is limited by its propensity to cause birth defects and polycystic ovaries.

“We should not be using divalproex as first-line therapy in women of childbearing age,” Dr. Tepper said, adding that patients offered topiramate should be warned about the risk of paresthesias and of reversible angle-closure glaucoma. “When patients develop paresthesias, I find that potassium supplementation is helpful.”

The group 2 antiepilepsy drug gabapentin is class B but has not received Food and Drug Administration approval for migraine prevention. All three medications in this class produced modest reductions in migraine attacks in clinical trials. Gabapentin, which produced its best results at a dose of 2,400 mg, had a high dropout rate due to dizziness and drowsiness, he said.

Included on the consortium's group 1 list are five alternative medications, of which three–chelated magnesium, riboflavin, and feverfew–are listed as class B. However, feverfew may be dropped from class B in the revision because of bad showings in two randomized, controlled trials.

The revision is also expected to include butterbur root and coenzyme Q10 in class B, Dr. Tepper noted.

Tricyclic antidepressants are clearly the standard when there are such comorbid illnesses as insomnia, neck pain, and depression, he said.

“Amitriptyline is a class A drug in group 1 but is not FDA approved for this indication. The other tricyclics are all class C in the guidelines, but since the guidelines were released there have been two small randomized, controlled trials of venlafaxine showing effectiveness in episodic migraine at a dose of 150 mg.”

Dr. Tepper predicts that selective serotonin reuptake inhibitors, currently listed as class B and C medications, will be demoted in the revised guidelines.

“And I don't list botulinum neurotoxin type A because the evidence has shown ineffectiveness in episodic migraine, and studies are pending in chronic migraine,” he added.

Two β-blockers, which Dr. Tepper prescribes for comorbid anxiety and hypertension, have been approved for episodic migraine prevention: Propranolol and timolol both have class A evidence and lie in group 1.

All of the calcium channel blocking agents available in the United States have class B scientific evidence. Calcium channel blockers are the drugs of choice for hemiplegic migraine and basilar-type migraine, Dr. Tepper explained.

Dr. Tepper disclosed significant relationships with Valeant Pharmaceuticals, Pfizer, Alexa, AstraZeneca, Endo Pharmaceuticals, and Eisai as the recipient of research grants; with Allergan Inc. as a consultant, lecturer, and recipient of research grants; with Johnson and Johnson as a lecturer and recipient of research grants; and with Merck U.S. Human Health as a consultant and recipient of research grants.

CHICAGO — Adding food provocation to a standard upper GI series may better characterize alimentary tract dysfunction and guide therapy, compared with use of liquid barium alone, according to a study presented at the annual meeting of the Radiological Society of North America.

“While a food provocation study may be overkill for the typical reflux patient, it may be a useful adjunct to a standard upper GI series in patients who have severe symptoms when they eat specific foods and who have otherwise unremarkable prior exams,” Dr. Ashraf Thabet said.

He and his associates reviewed the medical records for all provocative food studies requested by surgeons and gastroenterologists that were performed from 1997 to 2005 at Massachusetts General Hospital, Boston.

The study group included 29 patients with a mean age of 56 years. All had severe symptoms after meals and unremarkable upper GI exams or cross-sectional imaging or gastric emptying studies, said Dr. Thabet, who is an interventional radiologist.

Patient histories detailed the food type and amount that elicited symptoms and described prior GI surgery. Symptoms caused by food ingestion included dysphagia, abdominal pain, odynophagia, nausea, vomiting, heartburn, weight loss, and recurrent aspiration. Two-thirds of the patient cohort had histories of upper GI surgery, most commonly esophagectomy, fundoplication, and gastric bypass.

The provocative food study began with a standard upper GI exam using liquid barium alone. Then the patient was asked to eat food brought from home and was reexamined fluoroscopically. The researchers looked at whether symptoms were elicited when the food was eaten and whether fluoroscopy detected an abnormality.

One 62-year-old man who had undergone esophagectomy for esophageal cancer had complained of postprandial nausea and abdominal pain. A work-up at an outside institution included negative findings from a standard upper GI barium exam and unremarkable right upper-quadrant ultrasound findings. When the patient came to Massachusetts General for a second opinion, a surgeon recommended a provocative study, Dr. Thabet said.

“The barium study produced no symptoms, but when the patient ate a muffin he developed nausea and abdominal pain, and it was observed fluoroscopically that there was a delay in propagation of food from the intrathoracic stomach distally to [the] small bowel. The patient's surgeon then performed an endoscopic [dilation] of the pylorus, and the patient's symptoms improved,” he said.

Liquid barium alone reproduced symptoms in only 3 of the 29 patients; after the addition of food provocation, 2 of those 3 patients had worsening symptoms. Of the remaining 26 patients, 13 reported symptoms after food provocation.

About half of the patients (14 of 29) had a fluoroscopic abnormality (FA) with barium only. Of those 14, all but 1 had an additional or more prominent FA with food. Of the 15 patients in whom barium alone did not result in an FA, 7 had an FA after food provocation. Abnormalities included altered peristalsis (20 patients), luminal narrowing (3), reflux alone (2), and a grapefruit-sized epiphrenic diverticulum (1).

Surgical therapy (esophagectomy, gastroplasty, and fundoplication) was pursued in 40% of the patients. Endoscopic therapy (dilation and/or botulinum toxin therapy) was pursued in 20%, and 40% had medical therapy or continued observation.

“Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half of them, and almost all of them had a fluoroscopic abnormality. Of the other 50% who had no symptoms even after food provocation, a fluoroscopic abnormality was still demonstrated in 54%,” Dr. Thabet said, adding that referring physicians appeared to be more confident about treatment decisions after a food study was performed.

'Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half.' DR. THABET

CHICAGO — Adding food provocation to a standard upper GI series may better characterize alimentary tract dysfunction and guide therapy, compared with use of liquid barium alone, according to a study presented at the annual meeting of the Radiological Society of North America.

