Doug Brunk

Ob.gyns. and other primary care providers play a major role in helping women identify and manage symptoms of urinary incontinence, a condition estimated by the American Urogynecologic Society to affect 30%–50% of women, but that notion appears to be lost on some generalist clinicians.

“Since we know it's such a problem, maybe we should be asking our patients more about it and have them 'fess up, but we don't, because we only have 15 minutes of managed care time where we're assessing risks for heart disease, cancer, and other medical conditions,” said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. “Urinary incontinence is a quality of life issue that's not going to kill you, but it really does take away your quality of life.”

Some physicians take a fatalistic view of the condition, she continued, telling women “there's nothing that can be done about it. There's where we go wrong. It's a highly prevalent condition, and we have a growing Medicare population,” said Dr. Iglesia, who is also associate professor of obstetrics and gynecology and urology at Georgetown University in Washington. “In fact, 80% of women by the time they're 80 have some form of incontinence. At the same time there's a misconception that incontinence happens as a normal part of aging, [the notion of] 'What do you expect? You're getting older. Just deal with it. Wear the incontinence pads.' That message is always wrong.”

Then there are the patients who avoid discussing the issue during office visits. “A lot of patients are so embarrassed by the situation that they become reclusive, or it's affecting their quality of life but they don't want to bring it up with their physician because of the shame factor,” she said. “They become more isolated, not wanting to be physically active, wearing pads, or bringing along changes of underwear, so coping in a way, but they don't want to talk about it.”

The Problem

According to a recent review from the Agency for Healthcare Research and Quality, some degree of involuntary urine loss is experienced by 25% of young women, 44%–57% of middle-age and postmenopausal women, and 75% of elderly women in nursing homes. It went on to note that in 2004, annual costs associated with treating the condition averaged $19.5 billion.

The two main types of incontinence are stress incontinence and urge incontinence, although most women have a mix of each, said Dr. Linda Brubaker, who directs the division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. “It's kind of like height and weight: You can be tall and fat, short and skinny, or tall and skinny. You can have any combination of stress incontinence or urge incontinence.”

In stress incontinence, women experience loss of urine during physical activities that increase abdominal pressure, such as sneezing, coughing, or exercising. In this form, the urinary sphincter “may not be doing its job well because it's lost some of its normal function or it's lost some of its normal anatomic positioning,” explained Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. “The function doesn't usually get restored, but what we do with surgery is add a material that is a secondary mechanism, which helps the sphincter do its job. So while the sphincter itself isn't any better, the backup team is on board now. That usually will bring a patient to have resolution of stress incontinence.”

Urge incontinence, also known as overactive bladder, is more common with advancing age. It is characterized by a sudden need to urinate with or without urinary leakage. This form is generally treated behaviorally by decreasing intake of caffeine and other known bladder irritants, and by strengthening the pelvic floor muscles, but some patients require treatment with medications that impact the muscarinic receptors in the bladder. Pregnancy commonly contributes to incontinence, as can chronic constipation and disorders associated with chronic cough.

“There is also an increasing relationship between obesity and urinary incontinence,” said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. “It's been shown that even modest weight loss in women who have urinary incontinence and obesity can greatly reduce their symptoms. Losing 10 or 15 pounds for a patient who is morbidly obese can help reduce her symptoms.”

According to the American Urogynecologic Society, other causes of urinary incontinence include pelvic radiation, occupations that require heavy lifting or exertion, medications taken for other conditions, and stones or tumors in the bladder.

Keep the Initial Workup Simple

Step one is to ask women whether they're experiencing urinary incontinence symptoms. Dr. Fenner recommends including a focused question on your intake questionnaire and in person during routine office visits such as, “Are you having difficulty holding your urine?” Or, “Is urinary incontinence a bother?”

Dr. Brubaker offered the following phrase to use during visits with patients: “Women experience urinary incontinence commonly. If you do, let me know, because there are things we can do to help.” This approach creates “a safety net so the woman can talk about this without feeling humiliated, or embarrassed, or alone.”

If a patient informs you of urinary incontinence symptoms at the end of an office visit, Dr. Brubaker recommends ordering a urine culture to rule out a urinary tract infection. Then ask her to schedule a follow-up visit by saying something like, “I'm so glad you raised this. I'd like to order some basic urine tests today, but I'd like to set up a dedicated time in the near future so that we can investigate what's going on.”

Experts interviewed for this story emphasized that most women do not require a complex evaluation such as a multichannel urodynamic study to make a diagnosis of stress, urge, or mixed urinary incontinence. “A lot of what we recommend is based on her symptoms: when she leaks, what promotes her incontinence,” said Dr. Fenner, who is also director of gynecology for the University of Michigan Health System. “That can help direct your therapy. In addition, we recommend looking for prolapse and testing to see how well she can squeeze and perform a Kegel contraction. That gives you an idea of whether physical therapy may be of benefit or not.”

Dr. Fenner recommends post-void residual testing in symptomatic patients, “to make sure that women are emptying their bladder completely, that they don't have a more complex neurologic etiology. You can do that with a catheter or with an ultrasound.” Full bladder stress testing also can be helpful. For this test, have the woman lie down with a full bladder. “If she doesn't leak lying down, we have her do three strong coughs,” she said. “Have her stand up and see if that makes her leak.”

Workups should include consideration of potentially reversible factors. In 1985, geriatrician Dr. Neil M Resnick, chief of the division of geriatrics at the University of Pittsburgh, proposed the mnemonic DIAPPERS for the following treatable causes of urinary incontinence: delirium, infection, atrophic urethritis and vaginitis, pharmaceuticals, psychologic disorders, excessive urine output (such as from heart failure of hyperglycemia), restricted mobility, and stool impaction (N. Engl. J. Med. 1985;313:800–5).

“Defining etiology directs therapy,” Dr. Fenner said. “There are things that can go wrong with the bladder. There are things that can go wrong with the urethra. There are things that can irritate the bladder. There can be systemic problems like diabetes, Parkinson's or multiple sclerosis that can impact urinary incontinence.”

If you'd like to get a more detailed sense of how symptoms are impacting your patients, Dr. Iglesia recommends two validated questionnaires. One is called the Medical, Epidemiological, and Social aspects of Aging, “which tells you more about stress and urge incontinence symptoms,” she said. Another is the Incontinence Impact Questionnaire, which measures the impact of urinary incontinence on activities, roles, and emotional states (Neurourol. Urodyn. 1995;14:131–9). Other questionnaires to consider using, she said, include the Incontinence Severity Index (ISI) and the six-item Urogenital Distress Inventory—6 (UDI-6).

Support and Education Efforts

Consumer groups such as The Accidental Sisterhood (

www.accidentalsisterhood.com

www.nafc.org

www.voicesforpfd.org

Progress is being made on that front. In April of 2011, the American Board of Medical Specialties accredited the new subspecialty of female pelvic medicine and reconstructive surgery. According to Dr. Fenner, the American Board of Obstetrics and Gynecology and the American Board of Urology are working together to develop board testing and certification, which is expected to be available in 2013. “The purpose is to have subspecialists for complex surgical procedures and for the complex patients who have failed initial treatment,” Dr. Fenner said. “With the increase in the population and the growing number of healthy women who want to live very active lives, urinary incontinence is only going to be increasing. There won't be enough providers to care for this population. It will be very important that general ob.gyns. and other primary health care providers ask patients if they're having issues with urinary incontinence. They certainly can care for many of these women.”

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate. Dr. Brubaker and Dr. Iglesia said that they had no relevant financial conflicts to disclose.

If you would like to get a more detailed sense of how symptoms are impacting your patients, Dr. Cheryl Iglesia recommends two questionnaires.

Ob.gyns. and other primary care providers play a major role in helping women identify and manage symptoms of urinary incontinence, a condition estimated by the American Urogynecologic Society to affect 30%–50% of women, but that notion appears to be lost on some generalist clinicians.

“Since we know it's such a problem, maybe we should be asking our patients more about it and have them 'fess up, but we don't, because we only have 15 minutes of managed care time where we're assessing risks for heart disease, cancer, and other medical conditions,” said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. “Urinary incontinence is a quality of life issue that's not going to kill you, but it really does take away your quality of life.”

Some physicians take a fatalistic view of the condition, she continued, telling women “there's nothing that can be done about it. There's where we go wrong. It's a highly prevalent condition, and we have a growing Medicare population,” said Dr. Iglesia, who is also associate professor of obstetrics and gynecology and urology at Georgetown University in Washington. “In fact, 80% of women by the time they're 80 have some form of incontinence. At the same time there's a misconception that incontinence happens as a normal part of aging, [the notion of] 'What do you expect? You're getting older. Just deal with it. Wear the incontinence pads.' That message is always wrong.”

Then there are the patients who avoid discussing the issue during office visits. “A lot of patients are so embarrassed by the situation that they become reclusive, or it's affecting their quality of life but they don't want to bring it up with their physician because of the shame factor,” she said. “They become more isolated, not wanting to be physically active, wearing pads, or bringing along changes of underwear, so coping in a way, but they don't want to talk about it.”

The Problem

According to a recent review from the Agency for Healthcare Research and Quality, some degree of involuntary urine loss is experienced by 25% of young women, 44%–57% of middle-age and postmenopausal women, and 75% of elderly women in nursing homes. It went on to note that in 2004, annual costs associated with treating the condition averaged $19.5 billion.

The two main types of incontinence are stress incontinence and urge incontinence, although most women have a mix of each, said Dr. Linda Brubaker, who directs the division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. “It's kind of like height and weight: You can be tall and fat, short and skinny, or tall and skinny. You can have any combination of stress incontinence or urge incontinence.”

In stress incontinence, women experience loss of urine during physical activities that increase abdominal pressure, such as sneezing, coughing, or exercising. In this form, the urinary sphincter “may not be doing its job well because it's lost some of its normal function or it's lost some of its normal anatomic positioning,” explained Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. “The function doesn't usually get restored, but what we do with surgery is add a material that is a secondary mechanism, which helps the sphincter do its job. So while the sphincter itself isn't any better, the backup team is on board now. That usually will bring a patient to have resolution of stress incontinence.”

Urge incontinence, also known as overactive bladder, is more common with advancing age. It is characterized by a sudden need to urinate with or without urinary leakage. This form is generally treated behaviorally by decreasing intake of caffeine and other known bladder irritants, and by strengthening the pelvic floor muscles, but some patients require treatment with medications that impact the muscarinic receptors in the bladder. Pregnancy commonly contributes to incontinence, as can chronic constipation and disorders associated with chronic cough.

“There is also an increasing relationship between obesity and urinary incontinence,” said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. “It's been shown that even modest weight loss in women who have urinary incontinence and obesity can greatly reduce their symptoms. Losing 10 or 15 pounds for a patient who is morbidly obese can help reduce her symptoms.”

According to the American Urogynecologic Society, other causes of urinary incontinence include pelvic radiation, occupations that require heavy lifting or exertion, medications taken for other conditions, and stones or tumors in the bladder.

Keep the Initial Workup Simple

Step one is to ask women whether they're experiencing urinary incontinence symptoms. Dr. Fenner recommends including a focused question on your intake questionnaire and in person during routine office visits such as, “Are you having difficulty holding your urine?” Or, “Is urinary incontinence a bother?”

Dr. Brubaker offered the following phrase to use during visits with patients: “Women experience urinary incontinence commonly. If you do, let me know, because there are things we can do to help.” This approach creates “a safety net so the woman can talk about this without feeling humiliated, or embarrassed, or alone.”

If a patient informs you of urinary incontinence symptoms at the end of an office visit, Dr. Brubaker recommends ordering a urine culture to rule out a urinary tract infection. Then ask her to schedule a follow-up visit by saying something like, “I'm so glad you raised this. I'd like to order some basic urine tests today, but I'd like to set up a dedicated time in the near future so that we can investigate what's going on.”

Experts interviewed for this story emphasized that most women do not require a complex evaluation such as a multichannel urodynamic study to make a diagnosis of stress, urge, or mixed urinary incontinence. “A lot of what we recommend is based on her symptoms: when she leaks, what promotes her incontinence,” said Dr. Fenner, who is also director of gynecology for the University of Michigan Health System. “That can help direct your therapy. In addition, we recommend looking for prolapse and testing to see how well she can squeeze and perform a Kegel contraction. That gives you an idea of whether physical therapy may be of benefit or not.”

Dr. Fenner recommends post-void residual testing in symptomatic patients, “to make sure that women are emptying their bladder completely, that they don't have a more complex neurologic etiology. You can do that with a catheter or with an ultrasound.” Full bladder stress testing also can be helpful. For this test, have the woman lie down with a full bladder. “If she doesn't leak lying down, we have her do three strong coughs,” she said. “Have her stand up and see if that makes her leak.”

Workups should include consideration of potentially reversible factors. In 1985, geriatrician Dr. Neil M Resnick, chief of the division of geriatrics at the University of Pittsburgh, proposed the mnemonic DIAPPERS for the following treatable causes of urinary incontinence: delirium, infection, atrophic urethritis and vaginitis, pharmaceuticals, psychologic disorders, excessive urine output (such as from heart failure of hyperglycemia), restricted mobility, and stool impaction (N. Engl. J. Med. 1985;313:800–5).

“Defining etiology directs therapy,” Dr. Fenner said. “There are things that can go wrong with the bladder. There are things that can go wrong with the urethra. There are things that can irritate the bladder. There can be systemic problems like diabetes, Parkinson's or multiple sclerosis that can impact urinary incontinence.”

If you'd like to get a more detailed sense of how symptoms are impacting your patients, Dr. Iglesia recommends two validated questionnaires. One is called the Medical, Epidemiological, and Social aspects of Aging, “which tells you more about stress and urge incontinence symptoms,” she said. Another is the Incontinence Impact Questionnaire, which measures the impact of urinary incontinence on activities, roles, and emotional states (Neurourol. Urodyn. 1995;14:131–9). Other questionnaires to consider using, she said, include the Incontinence Severity Index (ISI) and the six-item Urogenital Distress Inventory—6 (UDI-6).

Support and Education Efforts

Consumer groups such as The Accidental Sisterhood (

www.accidentalsisterhood.com

www.nafc.org

www.voicesforpfd.org

Progress is being made on that front. In April of 2011, the American Board of Medical Specialties accredited the new subspecialty of female pelvic medicine and reconstructive surgery. According to Dr. Fenner, the American Board of Obstetrics and Gynecology and the American Board of Urology are working together to develop board testing and certification, which is expected to be available in 2013. “The purpose is to have subspecialists for complex surgical procedures and for the complex patients who have failed initial treatment,” Dr. Fenner said. “With the increase in the population and the growing number of healthy women who want to live very active lives, urinary incontinence is only going to be increasing. There won't be enough providers to care for this population. It will be very important that general ob.gyns. and other primary health care providers ask patients if they're having issues with urinary incontinence. They certainly can care for many of these women.”

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate. Dr. Brubaker and Dr. Iglesia said that they had no relevant financial conflicts to disclose.

If you would like to get a more detailed sense of how symptoms are impacting your patients, Dr. Cheryl Iglesia recommends two questionnaires.

Ob.gyns. and other primary care providers play a major role in helping women identify and manage symptoms of urinary incontinence, a condition estimated by the American Urogynecologic Society to affect 30%–50% of women, but that notion appears to be lost on some generalist clinicians.

“Since we know it's such a problem, maybe we should be asking our patients more about it and have them 'fess up, but we don't, because we only have 15 minutes of managed care time where we're assessing risks for heart disease, cancer, and other medical conditions,” said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. “Urinary incontinence is a quality of life issue that's not going to kill you, but it really does take away your quality of life.”

Some physicians take a fatalistic view of the condition, she continued, telling women “there's nothing that can be done about it. There's where we go wrong. It's a highly prevalent condition, and we have a growing Medicare population,” said Dr. Iglesia, who is also associate professor of obstetrics and gynecology and urology at Georgetown University in Washington. “In fact, 80% of women by the time they're 80 have some form of incontinence. At the same time there's a misconception that incontinence happens as a normal part of aging, [the notion of] 'What do you expect? You're getting older. Just deal with it. Wear the incontinence pads.' That message is always wrong.”

Then there are the patients who avoid discussing the issue during office visits. “A lot of patients are so embarrassed by the situation that they become reclusive, or it's affecting their quality of life but they don't want to bring it up with their physician because of the shame factor,” she said. “They become more isolated, not wanting to be physically active, wearing pads, or bringing along changes of underwear, so coping in a way, but they don't want to talk about it.”

The Problem

According to a recent review from the Agency for Healthcare Research and Quality, some degree of involuntary urine loss is experienced by 25% of young women, 44%–57% of middle-age and postmenopausal women, and 75% of elderly women in nursing homes. It went on to note that in 2004, annual costs associated with treating the condition averaged $19.5 billion.

The two main types of incontinence are stress incontinence and urge incontinence, although most women have a mix of each, said Dr. Linda Brubaker, who directs the division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. “It's kind of like height and weight: You can be tall and fat, short and skinny, or tall and skinny. You can have any combination of stress incontinence or urge incontinence.”

In stress incontinence, women experience loss of urine during physical activities that increase abdominal pressure, such as sneezing, coughing, or exercising. In this form, the urinary sphincter “may not be doing its job well because it's lost some of its normal function or it's lost some of its normal anatomic positioning,” explained Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. “The function doesn't usually get restored, but what we do with surgery is add a material that is a secondary mechanism, which helps the sphincter do its job. So while the sphincter itself isn't any better, the backup team is on board now. That usually will bring a patient to have resolution of stress incontinence.”

Urge incontinence, also known as overactive bladder, is more common with advancing age. It is characterized by a sudden need to urinate with or without urinary leakage. This form is generally treated behaviorally by decreasing intake of caffeine and other known bladder irritants, and by strengthening the pelvic floor muscles, but some patients require treatment with medications that impact the muscarinic receptors in the bladder. Pregnancy commonly contributes to incontinence, as can chronic constipation and disorders associated with chronic cough.

“There is also an increasing relationship between obesity and urinary incontinence,” said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. “It's been shown that even modest weight loss in women who have urinary incontinence and obesity can greatly reduce their symptoms. Losing 10 or 15 pounds for a patient who is morbidly obese can help reduce her symptoms.”

According to the American Urogynecologic Society, other causes of urinary incontinence include pelvic radiation, occupations that require heavy lifting or exertion, medications taken for other conditions, and stones or tumors in the bladder.

Keep the Initial Workup Simple

Step one is to ask women whether they're experiencing urinary incontinence symptoms. Dr. Fenner recommends including a focused question on your intake questionnaire and in person during routine office visits such as, “Are you having difficulty holding your urine?” Or, “Is urinary incontinence a bother?”

Dr. Brubaker offered the following phrase to use during visits with patients: “Women experience urinary incontinence commonly. If you do, let me know, because there are things we can do to help.” This approach creates “a safety net so the woman can talk about this without feeling humiliated, or embarrassed, or alone.”

If a patient informs you of urinary incontinence symptoms at the end of an office visit, Dr. Brubaker recommends ordering a urine culture to rule out a urinary tract infection. Then ask her to schedule a follow-up visit by saying something like, “I'm so glad you raised this. I'd like to order some basic urine tests today, but I'd like to set up a dedicated time in the near future so that we can investigate what's going on.”

Experts interviewed for this story emphasized that most women do not require a complex evaluation such as a multichannel urodynamic study to make a diagnosis of stress, urge, or mixed urinary incontinence. “A lot of what we recommend is based on her symptoms: when she leaks, what promotes her incontinence,” said Dr. Fenner, who is also director of gynecology for the University of Michigan Health System. “That can help direct your therapy. In addition, we recommend looking for prolapse and testing to see how well she can squeeze and perform a Kegel contraction. That gives you an idea of whether physical therapy may be of benefit or not.”

Dr. Fenner recommends post-void residual testing in symptomatic patients, “to make sure that women are emptying their bladder completely, that they don't have a more complex neurologic etiology. You can do that with a catheter or with an ultrasound.” Full bladder stress testing also can be helpful. For this test, have the woman lie down with a full bladder. “If she doesn't leak lying down, we have her do three strong coughs,” she said. “Have her stand up and see if that makes her leak.”

Workups should include consideration of potentially reversible factors. In 1985, geriatrician Dr. Neil M Resnick, chief of the division of geriatrics at the University of Pittsburgh, proposed the mnemonic DIAPPERS for the following treatable causes of urinary incontinence: delirium, infection, atrophic urethritis and vaginitis, pharmaceuticals, psychologic disorders, excessive urine output (such as from heart failure of hyperglycemia), restricted mobility, and stool impaction (N. Engl. J. Med. 1985;313:800–5).