“While a food provocation study may be overkill for the typical reflux patient, it may be a useful adjunct to a standard upper GI series in patients who have severe symptoms when they eat specific foods and who have otherwise unremarkable prior exams,” Dr. Ashraf Thabet said.

He and his associates reviewed the medical records for all provocative food studies requested by surgeons and gastroenterologists that were performed from 1997 to 2005 at Massachusetts General Hospital, Boston.

The study group included 29 patients with a mean age of 56 years. All had severe symptoms after meals and unremarkable upper GI exams or cross-sectional imaging or gastric emptying studies, said Dr. Thabet, who is an interventional radiologist.

Patient histories detailed the food type and amount that elicited symptoms and described prior GI surgery. Symptoms caused by food ingestion included dysphagia, abdominal pain, odynophagia, nausea, vomiting, heartburn, weight loss, and recurrent aspiration. Two-thirds of the patient cohort had histories of upper GI surgery, most commonly esophagectomy, fundoplication, and gastric bypass.

The provocative food study began with a standard upper GI exam using liquid barium alone. Then the patient was asked to eat food brought from home and was reexamined fluoroscopically. The researchers looked at whether symptoms were elicited when the food was eaten and whether fluoroscopy detected an abnormality.

One 62-year-old man who had undergone esophagectomy for esophageal cancer had complained of postprandial nausea and abdominal pain. A work-up at an outside institution included negative findings from a standard upper GI barium exam and unremarkable right upper-quadrant ultrasound findings. When the patient came to Massachusetts General for a second opinion, a surgeon recommended a provocative study, Dr. Thabet said.

“The barium study produced no symptoms, but when the patient ate a muffin he developed nausea and abdominal pain, and it was observed fluoroscopically that there was a delay in propagation of food from the intrathoracic stomach distally to [the] small bowel. The patient's surgeon then performed an endoscopic [dilation] of the pylorus, and the patient's symptoms improved,” he said.

Liquid barium alone reproduced symptoms in only 3 of the 29 patients; after the addition of food provocation, 2 of those 3 patients had worsening symptoms. Of the remaining 26 patients, 13 reported symptoms after food provocation.

About half of the patients (14 of 29) had a fluoroscopic abnormality (FA) with barium only. Of those 14, all but 1 had an additional or more prominent FA with food. Of the 15 patients in whom barium alone did not result in an FA, 7 had an FA after food provocation. Abnormalities included altered peristalsis (20 patients), luminal narrowing (3), reflux alone (2), and a grapefruit-sized epiphrenic diverticulum (1).

Surgical therapy (esophagectomy, gastroplasty, and fundoplication) was pursued in 40% of the patients. Endoscopic therapy (dilation and/or botulinum toxin therapy) was pursued in 20%, and 40% had medical therapy or continued observation.

“Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half of them, and almost all of them had a fluoroscopic abnormality. Of the other 50% who had no symptoms even after food provocation, a fluoroscopic abnormality was still demonstrated in 54%,” Dr. Thabet said, adding that referring physicians appeared to be more confident about treatment decisions after a food study was performed.

'Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half.' DR. THABET

CHICAGO — Adding food provocation to a standard upper GI series may better characterize alimentary tract dysfunction and guide therapy, compared with use of liquid barium alone, according to a study presented at the annual meeting of the Radiological Society of North America.

“While a food provocation study may be overkill for the typical reflux patient, it may be a useful adjunct to a standard upper GI series in patients who have severe symptoms when they eat specific foods and who have otherwise unremarkable prior exams,” Dr. Ashraf Thabet said.

He and his associates reviewed the medical records for all provocative food studies requested by surgeons and gastroenterologists that were performed from 1997 to 2005 at Massachusetts General Hospital, Boston.

The study group included 29 patients with a mean age of 56 years. All had severe symptoms after meals and unremarkable upper GI exams or cross-sectional imaging or gastric emptying studies, said Dr. Thabet, who is an interventional radiologist.

Patient histories detailed the food type and amount that elicited symptoms and described prior GI surgery. Symptoms caused by food ingestion included dysphagia, abdominal pain, odynophagia, nausea, vomiting, heartburn, weight loss, and recurrent aspiration. Two-thirds of the patient cohort had histories of upper GI surgery, most commonly esophagectomy, fundoplication, and gastric bypass.

The provocative food study began with a standard upper GI exam using liquid barium alone. Then the patient was asked to eat food brought from home and was reexamined fluoroscopically. The researchers looked at whether symptoms were elicited when the food was eaten and whether fluoroscopy detected an abnormality.

One 62-year-old man who had undergone esophagectomy for esophageal cancer had complained of postprandial nausea and abdominal pain. A work-up at an outside institution included negative findings from a standard upper GI barium exam and unremarkable right upper-quadrant ultrasound findings. When the patient came to Massachusetts General for a second opinion, a surgeon recommended a provocative study, Dr. Thabet said.

“The barium study produced no symptoms, but when the patient ate a muffin he developed nausea and abdominal pain, and it was observed fluoroscopically that there was a delay in propagation of food from the intrathoracic stomach distally to [the] small bowel. The patient's surgeon then performed an endoscopic [dilation] of the pylorus, and the patient's symptoms improved,” he said.

Liquid barium alone reproduced symptoms in only 3 of the 29 patients; after the addition of food provocation, 2 of those 3 patients had worsening symptoms. Of the remaining 26 patients, 13 reported symptoms after food provocation.

About half of the patients (14 of 29) had a fluoroscopic abnormality (FA) with barium only. Of those 14, all but 1 had an additional or more prominent FA with food. Of the 15 patients in whom barium alone did not result in an FA, 7 had an FA after food provocation. Abnormalities included altered peristalsis (20 patients), luminal narrowing (3), reflux alone (2), and a grapefruit-sized epiphrenic diverticulum (1).

Surgical therapy (esophagectomy, gastroplasty, and fundoplication) was pursued in 40% of the patients. Endoscopic therapy (dilation and/or botulinum toxin therapy) was pursued in 20%, and 40% had medical therapy or continued observation.

“Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half of them, and almost all of them had a fluoroscopic abnormality. Of the other 50% who had no symptoms even after food provocation, a fluoroscopic abnormality was still demonstrated in 54%,” Dr. Thabet said, adding that referring physicians appeared to be more confident about treatment decisions after a food study was performed.

'Of all of the patients who had no symptoms with liquid barium alone, symptoms were provoked with food in half.' DR. THABET

If you're tired of filling out hospital admission forms by hand, Dr. Arnold Jay Simon offers a suggestion: Switch to a paperless direct admission form.

“My hospital created a paperless direct admission form for me using the Microsoft Word form field, and the form was sanctioned by the hospital executive committee,” said Dr. Simon, a solo-practice internist specializing in geriatrics in Palm Springs, Fla.

“The form fits perfectly into my routine and eliminates the inefficient process of hand-copying data from computer screen onto little boxes on the old paper form, which I hated,” he said in an interview. Dr. Simon opens the form at the end of an office visit when he feels a patient needs to be admitted to the hospital.

“I can easily navigate through the form fields using the tab key to add, delete, or change small amounts of patient data,” Dr. Simon said. Larger entries, such as office notes and patient medications, can be pasted into the form. “This simple Word form has saved me the dreaded task of having to copy a long list of medications by hand onto the admission form. Using the tab keys and the cut-and-paste feature saves me a lot of time and reduces errors,” he explained.

Hospital personnel and patients are happier because the information is easier to read and hospitalizations are expedited. “The nursing staff appreciates having neatly typed admit forms faxed to them,” Dr. Simon added.

If you're tired of filling out hospital admission forms by hand, Dr. Arnold Jay Simon offers a suggestion: Switch to a paperless direct admission form.

“My hospital created a paperless direct admission form for me using the Microsoft Word form field, and the form was sanctioned by the hospital executive committee,” said Dr. Simon, a solo-practice internist specializing in geriatrics in Palm Springs, Fla.

“The form fits perfectly into my routine and eliminates the inefficient process of hand-copying data from computer screen onto little boxes on the old paper form, which I hated,” he said in an interview. Dr. Simon opens the form at the end of an office visit when he feels a patient needs to be admitted to the hospital.

“I can easily navigate through the form fields using the tab key to add, delete, or change small amounts of patient data,” Dr. Simon said. Larger entries, such as office notes and patient medications, can be pasted into the form. “This simple Word form has saved me the dreaded task of having to copy a long list of medications by hand onto the admission form. Using the tab keys and the cut-and-paste feature saves me a lot of time and reduces errors,” he explained.

Hospital personnel and patients are happier because the information is easier to read and hospitalizations are expedited. “The nursing staff appreciates having neatly typed admit forms faxed to them,” Dr. Simon added.

If you're tired of filling out hospital admission forms by hand, Dr. Arnold Jay Simon offers a suggestion: Switch to a paperless direct admission form.

“My hospital created a paperless direct admission form for me using the Microsoft Word form field, and the form was sanctioned by the hospital executive committee,” said Dr. Simon, a solo-practice internist specializing in geriatrics in Palm Springs, Fla.

“The form fits perfectly into my routine and eliminates the inefficient process of hand-copying data from computer screen onto little boxes on the old paper form, which I hated,” he said in an interview. Dr. Simon opens the form at the end of an office visit when he feels a patient needs to be admitted to the hospital.

“I can easily navigate through the form fields using the tab key to add, delete, or change small amounts of patient data,” Dr. Simon said. Larger entries, such as office notes and patient medications, can be pasted into the form. “This simple Word form has saved me the dreaded task of having to copy a long list of medications by hand onto the admission form. Using the tab keys and the cut-and-paste feature saves me a lot of time and reduces errors,” he explained.

Hospital personnel and patients are happier because the information is easier to read and hospitalizations are expedited. “The nursing staff appreciates having neatly typed admit forms faxed to them,” Dr. Simon added.

For Dr. Rod Tanchanko's patients, his tablet PC has become as emblematic of the internist as the traditional stethoscope.

That ever-present computer is the locus of a complete electronic medical records (EMR) and practice management system, according to Dr. Tanchanko, who is in solo practice in Middletown, Del.

Tablet PCs are equipped with a sensitive screen designed to interact with a complementary stylus. Because the user is interacting directly with the screen, rather than through a mouse and keyboard, the PC is more portable and easier to use than laptops and can even be used while standing.

Each morning, Dr. Tanchanko starts the EMR program and opens his Internet browser. Wireless access provides immediate access to patient records and other information.

“I have a folder for my most commonly used patient education materials, and there's another folder for vaccine information sheets, and another for screening forms for various conditions. We're virtually paperless. Charts, lab data, patient records … everything is right there at my fingertips, most often in PDF format,” he said in an interview.

Dr. Tanchanko prints documents and patient education materials directly off the Web, from sources such as the American Academy of Family Physicians (www.familydoctor.orgwww.medscape.com

“Medscape even has animations, which are a wonderful teaching tool for conditions such as disk herniation. For evidence-based and medication information, I access the American College of Physicians' Physician Information and Education Resource, or PIER, and Epocrates, which serves as backup to my EMR's e-prescribing feature,” he explained.

Efficiency is further enhanced with central printing, so that all printed materials, including controlled prescriptions, are ready by the end of the patient's visit, Dr. Tanchanko said.

Why carry a tablet PC instead of installing computer stations? “The tablet PC allows better face-to-face contact with the patient, it's portable, and I don't have the expense of buying and installing desktop computers,” he explained.

“This system significantly reduces clutter, keeps materials up to date, boosts efficiency, and, best of all, the information is almost free. It has enhanced the visit experience for both myself and for patients, who generally feel that I have done a little extra for them,” he added.

Dr. Tanchanko is author of “An EMR Journey,” an e-Book available at www.anemrjourney.com

For Dr. Rod Tanchanko's patients, his tablet PC has become as emblematic of the internist as the traditional stethoscope.

That ever-present computer is the locus of a complete electronic medical records (EMR) and practice management system, according to Dr. Tanchanko, who is in solo practice in Middletown, Del.

Tablet PCs are equipped with a sensitive screen designed to interact with a complementary stylus. Because the user is interacting directly with the screen, rather than through a mouse and keyboard, the PC is more portable and easier to use than laptops and can even be used while standing.

Each morning, Dr. Tanchanko starts the EMR program and opens his Internet browser. Wireless access provides immediate access to patient records and other information.

“I have a folder for my most commonly used patient education materials, and there's another folder for vaccine information sheets, and another for screening forms for various conditions. We're virtually paperless. Charts, lab data, patient records … everything is right there at my fingertips, most often in PDF format,” he said in an interview.

Dr. Tanchanko prints documents and patient education materials directly off the Web, from sources such as the American Academy of Family Physicians (www.familydoctor.orgwww.medscape.com

“Medscape even has animations, which are a wonderful teaching tool for conditions such as disk herniation. For evidence-based and medication information, I access the American College of Physicians' Physician Information and Education Resource, or PIER, and Epocrates, which serves as backup to my EMR's e-prescribing feature,” he explained.

Efficiency is further enhanced with central printing, so that all printed materials, including controlled prescriptions, are ready by the end of the patient's visit, Dr. Tanchanko said.

Why carry a tablet PC instead of installing computer stations? “The tablet PC allows better face-to-face contact with the patient, it's portable, and I don't have the expense of buying and installing desktop computers,” he explained.

“This system significantly reduces clutter, keeps materials up to date, boosts efficiency, and, best of all, the information is almost free. It has enhanced the visit experience for both myself and for patients, who generally feel that I have done a little extra for them,” he added.

Dr. Tanchanko is author of “An EMR Journey,” an e-Book available at www.anemrjourney.com

For Dr. Rod Tanchanko's patients, his tablet PC has become as emblematic of the internist as the traditional stethoscope.

That ever-present computer is the locus of a complete electronic medical records (EMR) and practice management system, according to Dr. Tanchanko, who is in solo practice in Middletown, Del.

Tablet PCs are equipped with a sensitive screen designed to interact with a complementary stylus. Because the user is interacting directly with the screen, rather than through a mouse and keyboard, the PC is more portable and easier to use than laptops and can even be used while standing.

Each morning, Dr. Tanchanko starts the EMR program and opens his Internet browser. Wireless access provides immediate access to patient records and other information.

“I have a folder for my most commonly used patient education materials, and there's another folder for vaccine information sheets, and another for screening forms for various conditions. We're virtually paperless. Charts, lab data, patient records … everything is right there at my fingertips, most often in PDF format,” he said in an interview.

Dr. Tanchanko prints documents and patient education materials directly off the Web, from sources such as the American Academy of Family Physicians (www.familydoctor.orgwww.medscape.com

“Medscape even has animations, which are a wonderful teaching tool for conditions such as disk herniation. For evidence-based and medication information, I access the American College of Physicians' Physician Information and Education Resource, or PIER, and Epocrates, which serves as backup to my EMR's e-prescribing feature,” he explained.

Efficiency is further enhanced with central printing, so that all printed materials, including controlled prescriptions, are ready by the end of the patient's visit, Dr. Tanchanko said.

Why carry a tablet PC instead of installing computer stations? “The tablet PC allows better face-to-face contact with the patient, it's portable, and I don't have the expense of buying and installing desktop computers,” he explained.

“This system significantly reduces clutter, keeps materials up to date, boosts efficiency, and, best of all, the information is almost free. It has enhanced the visit experience for both myself and for patients, who generally feel that I have done a little extra for them,” he added.

Dr. Tanchanko is author of “An EMR Journey,” an e-Book available at www.anemrjourney.com

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

CHICAGO — Use of real-time magnetic resonance imaging to guide sacroiliac joint puncture is feasible and safe, and allows for interactive interventions in patients who have refractory sacroiliitis, according to a study presented at the annual meeting of the Radiological Society of North America.

Researchers injected steroids into the sacroiliac joints (SIJs) of 73 patients who had inflammatory back pain and acute sacroiliitis unresponsive to conventional drug therapy for longer than 6 months using real-time magnetic resonance (MR) guidance exposure, Dr. Jan Fritz said at a poster session. The other term for the imaging technique, MR fluoroscopy, is a misnomer; unlike traditional fluoroscopy, MR fluoroscopy does not involve radiation. The entire procedure is performed using an interventional C-shaped open ultrafast MR scanner that provides an image every 1.2 seconds as the needle is being advanced.

“This allows you patient access while doing a procedure that formerly was done using x-ray fluoroscopy [and] CT, which have the disadvantage of exposure to ionizing radiation,” said Dr. Fritz, with the department of diagnostic radiology at Eberhard Karls University of Tübingen (Germany). “Spondyloarthropathy patients are typically under age 30 and in their reproductive years, and we don't like to expose them to ionizing radiation,” he said.

Each SIJ was injected with 40 mg triamcinolone acetonide using an MR-compatible 20-G puncture needle, they wrote.

Prior to intervention and 3 months after intervention, inflammatory back pain (IBP) was assessed on a visual analog scale, and volume and signal intensity of the sacroiliac bone marrow edema (BME) were quantified on high-field short-TI inversion-recovery (STIR) MR images with a semi-automatic algorithm using Matlab software.

Technical success was achieved in 72 of the 73 patients, most of whom were injected bilaterally, Dr. Fritz said, adding that there were no complications.

In bilateral intervention (n=64), real-time MR guidance (n=36) required a mean time of 40.5 minutes, compared with 55 minutes for intermittent MR imaging guidance (n=28).