“Defining etiology directs therapy,” Dr. Fenner said. “There are things that can go wrong with the bladder. There are things that can go wrong with the urethra. There are things that can irritate the bladder. There can be systemic problems like diabetes, Parkinson's or multiple sclerosis that can impact urinary incontinence.”

If you'd like to get a more detailed sense of how symptoms are impacting your patients, Dr. Iglesia recommends two validated questionnaires. One is called the Medical, Epidemiological, and Social aspects of Aging, “which tells you more about stress and urge incontinence symptoms,” she said. Another is the Incontinence Impact Questionnaire, which measures the impact of urinary incontinence on activities, roles, and emotional states (Neurourol. Urodyn. 1995;14:131–9). Other questionnaires to consider using, she said, include the Incontinence Severity Index (ISI) and the six-item Urogenital Distress Inventory—6 (UDI-6).

Support and Education Efforts

Consumer groups such as The Accidental Sisterhood (

www.accidentalsisterhood.com

www.nafc.org

www.voicesforpfd.org

Progress is being made on that front. In April of 2011, the American Board of Medical Specialties accredited the new subspecialty of female pelvic medicine and reconstructive surgery. According to Dr. Fenner, the American Board of Obstetrics and Gynecology and the American Board of Urology are working together to develop board testing and certification, which is expected to be available in 2013. “The purpose is to have subspecialists for complex surgical procedures and for the complex patients who have failed initial treatment,” Dr. Fenner said. “With the increase in the population and the growing number of healthy women who want to live very active lives, urinary incontinence is only going to be increasing. There won't be enough providers to care for this population. It will be very important that general ob.gyns. and other primary health care providers ask patients if they're having issues with urinary incontinence. They certainly can care for many of these women.”

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate. Dr. Brubaker and Dr. Iglesia said that they had no relevant financial conflicts to disclose.

If you would like to get a more detailed sense of how symptoms are impacting your patients, Dr. Cheryl Iglesia recommends two questionnaires.

CHICAGO – If you think the privacy curtains at your health care facility are free of potentially harmful bacteria, think again.

Within one week of being laundered, 92% of hospital curtains were contaminated with pathogens that included methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) species, results from a single-center study showed.

"Usually when health care workers walk into a patient room, they’ll wash their hands, grab the curtain, pull it aside, and then touch the patient, without realizing that they touched the curtain," Marin L. Schweizer, Ph.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "The message here is that health care workers should wash their hands after touching privacy curtains and before touching the patient."

Over a period of 3 weeks, Dr. Schweizer and her associates obtained 180 swab cultures from 43 privacy curtains in 30 rooms at the University of Iowa Hospitals and Clinics (8 medical intensive care units, 7 surgical ICUs, and 15 medical wards). They obtained the cultures twice weekly from an 800-cm² area on the leading edge of each curtain, and marked each curtain to determine when it was changed.

Standard microbiologic methods, including broth enrichment, were used to determine contamination. To distinguish persistence of pathogens on curtains from recontamination, all MRSA and VRE were typed using pulsed-field gel electrophoresis.

Of the 13 curtains placed during the study, 12 (92%) demonstrated contamination within 1 week, while 41 of the 45 curtains (95%) demonstrated contamination on at least one occasion. "We thought the prevalence would be high, but we didn’t think it would be that high," commented Dr. Schweizer of the department of general internal medicine at the University of Iowa, Iowa City.

She went on to report that VRE and MRSA were isolated from 42% and 21% of the curtains, respectively. Eight curtains were contaminated with VRE at more than one time point: three with persistence of a single genetic type and five with genetic types over time. "This shows that there are lots of pathogens on the curtains," Dr. Schweizer said. "They stick around for a long time and they’re constantly being recontaminated."

Two-thirds of all swab cultures (66%) were positive for either S. aureus, Enterococcus spp. (44%), or gram-negative rods (22%).

The study was funded by PurThread, a manufacturer of antimicrobial fabrics for use in health care settings. One of the study investigators, Dr. Eli Perenchevich, is a paid consultant for PurThread.

According to Dr. Schweizer, none of the curtains studied were made by PurThread.

CHICAGO – If you think the privacy curtains at your health care facility are free of potentially harmful bacteria, think again.

Within one week of being laundered, 92% of hospital curtains were contaminated with pathogens that included methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) species, results from a single-center study showed.

"Usually when health care workers walk into a patient room, they’ll wash their hands, grab the curtain, pull it aside, and then touch the patient, without realizing that they touched the curtain," Marin L. Schweizer, Ph.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "The message here is that health care workers should wash their hands after touching privacy curtains and before touching the patient."

Over a period of 3 weeks, Dr. Schweizer and her associates obtained 180 swab cultures from 43 privacy curtains in 30 rooms at the University of Iowa Hospitals and Clinics (8 medical intensive care units, 7 surgical ICUs, and 15 medical wards). They obtained the cultures twice weekly from an 800-cm² area on the leading edge of each curtain, and marked each curtain to determine when it was changed.

Standard microbiologic methods, including broth enrichment, were used to determine contamination. To distinguish persistence of pathogens on curtains from recontamination, all MRSA and VRE were typed using pulsed-field gel electrophoresis.

Of the 13 curtains placed during the study, 12 (92%) demonstrated contamination within 1 week, while 41 of the 45 curtains (95%) demonstrated contamination on at least one occasion. "We thought the prevalence would be high, but we didn’t think it would be that high," commented Dr. Schweizer of the department of general internal medicine at the University of Iowa, Iowa City.

She went on to report that VRE and MRSA were isolated from 42% and 21% of the curtains, respectively. Eight curtains were contaminated with VRE at more than one time point: three with persistence of a single genetic type and five with genetic types over time. "This shows that there are lots of pathogens on the curtains," Dr. Schweizer said. "They stick around for a long time and they’re constantly being recontaminated."

Two-thirds of all swab cultures (66%) were positive for either S. aureus, Enterococcus spp. (44%), or gram-negative rods (22%).

The study was funded by PurThread, a manufacturer of antimicrobial fabrics for use in health care settings. One of the study investigators, Dr. Eli Perenchevich, is a paid consultant for PurThread.

According to Dr. Schweizer, none of the curtains studied were made by PurThread.

CHICAGO – If you think the privacy curtains at your health care facility are free of potentially harmful bacteria, think again.

Within one week of being laundered, 92% of hospital curtains were contaminated with pathogens that included methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) species, results from a single-center study showed.

"Usually when health care workers walk into a patient room, they’ll wash their hands, grab the curtain, pull it aside, and then touch the patient, without realizing that they touched the curtain," Marin L. Schweizer, Ph.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "The message here is that health care workers should wash their hands after touching privacy curtains and before touching the patient."

Over a period of 3 weeks, Dr. Schweizer and her associates obtained 180 swab cultures from 43 privacy curtains in 30 rooms at the University of Iowa Hospitals and Clinics (8 medical intensive care units, 7 surgical ICUs, and 15 medical wards). They obtained the cultures twice weekly from an 800-cm² area on the leading edge of each curtain, and marked each curtain to determine when it was changed.

Standard microbiologic methods, including broth enrichment, were used to determine contamination. To distinguish persistence of pathogens on curtains from recontamination, all MRSA and VRE were typed using pulsed-field gel electrophoresis.

Of the 13 curtains placed during the study, 12 (92%) demonstrated contamination within 1 week, while 41 of the 45 curtains (95%) demonstrated contamination on at least one occasion. "We thought the prevalence would be high, but we didn’t think it would be that high," commented Dr. Schweizer of the department of general internal medicine at the University of Iowa, Iowa City.

She went on to report that VRE and MRSA were isolated from 42% and 21% of the curtains, respectively. Eight curtains were contaminated with VRE at more than one time point: three with persistence of a single genetic type and five with genetic types over time. "This shows that there are lots of pathogens on the curtains," Dr. Schweizer said. "They stick around for a long time and they’re constantly being recontaminated."

Two-thirds of all swab cultures (66%) were positive for either S. aureus, Enterococcus spp. (44%), or gram-negative rods (22%).

The study was funded by PurThread, a manufacturer of antimicrobial fabrics for use in health care settings. One of the study investigators, Dr. Eli Perenchevich, is a paid consultant for PurThread.

According to Dr. Schweizer, none of the curtains studied were made by PurThread.

CHICAGO – Oral metronidazole was just as effective as oral vancomycin in treating Clostridium difficile diarrhea, regardless of the severity of illness, in a single-center study.

There also were no differences in mortality with use of either antibiotic, primary author Dr. Qamar Saleheen reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Based on these findings, we ask this question to the medical community: ‘Is using one antibiotic over the other justified based upon severity of illness without consideration to the financial impact of using vancomycin, which is much more expensive than metronidazole?’ " the researchers asked in a press statement.

According to guidelines on the treatment of C. difficile diarrhea published in May 2010 by the Society for Healthcare Epidemiology of America, oral metronidazole is recommended for mild to moderate illness while oral vancomycin is recommend for severe illness (Infect. Control Hosp. Epidemiol. 2010;31:431-55).

Between Jan. 1, 2009 and March 31, 2010, Dr. Saleheen and his associates at Edward Hines Jr. VA Hospital in Hines, Ill., reviewed the charts of 147 patients with C. difficile positive stools. A total of 25 patients with a mean age of 67 years initially received oral vancomycin and 122 with a mean age of 68 years initially received oral metronidazole. Of 122 patients initially treated with metronidazole, 28 received crossover treatment with vancomycin.

Dr. Saleheen, an infectious diseases fellow at Loyola University Medical Center, Maywood, Ill., reported that in the vancomycin group, 14 patients (56%) had severe disease, of whom 3 patients (12%) had recurrence. Of the 11 patients (44%) who had nonsevere disease, none had a recurrence.

In the metronidazole group, 59 patients (48%) had severe disease, of whom 16 (13%) had recurrence; of the 63 (52%) with nonsevere disease, 11 (9%) had recurrence.

The researchers found that metronidazole was equivalent to vancomycin regardless of the severity of illness (P = .14). There were also no statistically significant differences between the two groups in the rate of recurrence or complications.

The researchers acknowledged certain limitations of the study, including its retrospective design, its relatively small sample size, and the fact that only two patients were female.

"There is a need for a prospective, head-to-head trial of these two medications, but I’m not sure who’s going to fund that study," Dr. Saleheen said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "There is a paucity of data on this topic so it’s hard to say which antibiotic is better. We’re not jumping to any conclusions. There is no fixed management. We have to individualize each patient and treat accordingly."

The study’s principal investigators were Dr. Joseph R. Lentino and Dr. Constance Pachucki, both of Loyola University Chicago. The study’s fourth investigator was Dr. Mohammed Bilgrami, who is also an infectious diseases fellow at Loyola University Medical Center.

The researchers stated that they had no relevant financial conflicts to disclose.

CHICAGO – Oral metronidazole was just as effective as oral vancomycin in treating Clostridium difficile diarrhea, regardless of the severity of illness, in a single-center study.

There also were no differences in mortality with use of either antibiotic, primary author Dr. Qamar Saleheen reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Based on these findings, we ask this question to the medical community: ‘Is using one antibiotic over the other justified based upon severity of illness without consideration to the financial impact of using vancomycin, which is much more expensive than metronidazole?’ " the researchers asked in a press statement.

According to guidelines on the treatment of C. difficile diarrhea published in May 2010 by the Society for Healthcare Epidemiology of America, oral metronidazole is recommended for mild to moderate illness while oral vancomycin is recommend for severe illness (Infect. Control Hosp. Epidemiol. 2010;31:431-55).

Between Jan. 1, 2009 and March 31, 2010, Dr. Saleheen and his associates at Edward Hines Jr. VA Hospital in Hines, Ill., reviewed the charts of 147 patients with C. difficile positive stools. A total of 25 patients with a mean age of 67 years initially received oral vancomycin and 122 with a mean age of 68 years initially received oral metronidazole. Of 122 patients initially treated with metronidazole, 28 received crossover treatment with vancomycin.

Dr. Saleheen, an infectious diseases fellow at Loyola University Medical Center, Maywood, Ill., reported that in the vancomycin group, 14 patients (56%) had severe disease, of whom 3 patients (12%) had recurrence. Of the 11 patients (44%) who had nonsevere disease, none had a recurrence.

In the metronidazole group, 59 patients (48%) had severe disease, of whom 16 (13%) had recurrence; of the 63 (52%) with nonsevere disease, 11 (9%) had recurrence.

The researchers found that metronidazole was equivalent to vancomycin regardless of the severity of illness (P = .14). There were also no statistically significant differences between the two groups in the rate of recurrence or complications.

The researchers acknowledged certain limitations of the study, including its retrospective design, its relatively small sample size, and the fact that only two patients were female.

"There is a need for a prospective, head-to-head trial of these two medications, but I’m not sure who’s going to fund that study," Dr. Saleheen said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "There is a paucity of data on this topic so it’s hard to say which antibiotic is better. We’re not jumping to any conclusions. There is no fixed management. We have to individualize each patient and treat accordingly."

The study’s principal investigators were Dr. Joseph R. Lentino and Dr. Constance Pachucki, both of Loyola University Chicago. The study’s fourth investigator was Dr. Mohammed Bilgrami, who is also an infectious diseases fellow at Loyola University Medical Center.

The researchers stated that they had no relevant financial conflicts to disclose.

CHICAGO – Oral metronidazole was just as effective as oral vancomycin in treating Clostridium difficile diarrhea, regardless of the severity of illness, in a single-center study.

There also were no differences in mortality with use of either antibiotic, primary author Dr. Qamar Saleheen reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Based on these findings, we ask this question to the medical community: ‘Is using one antibiotic over the other justified based upon severity of illness without consideration to the financial impact of using vancomycin, which is much more expensive than metronidazole?’ " the researchers asked in a press statement.

According to guidelines on the treatment of C. difficile diarrhea published in May 2010 by the Society for Healthcare Epidemiology of America, oral metronidazole is recommended for mild to moderate illness while oral vancomycin is recommend for severe illness (Infect. Control Hosp. Epidemiol. 2010;31:431-55).

Between Jan. 1, 2009 and March 31, 2010, Dr. Saleheen and his associates at Edward Hines Jr. VA Hospital in Hines, Ill., reviewed the charts of 147 patients with C. difficile positive stools. A total of 25 patients with a mean age of 67 years initially received oral vancomycin and 122 with a mean age of 68 years initially received oral metronidazole. Of 122 patients initially treated with metronidazole, 28 received crossover treatment with vancomycin.

Dr. Saleheen, an infectious diseases fellow at Loyola University Medical Center, Maywood, Ill., reported that in the vancomycin group, 14 patients (56%) had severe disease, of whom 3 patients (12%) had recurrence. Of the 11 patients (44%) who had nonsevere disease, none had a recurrence.

In the metronidazole group, 59 patients (48%) had severe disease, of whom 16 (13%) had recurrence; of the 63 (52%) with nonsevere disease, 11 (9%) had recurrence.

The researchers found that metronidazole was equivalent to vancomycin regardless of the severity of illness (P = .14). There were also no statistically significant differences between the two groups in the rate of recurrence or complications.

The researchers acknowledged certain limitations of the study, including its retrospective design, its relatively small sample size, and the fact that only two patients were female.

"There is a need for a prospective, head-to-head trial of these two medications, but I’m not sure who’s going to fund that study," Dr. Saleheen said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "There is a paucity of data on this topic so it’s hard to say which antibiotic is better. We’re not jumping to any conclusions. There is no fixed management. We have to individualize each patient and treat accordingly."

The study’s principal investigators were Dr. Joseph R. Lentino and Dr. Constance Pachucki, both of Loyola University Chicago. The study’s fourth investigator was Dr. Mohammed Bilgrami, who is also an infectious diseases fellow at Loyola University Medical Center.

The researchers stated that they had no relevant financial conflicts to disclose.

CHICAGO – Intra-abdominal infections are the most common source of hospital-acquired bloodstream infections, results from a year-long, single-center study found.

"With the movement toward reducing all hospital-acquired infections, it is important to find out where to put our efforts," lead investigator Dr. Mohamad G. Fakih said in an interview before a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, where the research was presented in poster form.

To better understand the main sources of hospital-acquired bloodstream infections, Dr. Fakih and his associates at the 804-bed St. John Hospital and Medical Center, Detroit, retrospectively evaluated 180 cases of patients with positive blood cultures from 10 adult nonintensive medical-surgical units at the hospital between October 2009 and September of 2010. They collected data on infection source, causative organism, and whether it was hospital-acquired (defined as the emergence of a bloodstream infection greater than 48 hours after admission).

In all, 47 of the cases were considered to be contaminants. That left 133 cases of bloodstream infections: 42 of them had a community-onset and 91 were acquired in the hospital.

Dr. Fakih, medical director of infection prevention and control at the hospital, reported that of the 91 hospital-acquired cases of bloodstream infection, 20 (22%) were related to Staphylococcus aureus, 3 (3.3%) to coagulase-negative staphylococci, 11 (12.1%) to other gram-positive organisms, 25 (27.5%) to gram-negative bacilli, 21 (23.1%) to mixed organisms, 5 (5.5%) to anaerobes, and 6 (6.6%) to Candida species.

As for common sources of hospital-acquired bloodstream infections, 32 (35.2%) were intra-abdominal, 19 (20.9%) were vascular catheter, 11 (12.9%) were urinary tract, and 9 (9.9%) were soft tissue.

Dr. Fakih noted that peripheral intravenous catheters were the source of 42.1% of bloodstream infections that were associated with vascular catheters.

He indicated certain limitations of the study, including its single-center design. Dr. Fakih also encouraged clinicians to cast a wide net when it comes to infection control practices. "Look at what is important in your hospital and not only what is mandated by external agencies or what is now considered to be hospital-acquired conditions," he advised.

The conference was sponsored by the American Society for Microbiology. Dr. Fakih said that he had no relevant financial conflicts to disclose.

CHICAGO – Intra-abdominal infections are the most common source of hospital-acquired bloodstream infections, results from a year-long, single-center study found.

"With the movement toward reducing all hospital-acquired infections, it is important to find out where to put our efforts," lead investigator Dr. Mohamad G. Fakih said in an interview before a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, where the research was presented in poster form.

To better understand the main sources of hospital-acquired bloodstream infections, Dr. Fakih and his associates at the 804-bed St. John Hospital and Medical Center, Detroit, retrospectively evaluated 180 cases of patients with positive blood cultures from 10 adult nonintensive medical-surgical units at the hospital between October 2009 and September of 2010. They collected data on infection source, causative organism, and whether it was hospital-acquired (defined as the emergence of a bloodstream infection greater than 48 hours after admission).

In all, 47 of the cases were considered to be contaminants. That left 133 cases of bloodstream infections: 42 of them had a community-onset and 91 were acquired in the hospital.

Dr. Fakih, medical director of infection prevention and control at the hospital, reported that of the 91 hospital-acquired cases of bloodstream infection, 20 (22%) were related to Staphylococcus aureus, 3 (3.3%) to coagulase-negative staphylococci, 11 (12.1%) to other gram-positive organisms, 25 (27.5%) to gram-negative bacilli, 21 (23.1%) to mixed organisms, 5 (5.5%) to anaerobes, and 6 (6.6%) to Candida species.

As for common sources of hospital-acquired bloodstream infections, 32 (35.2%) were intra-abdominal, 19 (20.9%) were vascular catheter, 11 (12.9%) were urinary tract, and 9 (9.9%) were soft tissue.

Dr. Fakih noted that peripheral intravenous catheters were the source of 42.1% of bloodstream infections that were associated with vascular catheters.

He indicated certain limitations of the study, including its single-center design. Dr. Fakih also encouraged clinicians to cast a wide net when it comes to infection control practices. "Look at what is important in your hospital and not only what is mandated by external agencies or what is now considered to be hospital-acquired conditions," he advised.

The conference was sponsored by the American Society for Microbiology. Dr. Fakih said that he had no relevant financial conflicts to disclose.

CHICAGO – Intra-abdominal infections are the most common source of hospital-acquired bloodstream infections, results from a year-long, single-center study found.

"With the movement toward reducing all hospital-acquired infections, it is important to find out where to put our efforts," lead investigator Dr. Mohamad G. Fakih said in an interview before a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, where the research was presented in poster form.

To better understand the main sources of hospital-acquired bloodstream infections, Dr. Fakih and his associates at the 804-bed St. John Hospital and Medical Center, Detroit, retrospectively evaluated 180 cases of patients with positive blood cultures from 10 adult nonintensive medical-surgical units at the hospital between October 2009 and September of 2010. They collected data on infection source, causative organism, and whether it was hospital-acquired (defined as the emergence of a bloodstream infection greater than 48 hours after admission).