Postintervention, IBP decreased by 63%. Volume and signal intensity of the sacroiliac BME decreased by 69% and 64%, respectively, which was a statistically significant difference. Mean remission time was 10 months. “MR fluoroscopy guidance for percutaneous steroid injections into the SIJ is safe and accurate, allowing for shorter interventions. MR fluoroscopy proved to be effective in sacroiliitis unresponsive to conventional drug therapy,” Dr. Fritz concluded.

The red arrows indicate the tip of the needle as it advances toward the site of sacroiliitis in a patient with back pain. Courtesy Dr. Jan Fritz

Use of real-time MRI in younger patients enables them to avoid radiation exposure. DR. FRITZ

Gadolinium-based contrast agents, when given to patients with renal disease, have been linked to a rare, potentially fatal, sclerodermalike skin disease called nephrogenic systemic fibrosis or nephrogenic fibrosing dermopathy.

In December, the Food and Drug Administration issued a public health advisory stating that the agency has received reports of 90 patients with moderate to end stage kidney disease who developed the new disease within 2 days to 18 months after they had magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) with a gadolinium-based contrast agent. Many—but not all—of these patients received a high dose of the contrast agent; some received only one dose, according to the FDA.

Nephrogenic fibrosing dermopathy (NFD) is marked by areas of tight, rigid skin and may progress to nephrogenic systemic fibrosis (NSF), which is associated with scarring of internal organs. Symptoms may include burning; itching; swelling; hardening and tightening of the skin; red or dark patches on the skin; yellow spots on the whites of the eyes; stiffness in joints, with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Worldwide, about 215 cases of NSF/NFD have been reported. The medical histories of 75 of these patients have been reviewed in detail, and all had received a gadolinium-based contrast agent.

The advisory recommends alternative imaging studies for patients with renal disease. When patients with renal disease must receive a gadolinium-based contrast agent, prompt dialysis following the MRI or MRA should be considered, the FDA statement said.

Reports of the new disease have been steadily increasing since April 2006, when two European hospitals reported 25 cases following Omniscan injection. These cases had accumulated over a period of 4 years. In June 2006, the FDA issued an initial advisory about the disorder. In its December advisory, the FDA said that cases have been associated with three of the five approved gadolinium-based contrast agents, but there is reason to believe that any of the approved agents could cause the disease. Currently, there are five FDA-approved gadolinium-based contrast agents: Magnevist, MultiHance, Omniscan, OptiMARK, and ProHance. These contrast agents are FDA approved for use during an MRI scan, but not for use during an MRA scan.

Dr. Emanuel Kanal, professor of radiology and neuroradiology at the University of Pittsburgh Medical Center, was one of several radiologists who reviewed concerns about the emerging disease at the annual meeting of the Radiological Society of North America in Chicago.

“Nearly 100% of the patients with known NSF were confirmed to have received a gadolinium-based MR contrast agent prior to the diagnosis being made. Of those, over 90% had received Omniscan, which is way out of proportion to Omniscan's market share,” said Dr. Kanal, who also is director of MR services at the medical center.

Fewer cases of NSF have been reported in patients who had been scanned using OptiMARK or Magnevist, and no cases have been linked to the remaining licensed agents, ProHance and MultiHance.

In a statement, GE Healthcare said the company is “concerned by this trend of a higher incidence of NSF concurrent with gadodiamide use, and we continue to urge caution in using Omniscan in renally compromised patients, consistent with our prescribing information.”

A revised guidance document for safe MRI practices is slated for publication early this year in the American Journal of Roentgenology and on the American College of Radiology Web site.

Nephrogenic systemic fibrosis may induce joint stiffening as well as skin changes and bone pain. Courtesy Dr. Shawn E. Cowper

Gadolinium-based contrast agents, when given to patients with renal disease, have been linked to a rare, potentially fatal, sclerodermalike skin disease called nephrogenic systemic fibrosis or nephrogenic fibrosing dermopathy.

In December, the Food and Drug Administration issued a public health advisory stating that the agency has received reports of 90 patients with moderate to end stage kidney disease who developed the new disease within 2 days to 18 months after they had magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) with a gadolinium-based contrast agent. Many—but not all—of these patients received a high dose of the contrast agent; some received only one dose, according to the FDA.

Nephrogenic fibrosing dermopathy (NFD) is marked by areas of tight, rigid skin and may progress to nephrogenic systemic fibrosis (NSF), which is associated with scarring of internal organs. Symptoms may include burning; itching; swelling; hardening and tightening of the skin; red or dark patches on the skin; yellow spots on the whites of the eyes; stiffness in joints, with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Worldwide, about 215 cases of NSF/NFD have been reported. The medical histories of 75 of these patients have been reviewed in detail, and all had received a gadolinium-based contrast agent.

The advisory recommends alternative imaging studies for patients with renal disease. When patients with renal disease must receive a gadolinium-based contrast agent, prompt dialysis following the MRI or MRA should be considered, the FDA statement said.

Reports of the new disease have been steadily increasing since April 2006, when two European hospitals reported 25 cases following Omniscan injection. These cases had accumulated over a period of 4 years. In June 2006, the FDA issued an initial advisory about the disorder. In its December advisory, the FDA said that cases have been associated with three of the five approved gadolinium-based contrast agents, but there is reason to believe that any of the approved agents could cause the disease. Currently, there are five FDA-approved gadolinium-based contrast agents: Magnevist, MultiHance, Omniscan, OptiMARK, and ProHance. These contrast agents are FDA approved for use during an MRI scan, but not for use during an MRA scan.

Dr. Emanuel Kanal, professor of radiology and neuroradiology at the University of Pittsburgh Medical Center, was one of several radiologists who reviewed concerns about the emerging disease at the annual meeting of the Radiological Society of North America in Chicago.

“Nearly 100% of the patients with known NSF were confirmed to have received a gadolinium-based MR contrast agent prior to the diagnosis being made. Of those, over 90% had received Omniscan, which is way out of proportion to Omniscan's market share,” said Dr. Kanal, who also is director of MR services at the medical center.

Fewer cases of NSF have been reported in patients who had been scanned using OptiMARK or Magnevist, and no cases have been linked to the remaining licensed agents, ProHance and MultiHance.

In a statement, GE Healthcare said the company is “concerned by this trend of a higher incidence of NSF concurrent with gadodiamide use, and we continue to urge caution in using Omniscan in renally compromised patients, consistent with our prescribing information.”

A revised guidance document for safe MRI practices is slated for publication early this year in the American Journal of Roentgenology and on the American College of Radiology Web site.

Nephrogenic systemic fibrosis may induce joint stiffening as well as skin changes and bone pain. Courtesy Dr. Shawn E. Cowper

Gadolinium-based contrast agents, when given to patients with renal disease, have been linked to a rare, potentially fatal, sclerodermalike skin disease called nephrogenic systemic fibrosis or nephrogenic fibrosing dermopathy.

In December, the Food and Drug Administration issued a public health advisory stating that the agency has received reports of 90 patients with moderate to end stage kidney disease who developed the new disease within 2 days to 18 months after they had magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) with a gadolinium-based contrast agent. Many—but not all—of these patients received a high dose of the contrast agent; some received only one dose, according to the FDA.

Nephrogenic fibrosing dermopathy (NFD) is marked by areas of tight, rigid skin and may progress to nephrogenic systemic fibrosis (NSF), which is associated with scarring of internal organs. Symptoms may include burning; itching; swelling; hardening and tightening of the skin; red or dark patches on the skin; yellow spots on the whites of the eyes; stiffness in joints, with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Worldwide, about 215 cases of NSF/NFD have been reported. The medical histories of 75 of these patients have been reviewed in detail, and all had received a gadolinium-based contrast agent.

The advisory recommends alternative imaging studies for patients with renal disease. When patients with renal disease must receive a gadolinium-based contrast agent, prompt dialysis following the MRI or MRA should be considered, the FDA statement said.

Reports of the new disease have been steadily increasing since April 2006, when two European hospitals reported 25 cases following Omniscan injection. These cases had accumulated over a period of 4 years. In June 2006, the FDA issued an initial advisory about the disorder. In its December advisory, the FDA said that cases have been associated with three of the five approved gadolinium-based contrast agents, but there is reason to believe that any of the approved agents could cause the disease. Currently, there are five FDA-approved gadolinium-based contrast agents: Magnevist, MultiHance, Omniscan, OptiMARK, and ProHance. These contrast agents are FDA approved for use during an MRI scan, but not for use during an MRA scan.

Dr. Emanuel Kanal, professor of radiology and neuroradiology at the University of Pittsburgh Medical Center, was one of several radiologists who reviewed concerns about the emerging disease at the annual meeting of the Radiological Society of North America in Chicago.

“Nearly 100% of the patients with known NSF were confirmed to have received a gadolinium-based MR contrast agent prior to the diagnosis being made. Of those, over 90% had received Omniscan, which is way out of proportion to Omniscan's market share,” said Dr. Kanal, who also is director of MR services at the medical center.

Fewer cases of NSF have been reported in patients who had been scanned using OptiMARK or Magnevist, and no cases have been linked to the remaining licensed agents, ProHance and MultiHance.

In a statement, GE Healthcare said the company is “concerned by this trend of a higher incidence of NSF concurrent with gadodiamide use, and we continue to urge caution in using Omniscan in renally compromised patients, consistent with our prescribing information.”

A revised guidance document for safe MRI practices is slated for publication early this year in the American Journal of Roentgenology and on the American College of Radiology Web site.

Nephrogenic systemic fibrosis may induce joint stiffening as well as skin changes and bone pain. Courtesy Dr. Shawn E. Cowper

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.

SCOTTSDALE, ARIZ. – Open-ended questions during patient interviews elicit the best information for guiding the management of patients with migraine headache, Dr. Richard B. Lipton said at a symposium sponsored by the American Headache Society.

Yet closed-end questions focusing on headache triggers, frequency, and symptoms comprised most of the dialogue between physicians and migraine headache patients, based on the American Migraine Communications Study (AMCS). And the patient and physician often differed in their assessments of headache frequency, disability, and impairment, said Dr. Lipton, who is professor of neurology at the Albert Einstein College of Medicine, New York.

Patients and physicians really weren't hearing and understanding each other during the office visit, he said. As a result of these miscommunications, physicians underappreciated the need for preventive treatment and patients had incomplete knowledge about medication use and inappropriate expectations of their outcomes.

The AMCS findings were based on analyses of videotaped encounters with 60 patients (80% women, mean age 42 years) and a geographically representative sample of 14 primary care physicians and 8 neurologists. The average duration of migraines was 14 years with a frequency of five episodes per month.

Dr. Lipton and his coinvestigator Dr. Steven R. Hahn analyzed the structure of questions posed during the recorded physician-patient interviews. Closed-ended questions allowed patients to make selections, while open-ended questions encouraged more wide-ranging dialogue. A typical closed-end question, for example, was: “Are the headaches on one side of your head or bilateral?” An example of an open-ended question would be: “Tell me about your headaches.”

Framing the interview with closed-ended questions gleans only limited information, said Dr. Hahn, professor of clinical medicine at Albert Einstein. “Open-ended questions are the foundation of patient-centered interviewing, and they allow patients to recount their symptoms in the narrative context, focusing on the things that are most important to them.”

Based on assessments after the interviews, 35 of the 60 patients were not receiving any therapy for their disabling headaches. The other 25 had been prescribed an average of two drugs, primarily triptans, but many did not have an accurate understanding of how to use the drugs or what they could reasonably expect from drug therapy.

Overall, “55% of physicians and patients were misaligned on migraine frequency post visit, which is amazing to me. It seems to me that the question of how many headache days occur over a 3-month period would be something patients and physicians could agree on,” Dr. Lipton said.