In all, 47 of the cases were considered to be contaminants. That left 133 cases of bloodstream infections: 42 of them had a community-onset and 91 were acquired in the hospital.

Dr. Fakih, medical director of infection prevention and control at the hospital, reported that of the 91 hospital-acquired cases of bloodstream infection, 20 (22%) were related to Staphylococcus aureus, 3 (3.3%) to coagulase-negative staphylococci, 11 (12.1%) to other gram-positive organisms, 25 (27.5%) to gram-negative bacilli, 21 (23.1%) to mixed organisms, 5 (5.5%) to anaerobes, and 6 (6.6%) to Candida species.

As for common sources of hospital-acquired bloodstream infections, 32 (35.2%) were intra-abdominal, 19 (20.9%) were vascular catheter, 11 (12.9%) were urinary tract, and 9 (9.9%) were soft tissue.

Dr. Fakih noted that peripheral intravenous catheters were the source of 42.1% of bloodstream infections that were associated with vascular catheters.

He indicated certain limitations of the study, including its single-center design. Dr. Fakih also encouraged clinicians to cast a wide net when it comes to infection control practices. "Look at what is important in your hospital and not only what is mandated by external agencies or what is now considered to be hospital-acquired conditions," he advised.

The conference was sponsored by the American Society for Microbiology. Dr. Fakih said that he had no relevant financial conflicts to disclose.

CHICAGO – Hospitalized patients who maintained short-term glucose levels less than 110mg/dL were less likely than those with higher short-term levels to develop bloodstream infections, according to the findings of a retrospective study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

By contrast, long-term glucose measures – hemoglobin A_1c – did not appear to be associated with the rates of bloodstream infections, said the study’s lead investigator Christie Y. Jeon, Sc.D., of Columbia University, New York.

"Given that people with diabetes are at increased risk of infections, monitoring glucose control may reduce the burden of bloodstream infections," she said at the conference, sponsored by the American Society for Microbiology.

There is currently a dearth of information on how short-term and long-term glucose control impact health care–associated bloodstream infections and what level of glucose control is optimal for reducing the risk of infection. Yet "health care–associated bloodstream infections are estimated to cause over 30,000 deaths in the United States annually," she said in an interview.

In the study, Dr. Jeon and associates analyzed 18,736 records from diabetes patients and 60,778 records from patients without diabetes admitted to one of three hospitals in New York City to examine the relationship between both short- and long-term glucose control on bloodstream infection rates.

For short-term glucose control, the researchers assessed glucose levels during three different periods leading up to the index date of infection: period 1, the index date and 2 days prior (day 0 to day -2); period 2, day -1 to day -3; and period 3, day -2 to day -4. Then they classified them into six categories: less than 80 mg/dL, 80-109 mg/dL, 110-139 mg/dL, 140-179 mg/dL, 180-199 mg/dL, and 200 mg/dL or higher.

Long-term glucose control was determined by hemoglobin A_1c.

The researchers controlled for confounding variables, including age, gender, severity of illness, malignancy, use of immunosuppressive medications, renal failure, prior hospitalization, use of mechanical ventilation, feeding tubes, and central venous and urinary catheterizations. The median age of patients was 53 years, and 54% were female.

Short-term glucose levels of 110 mg/dL or higher during period 1 were associated with an increase in bloodstream infections in people with diabetes (hazard ratio from 2.18 to 3.32) and in those without diabetes (HR from 1.62 to 1.80). Glucose levels measured more remotely in period 3 were not associated with bloodstream infections. Hypoglycemia and hemoglobin A_1c levels were not associated with bloodstream infections.

"The fact that long-term glucose control was not associated with bloodstream infection was surprising and informative to us, as it is an indication that for acute infections such as bloodstream infections, long-term glucose control is limited in its impact," Dr. Jeon said. "Further, the fact that glucose measured closest to the index date of infection was most predictive of bloodstream infections suggests that associations between glucose levels and infections may be due to hyperglycemia as an effect, and not a cause, of health care–associated infections."

The study was limited by its observational design. In addition, "there is a possibility that ... confounders may have influenced glucose levels as well as infection risk."

The study was funded by the National Institutes of Health. Dr. Jeon was supported by a National Research Service Award from the National Institute of Allergy and Infectious Diseases. Dr. Jeon’s coathors on the study were Dr. Emily Y. Furuya, Mandar Apte, and Elaine L. Larson, Ph.D.

Dr. Jeon said that she had no relevant financial conflicts of interest.

CHICAGO – Hospitalized patients who maintained short-term glucose levels less than 110mg/dL were less likely than those with higher short-term levels to develop bloodstream infections, according to the findings of a retrospective study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

By contrast, long-term glucose measures – hemoglobin A_1c – did not appear to be associated with the rates of bloodstream infections, said the study’s lead investigator Christie Y. Jeon, Sc.D., of Columbia University, New York.

"Given that people with diabetes are at increased risk of infections, monitoring glucose control may reduce the burden of bloodstream infections," she said at the conference, sponsored by the American Society for Microbiology.

There is currently a dearth of information on how short-term and long-term glucose control impact health care–associated bloodstream infections and what level of glucose control is optimal for reducing the risk of infection. Yet "health care–associated bloodstream infections are estimated to cause over 30,000 deaths in the United States annually," she said in an interview.

In the study, Dr. Jeon and associates analyzed 18,736 records from diabetes patients and 60,778 records from patients without diabetes admitted to one of three hospitals in New York City to examine the relationship between both short- and long-term glucose control on bloodstream infection rates.

For short-term glucose control, the researchers assessed glucose levels during three different periods leading up to the index date of infection: period 1, the index date and 2 days prior (day 0 to day -2); period 2, day -1 to day -3; and period 3, day -2 to day -4. Then they classified them into six categories: less than 80 mg/dL, 80-109 mg/dL, 110-139 mg/dL, 140-179 mg/dL, 180-199 mg/dL, and 200 mg/dL or higher.

Long-term glucose control was determined by hemoglobin A_1c.

The researchers controlled for confounding variables, including age, gender, severity of illness, malignancy, use of immunosuppressive medications, renal failure, prior hospitalization, use of mechanical ventilation, feeding tubes, and central venous and urinary catheterizations. The median age of patients was 53 years, and 54% were female.

Short-term glucose levels of 110 mg/dL or higher during period 1 were associated with an increase in bloodstream infections in people with diabetes (hazard ratio from 2.18 to 3.32) and in those without diabetes (HR from 1.62 to 1.80). Glucose levels measured more remotely in period 3 were not associated with bloodstream infections. Hypoglycemia and hemoglobin A_1c levels were not associated with bloodstream infections.

"The fact that long-term glucose control was not associated with bloodstream infection was surprising and informative to us, as it is an indication that for acute infections such as bloodstream infections, long-term glucose control is limited in its impact," Dr. Jeon said. "Further, the fact that glucose measured closest to the index date of infection was most predictive of bloodstream infections suggests that associations between glucose levels and infections may be due to hyperglycemia as an effect, and not a cause, of health care–associated infections."

The study was limited by its observational design. In addition, "there is a possibility that ... confounders may have influenced glucose levels as well as infection risk."

The study was funded by the National Institutes of Health. Dr. Jeon was supported by a National Research Service Award from the National Institute of Allergy and Infectious Diseases. Dr. Jeon’s coathors on the study were Dr. Emily Y. Furuya, Mandar Apte, and Elaine L. Larson, Ph.D.

Dr. Jeon said that she had no relevant financial conflicts of interest.

CHICAGO – Hospitalized patients who maintained short-term glucose levels less than 110mg/dL were less likely than those with higher short-term levels to develop bloodstream infections, according to the findings of a retrospective study presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

By contrast, long-term glucose measures – hemoglobin A_1c – did not appear to be associated with the rates of bloodstream infections, said the study’s lead investigator Christie Y. Jeon, Sc.D., of Columbia University, New York.

"Given that people with diabetes are at increased risk of infections, monitoring glucose control may reduce the burden of bloodstream infections," she said at the conference, sponsored by the American Society for Microbiology.

There is currently a dearth of information on how short-term and long-term glucose control impact health care–associated bloodstream infections and what level of glucose control is optimal for reducing the risk of infection. Yet "health care–associated bloodstream infections are estimated to cause over 30,000 deaths in the United States annually," she said in an interview.

In the study, Dr. Jeon and associates analyzed 18,736 records from diabetes patients and 60,778 records from patients without diabetes admitted to one of three hospitals in New York City to examine the relationship between both short- and long-term glucose control on bloodstream infection rates.

For short-term glucose control, the researchers assessed glucose levels during three different periods leading up to the index date of infection: period 1, the index date and 2 days prior (day 0 to day -2); period 2, day -1 to day -3; and period 3, day -2 to day -4. Then they classified them into six categories: less than 80 mg/dL, 80-109 mg/dL, 110-139 mg/dL, 140-179 mg/dL, 180-199 mg/dL, and 200 mg/dL or higher.

Long-term glucose control was determined by hemoglobin A_1c.

The researchers controlled for confounding variables, including age, gender, severity of illness, malignancy, use of immunosuppressive medications, renal failure, prior hospitalization, use of mechanical ventilation, feeding tubes, and central venous and urinary catheterizations. The median age of patients was 53 years, and 54% were female.

Short-term glucose levels of 110 mg/dL or higher during period 1 were associated with an increase in bloodstream infections in people with diabetes (hazard ratio from 2.18 to 3.32) and in those without diabetes (HR from 1.62 to 1.80). Glucose levels measured more remotely in period 3 were not associated with bloodstream infections. Hypoglycemia and hemoglobin A_1c levels were not associated with bloodstream infections.

"The fact that long-term glucose control was not associated with bloodstream infection was surprising and informative to us, as it is an indication that for acute infections such as bloodstream infections, long-term glucose control is limited in its impact," Dr. Jeon said. "Further, the fact that glucose measured closest to the index date of infection was most predictive of bloodstream infections suggests that associations between glucose levels and infections may be due to hyperglycemia as an effect, and not a cause, of health care–associated infections."

The study was limited by its observational design. In addition, "there is a possibility that ... confounders may have influenced glucose levels as well as infection risk."

The study was funded by the National Institutes of Health. Dr. Jeon was supported by a National Research Service Award from the National Institute of Allergy and Infectious Diseases. Dr. Jeon’s coathors on the study were Dr. Emily Y. Furuya, Mandar Apte, and Elaine L. Larson, Ph.D.

Dr. Jeon said that she had no relevant financial conflicts of interest.