Dr. Lipton and Dr. Hahn recommend an “ask, tell, ask” approach. First, ask the patient about the number of headache days. Then repeat what you have heard. Finally, ask whether you have stated the situation correctly.

The “ask, tell, ask” technique improves communication and thus will improve treatment, Dr. Lipton concluded.

Most 'physicians and patients were misaligned on migraine frequency post visit, which is amazing to me.' DR. LIPTON

SCOTTSDALE, ARIZ. – Open-ended questions during patient interviews elicit the best information for guiding the management of patients with migraine headache, Dr. Richard B. Lipton said at a symposium sponsored by the American Headache Society.

Yet closed-end questions focusing on headache triggers, frequency, and symptoms comprised most of the dialogue between physicians and migraine headache patients, based on the American Migraine Communications Study (AMCS). And the patient and physician often differed in their assessments of headache frequency, disability, and impairment, said Dr. Lipton, who is professor of neurology at the Albert Einstein College of Medicine, New York.

Patients and physicians really weren't hearing and understanding each other during the office visit, he said. As a result of these miscommunications, physicians underappreciated the need for preventive treatment and patients had incomplete knowledge about medication use and inappropriate expectations of their outcomes.

The AMCS findings were based on analyses of videotaped encounters with 60 patients (80% women, mean age 42 years) and a geographically representative sample of 14 primary care physicians and 8 neurologists. The average duration of migraines was 14 years with a frequency of five episodes per month.

Dr. Lipton and his coinvestigator Dr. Steven R. Hahn analyzed the structure of questions posed during the recorded physician-patient interviews. Closed-ended questions allowed patients to make selections, while open-ended questions encouraged more wide-ranging dialogue. A typical closed-end question, for example, was: “Are the headaches on one side of your head or bilateral?” An example of an open-ended question would be: “Tell me about your headaches.”

Framing the interview with closed-ended questions gleans only limited information, said Dr. Hahn, professor of clinical medicine at Albert Einstein. “Open-ended questions are the foundation of patient-centered interviewing, and they allow patients to recount their symptoms in the narrative context, focusing on the things that are most important to them.”

Based on assessments after the interviews, 35 of the 60 patients were not receiving any therapy for their disabling headaches. The other 25 had been prescribed an average of two drugs, primarily triptans, but many did not have an accurate understanding of how to use the drugs or what they could reasonably expect from drug therapy.

Overall, “55% of physicians and patients were misaligned on migraine frequency post visit, which is amazing to me. It seems to me that the question of how many headache days occur over a 3-month period would be something patients and physicians could agree on,” Dr. Lipton said.

Dr. Lipton and Dr. Hahn recommend an “ask, tell, ask” approach. First, ask the patient about the number of headache days. Then repeat what you have heard. Finally, ask whether you have stated the situation correctly.

The “ask, tell, ask” technique improves communication and thus will improve treatment, Dr. Lipton concluded.

Most 'physicians and patients were misaligned on migraine frequency post visit, which is amazing to me.' DR. LIPTON

SCOTTSDALE, ARIZ. – Open-ended questions during patient interviews elicit the best information for guiding the management of patients with migraine headache, Dr. Richard B. Lipton said at a symposium sponsored by the American Headache Society.

Yet closed-end questions focusing on headache triggers, frequency, and symptoms comprised most of the dialogue between physicians and migraine headache patients, based on the American Migraine Communications Study (AMCS). And the patient and physician often differed in their assessments of headache frequency, disability, and impairment, said Dr. Lipton, who is professor of neurology at the Albert Einstein College of Medicine, New York.

Patients and physicians really weren't hearing and understanding each other during the office visit, he said. As a result of these miscommunications, physicians underappreciated the need for preventive treatment and patients had incomplete knowledge about medication use and inappropriate expectations of their outcomes.

The AMCS findings were based on analyses of videotaped encounters with 60 patients (80% women, mean age 42 years) and a geographically representative sample of 14 primary care physicians and 8 neurologists. The average duration of migraines was 14 years with a frequency of five episodes per month.

Dr. Lipton and his coinvestigator Dr. Steven R. Hahn analyzed the structure of questions posed during the recorded physician-patient interviews. Closed-ended questions allowed patients to make selections, while open-ended questions encouraged more wide-ranging dialogue. A typical closed-end question, for example, was: “Are the headaches on one side of your head or bilateral?” An example of an open-ended question would be: “Tell me about your headaches.”

Framing the interview with closed-ended questions gleans only limited information, said Dr. Hahn, professor of clinical medicine at Albert Einstein. “Open-ended questions are the foundation of patient-centered interviewing, and they allow patients to recount their symptoms in the narrative context, focusing on the things that are most important to them.”

Based on assessments after the interviews, 35 of the 60 patients were not receiving any therapy for their disabling headaches. The other 25 had been prescribed an average of two drugs, primarily triptans, but many did not have an accurate understanding of how to use the drugs or what they could reasonably expect from drug therapy.

Overall, “55% of physicians and patients were misaligned on migraine frequency post visit, which is amazing to me. It seems to me that the question of how many headache days occur over a 3-month period would be something patients and physicians could agree on,” Dr. Lipton said.

Dr. Lipton and Dr. Hahn recommend an “ask, tell, ask” approach. First, ask the patient about the number of headache days. Then repeat what you have heard. Finally, ask whether you have stated the situation correctly.

The “ask, tell, ask” technique improves communication and thus will improve treatment, Dr. Lipton concluded.

Most 'physicians and patients were misaligned on migraine frequency post visit, which is amazing to me.' DR. LIPTON

How would you like to reduce your practice's patient data research load by 12 hours a week? That's precisely what Dr. Alan Brush did for his multispecialty practice in Cambridge, Mass.

“Using the EpicCare electronic medical record system's SmartPhrases feature, I created what we call 'RxRefill phrases' for all formulary drugs where lookup of essential information is required for a refill,” Dr. Brush said in an interview. “The process of making sure that lab tests, blood values, and mammogram results are current takes about 5 minutes per prescription. I do 100 refills a week in a practice that is about 60% full time.”