In patients diagnosed with invasive primary cutaneous melanoma, a detailed patient history is crucial, and a thorough examination of the skin and lymph nodes should be performed to help determine the extent of clinical spread of the disease. However, for patients with melanomas of any thickness, baseline blood tests and imaging studies are not recommended because clinical research does not support their use unless suspicious signs and symptoms are present.

Those are two recommendations contained in the American Academy of Dermatology’s updated guidelines for the treatment of primary cutaneous melanoma, which were published online in the Journal of the American Academy of Dermatology. Last updated in 2001, the new guidelines focus on biopsy techniques, pathology, surgical treatment, and long-term follow-up care.

"There are many factors that must be considered when diagnosing and treating melanoma, and these new guidelines offer physicians clinically sound recommendations on how to treat melanoma patients and potentially increase their chance of survival from this deadly disease," AAD President Dr. Ronald L. Moy said in a statement.

A 15-member work group of melanoma experts convened by the AAD and chaired by Dr. Allan C. Halpern of Memorial Sloan-Kettering Cancer Center, New York, and Timothy M. Johnson of the University of Michigan and its Comprehensive Cancer Center, Ann Arbor, reviewed clinical studies and guidelines related to melanoma treatment that appeared in English-language publications between 2000 and 2010. Members of the work group used a 3-point scale to grade evidence, and then developed clinical recommendations on the best available evidence (J. Am. Acad. Dermatol. 2011 Aug. 26 doi: 10.1016/j.jaad.2011.04.031]).

The recommendations were ranked as "A" (recommendation based on consistent and good-quality patient-oriented evidence); "B" (recommendation based on inconsistent or limited-quality patient-oriented evidence); and "C" (recommendation based on consensus, opinion, case studies, or disease-oriented evidence).

The Increased Value of Mitotic Rate

According to Dr. David E. Kent, the most significant change from the 2001 guidelines relates to staging, with mitotic rate replacing Clark level of invasion as the second factor predicting melanoma survival in addition to tumor (Breslow) thickness for tumors 1 mm or smaller in thickness.

Included as a prognostic value in the 2010 American Joint Committee on Cancer staging system to upstage patients with melanoma, the mitotic rate is defined as the number of mitoses in the dermis per mm².

"The placement of mitotic rate has substantial value for dermatologists because the question we get asked often is, ‘What is the risk of this superficial melanoma spreading to other parts of the body, either regionally to the lymph nodes or distantly to other sites?’" said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta, who was not involved in assembling the guidelines. "With the mitotic rate less than 1 mm², it gives us a little bit more comfort in recommending to the patient that there’s less risk of spread. However, if there were to be a substantial mitotic rate, such as 2 mm², 3 mm², 4 mm², or even higher, that would lead one to consider referring the patient for evaluation for a staging and lymph node biopsy, even though the depth of the lesion is thin."

The guidelines note that there is "strong evidence" to support mitotic rate and two other histologic features as the most important characteristics of the primary tumor to predict outcome. The other features are maximum tumor (Breslow) thickness, which "is measured from the granular layer of the overlying epidermis or base of a superficial ulceration to the deepest malignant cells invading dermis to the nearest 0.1 mm, not including deeper adventitial extension," and the presence or absence of microscopic ulceration, "defined as tumor-induced full thickness loss of epidermis with subjacent dermal tumor and reactive dermal changes."

A complete physical exam is recommended by the work group and "includes looking through the scalp, looking in the mouth, and a genital exam as well," Dr. Kent said. "In our practice we refer women to their gynecologist for that, because 1% of all melanomas are genital. We also recommend that they see their medical ophthalmologist every 2 years because you can get melanomas in different areas of the eye."

Screening blood tests, including serum lactate dehydrogenase, are "insensitive for the detection of metastatic disease," the guidelines state, while the use of routine imaging studies "is limited by a very low yield and the frequent occurrence of false positive findings. Ample evidence exists that a routine chest X-ray is a cost inefficient test for the detection of metastatic disease with a consistent relatively high false positive rate." The guidelines also note that advanced imaging studies such as positron emission tomography and computed tomography have lower sensitivity, compared with sentinel lymph node biopsy (SLNB).

As for follow-up of patients with newly diagnosed cutaneous melanoma, the guidelines recommend an annual visit with a dermatologist at the least, but note that visits may range from every 3-12 months based on a patient’s history and risk factors. "The goal of follow-up is to detect any evidence of local recurrence and to detect any additional primary melanomas that may have developed," Dr. Kent said. "I have several patients that have personally had over three melanomas. One patient has had five. Some high risk patients we see every 3 or 4 months for follow-up."

Sentinel Lymph Node Biopsy and Lentigo Maligna

The work group also addressed non-surgical treatments for lentigo maligna, a topic that was not contained in the older version of the guidelines. For example, while off-label use of topical imiquimod has been proposed for lentigo maligna, "studies are limited by highly variable treatment regimens and lack of long-term follow-up with an average of approximately 18 months," the work group wrote. "Histologic verification following treatment has shown persistent disease in approximately 25% of treated patients and progression to invasive melanoma has been noted. As an adjunctive modality following surgical excision, the efficacy of topical imiquimod has not been established. High cost of treatment, an appropriate low threshold for subsequent biopsy to exclude residual or recurrent disease, and the risk of a severe inflammatory reaction should be taken into account when considering imiquimod."

SLNB is another topic contained in the guidelines for the first time. While the work group acknowledged that SLNB is "not without controversy," it described sentinel lymph node status as "the most important prognostic factor for disease-specific survival of patients with melanoma greater than 1 mm in thickness. Whether early detection of occult nodal disease provides greater regional control has not been definitively shown, but available evidence suggests a lower rate of post-operative complications in patients who underwent completion lymph node dissection for micrometastatic disease detected by SLNB, compared to those who underwent therapeutic lymph node dissection for clinically palpable disease."

The work group acknowledged that "significant gaps" exist in research related to the management of primary cutaneous melanoma, including "standardization of the interpretation of mitotic rate; placebo-controlled trials for the treatment of lentigo maligna; the use and value of dermoscopy and other imaging modalities; the clinical and prognostic significance of the use of biomarkers and mutational analysis; and the use of sentinel lymph node biopsy."

For his part, Dr. Kent predicted that major advances in the treatment of cutaneous melanoma should occur in the coming years. "Melanoma is a very unpredictable disease," he said. "Hopefully sometime in the future, we’ll have biomarkers that will assist physicians in identifying patients who are a greater risk of more aggressive disease, of spread to both regional and distant sites. That area of research is very exciting."

Dr. Kent said that he had no relevant financial disclosures.

In patients diagnosed with invasive primary cutaneous melanoma, a detailed patient history is crucial, and a thorough examination of the skin and lymph nodes should be performed to help determine the extent of clinical spread of the disease. However, for patients with melanomas of any thickness, baseline blood tests and imaging studies are not recommended because clinical research does not support their use unless suspicious signs and symptoms are present.

Those are two recommendations contained in the American Academy of Dermatology’s updated guidelines for the treatment of primary cutaneous melanoma, which were published online in the Journal of the American Academy of Dermatology. Last updated in 2001, the new guidelines focus on biopsy techniques, pathology, surgical treatment, and long-term follow-up care.

"There are many factors that must be considered when diagnosing and treating melanoma, and these new guidelines offer physicians clinically sound recommendations on how to treat melanoma patients and potentially increase their chance of survival from this deadly disease," AAD President Dr. Ronald L. Moy said in a statement.

A 15-member work group of melanoma experts convened by the AAD and chaired by Dr. Allan C. Halpern of Memorial Sloan-Kettering Cancer Center, New York, and Timothy M. Johnson of the University of Michigan and its Comprehensive Cancer Center, Ann Arbor, reviewed clinical studies and guidelines related to melanoma treatment that appeared in English-language publications between 2000 and 2010. Members of the work group used a 3-point scale to grade evidence, and then developed clinical recommendations on the best available evidence (J. Am. Acad. Dermatol. 2011 Aug. 26 doi: 10.1016/j.jaad.2011.04.031]).

The recommendations were ranked as "A" (recommendation based on consistent and good-quality patient-oriented evidence); "B" (recommendation based on inconsistent or limited-quality patient-oriented evidence); and "C" (recommendation based on consensus, opinion, case studies, or disease-oriented evidence).

The Increased Value of Mitotic Rate

According to Dr. David E. Kent, the most significant change from the 2001 guidelines relates to staging, with mitotic rate replacing Clark level of invasion as the second factor predicting melanoma survival in addition to tumor (Breslow) thickness for tumors 1 mm or smaller in thickness.

Included as a prognostic value in the 2010 American Joint Committee on Cancer staging system to upstage patients with melanoma, the mitotic rate is defined as the number of mitoses in the dermis per mm².

"The placement of mitotic rate has substantial value for dermatologists because the question we get asked often is, ‘What is the risk of this superficial melanoma spreading to other parts of the body, either regionally to the lymph nodes or distantly to other sites?’" said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta, who was not involved in assembling the guidelines. "With the mitotic rate less than 1 mm², it gives us a little bit more comfort in recommending to the patient that there’s less risk of spread. However, if there were to be a substantial mitotic rate, such as 2 mm², 3 mm², 4 mm², or even higher, that would lead one to consider referring the patient for evaluation for a staging and lymph node biopsy, even though the depth of the lesion is thin."

The guidelines note that there is "strong evidence" to support mitotic rate and two other histologic features as the most important characteristics of the primary tumor to predict outcome. The other features are maximum tumor (Breslow) thickness, which "is measured from the granular layer of the overlying epidermis or base of a superficial ulceration to the deepest malignant cells invading dermis to the nearest 0.1 mm, not including deeper adventitial extension," and the presence or absence of microscopic ulceration, "defined as tumor-induced full thickness loss of epidermis with subjacent dermal tumor and reactive dermal changes."

A complete physical exam is recommended by the work group and "includes looking through the scalp, looking in the mouth, and a genital exam as well," Dr. Kent said. "In our practice we refer women to their gynecologist for that, because 1% of all melanomas are genital. We also recommend that they see their medical ophthalmologist every 2 years because you can get melanomas in different areas of the eye."

Screening blood tests, including serum lactate dehydrogenase, are "insensitive for the detection of metastatic disease," the guidelines state, while the use of routine imaging studies "is limited by a very low yield and the frequent occurrence of false positive findings. Ample evidence exists that a routine chest X-ray is a cost inefficient test for the detection of metastatic disease with a consistent relatively high false positive rate." The guidelines also note that advanced imaging studies such as positron emission tomography and computed tomography have lower sensitivity, compared with sentinel lymph node biopsy (SLNB).