Dr. Brush's office is 1 of 14 sites in the Harvard Vanguard group, all of which are served by EpicCare. “In moving from paper to EpicCare's EMR system, I noted little improvement in the efficiency of refilling medications; it was just a shift from paper to electronic medium. When refills required essential data such as creatinine and potassium and last blood pressure values for diuretic refills, someone still had to spend time looking up and communicating the information to the clinician ultimately responsible for that prescription.”

As the leader of the Harvard Vanguard group's Internal Medicine Design Team, Dr. Brush started working on a catalog of formulary drugs that had parameters one had to follow at the time of refill.

“Now, all my assistant has to do is type 'Rx' followed by the name of the drug—for example, 'RxSimvastatin'—and all the data are generated. These phrases contain the request for the drug, as well as data links that automatically bring the required lab tests and clinical information into the refill request,” Dr. Brush explained.

When the test is overdue or the last blood pressure test is beyond the time for a reasonable refill, the medical assistant or nurse requesting the clinician to sign off knows to first arrange the appropriate appointment or tests and to request a refill that lasts just beyond that date, he said.

When the timing is up to date, the request automatically includes the essential data for the clinician to view. This information becomes part of the medical record at the time of the refill, indicating that it has been reviewed, he added.

“Not only does the medical assistant or nurse save time in looking up the essential information, but the clinician sees [only] refill requests that are already adequately researched, much simplifying his or her work,” said Dr. Brush, who has no financial interest in EpiCare. “When I receive a prescription refill request now, if everything has been done, all the necessary data appear on the screen. To complete the process, I hit 'approve,' and 'close encounter,' and the refill process is complete.”

How would you like to reduce your practice's patient data research load by 12 hours a week? That's precisely what Dr. Alan Brush did for his multispecialty practice in Cambridge, Mass.

“Using the EpicCare electronic medical record system's SmartPhrases feature, I created what we call 'RxRefill phrases' for all formulary drugs where lookup of essential information is required for a refill,” Dr. Brush said in an interview. “The process of making sure that lab tests, blood values, and mammogram results are current takes about 5 minutes per prescription. I do 100 refills a week in a practice that is about 60% full time.”

Dr. Brush's office is 1 of 14 sites in the Harvard Vanguard group, all of which are served by EpicCare. “In moving from paper to EpicCare's EMR system, I noted little improvement in the efficiency of refilling medications; it was just a shift from paper to electronic medium. When refills required essential data such as creatinine and potassium and last blood pressure values for diuretic refills, someone still had to spend time looking up and communicating the information to the clinician ultimately responsible for that prescription.”

As the leader of the Harvard Vanguard group's Internal Medicine Design Team, Dr. Brush started working on a catalog of formulary drugs that had parameters one had to follow at the time of refill.

“Now, all my assistant has to do is type 'Rx' followed by the name of the drug—for example, 'RxSimvastatin'—and all the data are generated. These phrases contain the request for the drug, as well as data links that automatically bring the required lab tests and clinical information into the refill request,” Dr. Brush explained.

When the test is overdue or the last blood pressure test is beyond the time for a reasonable refill, the medical assistant or nurse requesting the clinician to sign off knows to first arrange the appropriate appointment or tests and to request a refill that lasts just beyond that date, he said.

When the timing is up to date, the request automatically includes the essential data for the clinician to view. This information becomes part of the medical record at the time of the refill, indicating that it has been reviewed, he added.

“Not only does the medical assistant or nurse save time in looking up the essential information, but the clinician sees [only] refill requests that are already adequately researched, much simplifying his or her work,” said Dr. Brush, who has no financial interest in EpiCare. “When I receive a prescription refill request now, if everything has been done, all the necessary data appear on the screen. To complete the process, I hit 'approve,' and 'close encounter,' and the refill process is complete.”

How would you like to reduce your practice's patient data research load by 12 hours a week? That's precisely what Dr. Alan Brush did for his multispecialty practice in Cambridge, Mass.

“Using the EpicCare electronic medical record system's SmartPhrases feature, I created what we call 'RxRefill phrases' for all formulary drugs where lookup of essential information is required for a refill,” Dr. Brush said in an interview. “The process of making sure that lab tests, blood values, and mammogram results are current takes about 5 minutes per prescription. I do 100 refills a week in a practice that is about 60% full time.”

Dr. Brush's office is 1 of 14 sites in the Harvard Vanguard group, all of which are served by EpicCare. “In moving from paper to EpicCare's EMR system, I noted little improvement in the efficiency of refilling medications; it was just a shift from paper to electronic medium. When refills required essential data such as creatinine and potassium and last blood pressure values for diuretic refills, someone still had to spend time looking up and communicating the information to the clinician ultimately responsible for that prescription.”

As the leader of the Harvard Vanguard group's Internal Medicine Design Team, Dr. Brush started working on a catalog of formulary drugs that had parameters one had to follow at the time of refill.

“Now, all my assistant has to do is type 'Rx' followed by the name of the drug—for example, 'RxSimvastatin'—and all the data are generated. These phrases contain the request for the drug, as well as data links that automatically bring the required lab tests and clinical information into the refill request,” Dr. Brush explained.

When the test is overdue or the last blood pressure test is beyond the time for a reasonable refill, the medical assistant or nurse requesting the clinician to sign off knows to first arrange the appropriate appointment or tests and to request a refill that lasts just beyond that date, he said.

When the timing is up to date, the request automatically includes the essential data for the clinician to view. This information becomes part of the medical record at the time of the refill, indicating that it has been reviewed, he added.

“Not only does the medical assistant or nurse save time in looking up the essential information, but the clinician sees [only] refill requests that are already adequately researched, much simplifying his or her work,” said Dr. Brush, who has no financial interest in EpiCare. “When I receive a prescription refill request now, if everything has been done, all the necessary data appear on the screen. To complete the process, I hit 'approve,' and 'close encounter,' and the refill process is complete.”