As for follow-up of patients with newly diagnosed cutaneous melanoma, the guidelines recommend an annual visit with a dermatologist at the least, but note that visits may range from every 3-12 months based on a patient’s history and risk factors. "The goal of follow-up is to detect any evidence of local recurrence and to detect any additional primary melanomas that may have developed," Dr. Kent said. "I have several patients that have personally had over three melanomas. One patient has had five. Some high risk patients we see every 3 or 4 months for follow-up."

Sentinel Lymph Node Biopsy and Lentigo Maligna

The work group also addressed non-surgical treatments for lentigo maligna, a topic that was not contained in the older version of the guidelines. For example, while off-label use of topical imiquimod has been proposed for lentigo maligna, "studies are limited by highly variable treatment regimens and lack of long-term follow-up with an average of approximately 18 months," the work group wrote. "Histologic verification following treatment has shown persistent disease in approximately 25% of treated patients and progression to invasive melanoma has been noted. As an adjunctive modality following surgical excision, the efficacy of topical imiquimod has not been established. High cost of treatment, an appropriate low threshold for subsequent biopsy to exclude residual or recurrent disease, and the risk of a severe inflammatory reaction should be taken into account when considering imiquimod."

SLNB is another topic contained in the guidelines for the first time. While the work group acknowledged that SLNB is "not without controversy," it described sentinel lymph node status as "the most important prognostic factor for disease-specific survival of patients with melanoma greater than 1 mm in thickness. Whether early detection of occult nodal disease provides greater regional control has not been definitively shown, but available evidence suggests a lower rate of post-operative complications in patients who underwent completion lymph node dissection for micrometastatic disease detected by SLNB, compared to those who underwent therapeutic lymph node dissection for clinically palpable disease."

The work group acknowledged that "significant gaps" exist in research related to the management of primary cutaneous melanoma, including "standardization of the interpretation of mitotic rate; placebo-controlled trials for the treatment of lentigo maligna; the use and value of dermoscopy and other imaging modalities; the clinical and prognostic significance of the use of biomarkers and mutational analysis; and the use of sentinel lymph node biopsy."

For his part, Dr. Kent predicted that major advances in the treatment of cutaneous melanoma should occur in the coming years. "Melanoma is a very unpredictable disease," he said. "Hopefully sometime in the future, we’ll have biomarkers that will assist physicians in identifying patients who are a greater risk of more aggressive disease, of spread to both regional and distant sites. That area of research is very exciting."

Dr. Kent said that he had no relevant financial disclosures.

In patients diagnosed with invasive primary cutaneous melanoma, a detailed patient history is crucial, and a thorough examination of the skin and lymph nodes should be performed to help determine the extent of clinical spread of the disease. However, for patients with melanomas of any thickness, baseline blood tests and imaging studies are not recommended because clinical research does not support their use unless suspicious signs and symptoms are present.

Those are two recommendations contained in the American Academy of Dermatology’s updated guidelines for the treatment of primary cutaneous melanoma, which were published online in the Journal of the American Academy of Dermatology. Last updated in 2001, the new guidelines focus on biopsy techniques, pathology, surgical treatment, and long-term follow-up care.

"There are many factors that must be considered when diagnosing and treating melanoma, and these new guidelines offer physicians clinically sound recommendations on how to treat melanoma patients and potentially increase their chance of survival from this deadly disease," AAD President Dr. Ronald L. Moy said in a statement.

A 15-member work group of melanoma experts convened by the AAD and chaired by Dr. Allan C. Halpern of Memorial Sloan-Kettering Cancer Center, New York, and Timothy M. Johnson of the University of Michigan and its Comprehensive Cancer Center, Ann Arbor, reviewed clinical studies and guidelines related to melanoma treatment that appeared in English-language publications between 2000 and 2010. Members of the work group used a 3-point scale to grade evidence, and then developed clinical recommendations on the best available evidence (J. Am. Acad. Dermatol. 2011 Aug. 26 doi: 10.1016/j.jaad.2011.04.031]).

The recommendations were ranked as "A" (recommendation based on consistent and good-quality patient-oriented evidence); "B" (recommendation based on inconsistent or limited-quality patient-oriented evidence); and "C" (recommendation based on consensus, opinion, case studies, or disease-oriented evidence).

The Increased Value of Mitotic Rate

According to Dr. David E. Kent, the most significant change from the 2001 guidelines relates to staging, with mitotic rate replacing Clark level of invasion as the second factor predicting melanoma survival in addition to tumor (Breslow) thickness for tumors 1 mm or smaller in thickness.

Included as a prognostic value in the 2010 American Joint Committee on Cancer staging system to upstage patients with melanoma, the mitotic rate is defined as the number of mitoses in the dermis per mm².

"The placement of mitotic rate has substantial value for dermatologists because the question we get asked often is, ‘What is the risk of this superficial melanoma spreading to other parts of the body, either regionally to the lymph nodes or distantly to other sites?’" said Dr. Kent, a clinical instructor in the division of dermatology at the Medical College of Georgia, Augusta, who was not involved in assembling the guidelines. "With the mitotic rate less than 1 mm², it gives us a little bit more comfort in recommending to the patient that there’s less risk of spread. However, if there were to be a substantial mitotic rate, such as 2 mm², 3 mm², 4 mm², or even higher, that would lead one to consider referring the patient for evaluation for a staging and lymph node biopsy, even though the depth of the lesion is thin."

The guidelines note that there is "strong evidence" to support mitotic rate and two other histologic features as the most important characteristics of the primary tumor to predict outcome. The other features are maximum tumor (Breslow) thickness, which "is measured from the granular layer of the overlying epidermis or base of a superficial ulceration to the deepest malignant cells invading dermis to the nearest 0.1 mm, not including deeper adventitial extension," and the presence or absence of microscopic ulceration, "defined as tumor-induced full thickness loss of epidermis with subjacent dermal tumor and reactive dermal changes."

A complete physical exam is recommended by the work group and "includes looking through the scalp, looking in the mouth, and a genital exam as well," Dr. Kent said. "In our practice we refer women to their gynecologist for that, because 1% of all melanomas are genital. We also recommend that they see their medical ophthalmologist every 2 years because you can get melanomas in different areas of the eye."

Screening blood tests, including serum lactate dehydrogenase, are "insensitive for the detection of metastatic disease," the guidelines state, while the use of routine imaging studies "is limited by a very low yield and the frequent occurrence of false positive findings. Ample evidence exists that a routine chest X-ray is a cost inefficient test for the detection of metastatic disease with a consistent relatively high false positive rate." The guidelines also note that advanced imaging studies such as positron emission tomography and computed tomography have lower sensitivity, compared with sentinel lymph node biopsy (SLNB).

As for follow-up of patients with newly diagnosed cutaneous melanoma, the guidelines recommend an annual visit with a dermatologist at the least, but note that visits may range from every 3-12 months based on a patient’s history and risk factors. "The goal of follow-up is to detect any evidence of local recurrence and to detect any additional primary melanomas that may have developed," Dr. Kent said. "I have several patients that have personally had over three melanomas. One patient has had five. Some high risk patients we see every 3 or 4 months for follow-up."

Sentinel Lymph Node Biopsy and Lentigo Maligna

The work group also addressed non-surgical treatments for lentigo maligna, a topic that was not contained in the older version of the guidelines. For example, while off-label use of topical imiquimod has been proposed for lentigo maligna, "studies are limited by highly variable treatment regimens and lack of long-term follow-up with an average of approximately 18 months," the work group wrote. "Histologic verification following treatment has shown persistent disease in approximately 25% of treated patients and progression to invasive melanoma has been noted. As an adjunctive modality following surgical excision, the efficacy of topical imiquimod has not been established. High cost of treatment, an appropriate low threshold for subsequent biopsy to exclude residual or recurrent disease, and the risk of a severe inflammatory reaction should be taken into account when considering imiquimod."

SLNB is another topic contained in the guidelines for the first time. While the work group acknowledged that SLNB is "not without controversy," it described sentinel lymph node status as "the most important prognostic factor for disease-specific survival of patients with melanoma greater than 1 mm in thickness. Whether early detection of occult nodal disease provides greater regional control has not been definitively shown, but available evidence suggests a lower rate of post-operative complications in patients who underwent completion lymph node dissection for micrometastatic disease detected by SLNB, compared to those who underwent therapeutic lymph node dissection for clinically palpable disease."

The work group acknowledged that "significant gaps" exist in research related to the management of primary cutaneous melanoma, including "standardization of the interpretation of mitotic rate; placebo-controlled trials for the treatment of lentigo maligna; the use and value of dermoscopy and other imaging modalities; the clinical and prognostic significance of the use of biomarkers and mutational analysis; and the use of sentinel lymph node biopsy."

For his part, Dr. Kent predicted that major advances in the treatment of cutaneous melanoma should occur in the coming years. "Melanoma is a very unpredictable disease," he said. "Hopefully sometime in the future, we’ll have biomarkers that will assist physicians in identifying patients who are a greater risk of more aggressive disease, of spread to both regional and distant sites. That area of research is very exciting."

Dr. Kent said that he had no relevant financial disclosures.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

SAN DIEGO – A 67-year-old woman with poorly controlled diabetes, diabetic retinopathy, and diabetic nephropathy visits your office for routine follow-up.

Her blood pressure is 165/95 mm Hg, her pulse is 71 beats per minute, her body mass index is 36 kg/m², and labs reveal that her creatinine level is 1.2 mg/dL, her potassium level is 5.5 mmol/L, and she is spilling 3,500 mg of albuminuria in her urine, "which is quite significant," Dr. Kimberly Harper said at a meeting on primary care medicine sponsored by the Scripps Clinic.

This patient is also on insulin, lisinopril 20 mg/day, amlodipine 5 mg/day, and simvastatin 10 mg/day. How would you manage her hypertension? In the clinical opinion of Dr. Harper, a nephrologist at Scripps Clinic, La Jolla, Calif., the best approach would be to advise her to exercise, watch her sodium intake, and lose weight, as well as to increase her dose of lisinopril and add a thiazide diuretic to help control her potassium.

"As physicians managing hypertension, lifestyle modification is of the utmost importance," Dr. Harper said. "This is easier said than done, but if we can motivate our patients to do these things, we can help to get their blood pressure under better control without the side effects of medications."

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for every 10 kg of weight loss, patients typically experience a 5-10 mm Hg reduction in systolic blood pressure, while keeping sodium intake to less than 2,400 mg/day can lead to a 2-8 mm Hg reduction. In addition, at least 30 minutes of aerobic exercise most days of the week can translate into a 4-9 mm Hg reduction, while moderate consumption of alcohol can mean a 2-4 mm Hg reduction. "This is defined as no more than one alcoholic beverage in a setting for women and no more than two alcoholic beverages in a setting for men," Dr. Harper said.

She makes it a point to inform patients on the risk of hyperkalemia, because over time diabetes can cause a type-4 renal tubular acidosis. In addition, all renin-angiotensin-aldosterone system medications can induce hyperkalemia. "I tell patients that hyperkalemia can lead to a fatal cardiac arrhythmia," Dr. Harper said. "Their ears tend to perk up when I say that."

She also instructs patients to follow a diet restricted to less than 2,000-3,000 mg potassium/day, depending on how high their potassium levels are.

In addition, Dr. Harper will often prescribe a thiazide or loop diuretic to help with the excretion of potassium.

She closed her presentation by highlighting experimental treatments for hypertension on the horizon. One is a hypertension vaccine that inhibits angiotensin II. A phase II trial of 24-hour blood pressure monitoring showed that patients who received the vaccine had significantly lower systolic and diastolic blood pressure, compared with those who received placebo (Lancet 2008;371:821-7).

Another emerging treatment is renal denervation, a catheter-based treatment in which radiofrequency is applied to sympathetic nerves in the kidney to help control blood pressure. A randomized trial found that renal denervation reduced blood pressure in treatment-resistant hypertensive patients, compared with those who did not receive the intervention (Lancet 2010;376:1903-9).

Finally, a new potential class of antihypertensive agents, known as vasopeptidase inhibitors, is being studied. These agents inhibit angiotensin-converting enzyme as well as neutral endopeptidase, an enzyme that helps rid the body of excess salt and water and would lower the blood pressure, she said.

Dr. Harper said that she had no relevant financial disclosures to make.

Probable posttraumatic stress disorder among New York City firefighters exposed to the terrorist attacks on the World Trade Center towers continues to be associated with early arrival to the site, even 9 years after the disaster.

Other factors associated with persistence or onset of PTSD symptoms were subsequent decreases in exercise, increases in alcohol intake, and concurrent symptoms of respiratory or gastroesophageal illness.

Michael Rieger/FEMA News Photo

The findings come from the longest follow-up to date of probable PTSD after the World Trade Center (WTC) attacks on Sept. 11, 2001, among New York City firefighters who were part of the rescue/recovery effort.

"Previous studies tracking the trajectory of PTSD after and event have ended within 6 years of follow-up," researchers led by Jackie Soo of the department of medicine at Montefiore Medical Center, New York, noted in the study, which was published online Sept. 7 (Disaster Med. Public Health Prep. 2011 [doi:10.1001/dmp.2011.48]). "Our work shows that the association between experiencing trauma and PTSD may persist well beyond that time frame."

Ms. Soo and her associates examined data from 11,006 uniformed New York City firefighters who completed 40,672 questionnaires during the 9 years after 9/11. Respondents were categorized into four groups: those who arrived during the morning of Sept. 11 (arrival group 1), those who arrived during the afternoon of Sept. 11 (arrival group 2), those who arrived on day 2 (arrival group 3), and those who arrived between days 3-14 (arrival group 4).

In years 1-4, the researchers evaluated PTSD with a modified version of the PTSD CheckList – Civilian Version (PCL), a 14-item self-reported survey that corresponds to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Respondents answered on a binary scale. In years 6-9, PTSD was evaluated with the original version of the PCL-C, which contains 17 items and which respondents answered on Likert scale.

The respondents also were asked about their change in alcohol intake since Sept. 11, change in exercise (since the individual’s last questionnaire), smoking status (at the time of the questionnaire), as well as the presence of wheeze, shortness of breath, or other aerodigestive symptoms.

Ms. Soo and her associates reported that 7.4% of the respondents met criteria for probable PTSD. By comparison, the National Comorbidity Survey Replication, administered from 2001-2003, estimated the prevalence of PTSD in the United States population to be 1.8%. Firefighters in arrival group 1 had the highest prevalence in all years, ending at 13.4% in year 9.

Longitudinal analyses revealed that a lower likelihood of recovery from probable PTSD was associated with an increasing number of aerodigestive symptoms (hazard ratio, 0.89/symptom) and reporting a decrease in exercise, whether the result of health (HR, 0.56 vs. no change in exercise) or other reasons (0.76 vs. no change in exercise).

Delayed onset of probable PTSD was associated with early arrival at the WTC (HR, 1.38 vs. later arrival), an increasing number of aerodigestive symptoms (HR, 1.45/symptoms), and reporting an increase in alcohol intake since Sept. 11 (HR 3.43 vs. no alcohol intake).

"PTSD may thus persist or may arise not solely because of the intensity of the event experienced but also because of physical injuries or illnesses sustained during the event and changes in health behaviors after the event," the researchers concluded. "A full comprehensive treatment approach that addresses the physical, behavioral, and mental health consequences of WTC exposure is of critical importance."

The researchers acknowledged certain limitations of the study, including the fact that they used two different screening instruments to establish probable PTSD: one in years 1-4 after the attacks and one in years 6-9. "Although the agreement (as measured by the kappa statistic) was high, we cannot rule out the possibility that the two versions may have produced minor inconsistencies in probable PTSD prevalence," they wrote. "In addition, because feasibility concerns required a screening rather than a diagnostic instrument for PTSD, there may be some lack of correspondence between ‘probable’ and actual PTSD."

The study also lacked information on the treatment of PTSD, "which could have influenced recovery or delayed onset of symptoms."

The study was funded by the National Institute for Occupational Safety and Health.

The researchers stated that they had no relevant financial conflicts to disclose.

Probable posttraumatic stress disorder among New York City firefighters exposed to the terrorist attacks on the World Trade Center towers continues to be associated with early arrival to the site, even 9 years after the disaster.

Other factors associated with persistence or onset of PTSD symptoms were subsequent decreases in exercise, increases in alcohol intake, and concurrent symptoms of respiratory or gastroesophageal illness.

Michael Rieger/FEMA News Photo

The findings come from the longest follow-up to date of probable PTSD after the World Trade Center (WTC) attacks on Sept. 11, 2001, among New York City firefighters who were part of the rescue/recovery effort.

"Previous studies tracking the trajectory of PTSD after and event have ended within 6 years of follow-up," researchers led by Jackie Soo of the department of medicine at Montefiore Medical Center, New York, noted in the study, which was published online Sept. 7 (Disaster Med. Public Health Prep. 2011 [doi:10.1001/dmp.2011.48]). "Our work shows that the association between experiencing trauma and PTSD may persist well beyond that time frame."

Ms. Soo and her associates examined data from 11,006 uniformed New York City firefighters who completed 40,672 questionnaires during the 9 years after 9/11. Respondents were categorized into four groups: those who arrived during the morning of Sept. 11 (arrival group 1), those who arrived during the afternoon of Sept. 11 (arrival group 2), those who arrived on day 2 (arrival group 3), and those who arrived between days 3-14 (arrival group 4).

In years 1-4, the researchers evaluated PTSD with a modified version of the PTSD CheckList – Civilian Version (PCL), a 14-item self-reported survey that corresponds to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Respondents answered on a binary scale. In years 6-9, PTSD was evaluated with the original version of the PCL-C, which contains 17 items and which respondents answered on Likert scale.

The respondents also were asked about their change in alcohol intake since Sept. 11, change in exercise (since the individual’s last questionnaire), smoking status (at the time of the questionnaire), as well as the presence of wheeze, shortness of breath, or other aerodigestive symptoms.

Ms. Soo and her associates reported that 7.4% of the respondents met criteria for probable PTSD. By comparison, the National Comorbidity Survey Replication, administered from 2001-2003, estimated the prevalence of PTSD in the United States population to be 1.8%. Firefighters in arrival group 1 had the highest prevalence in all years, ending at 13.4% in year 9.

Longitudinal analyses revealed that a lower likelihood of recovery from probable PTSD was associated with an increasing number of aerodigestive symptoms (hazard ratio, 0.89/symptom) and reporting a decrease in exercise, whether the result of health (HR, 0.56 vs. no change in exercise) or other reasons (0.76 vs. no change in exercise).

Delayed onset of probable PTSD was associated with early arrival at the WTC (HR, 1.38 vs. later arrival), an increasing number of aerodigestive symptoms (HR, 1.45/symptoms), and reporting an increase in alcohol intake since Sept. 11 (HR 3.43 vs. no alcohol intake).

"PTSD may thus persist or may arise not solely because of the intensity of the event experienced but also because of physical injuries or illnesses sustained during the event and changes in health behaviors after the event," the researchers concluded. "A full comprehensive treatment approach that addresses the physical, behavioral, and mental health consequences of WTC exposure is of critical importance."

The researchers acknowledged certain limitations of the study, including the fact that they used two different screening instruments to establish probable PTSD: one in years 1-4 after the attacks and one in years 6-9. "Although the agreement (as measured by the kappa statistic) was high, we cannot rule out the possibility that the two versions may have produced minor inconsistencies in probable PTSD prevalence," they wrote. "In addition, because feasibility concerns required a screening rather than a diagnostic instrument for PTSD, there may be some lack of correspondence between ‘probable’ and actual PTSD."

The study also lacked information on the treatment of PTSD, "which could have influenced recovery or delayed onset of symptoms."

The study was funded by the National Institute for Occupational Safety and Health.

The researchers stated that they had no relevant financial conflicts to disclose.

Probable posttraumatic stress disorder among New York City firefighters exposed to the terrorist attacks on the World Trade Center towers continues to be associated with early arrival to the site, even 9 years after the disaster.

Other factors associated with persistence or onset of PTSD symptoms were subsequent decreases in exercise, increases in alcohol intake, and concurrent symptoms of respiratory or gastroesophageal illness.

Michael Rieger/FEMA News Photo

The findings come from the longest follow-up to date of probable PTSD after the World Trade Center (WTC) attacks on Sept. 11, 2001, among New York City firefighters who were part of the rescue/recovery effort.

"Previous studies tracking the trajectory of PTSD after and event have ended within 6 years of follow-up," researchers led by Jackie Soo of the department of medicine at Montefiore Medical Center, New York, noted in the study, which was published online Sept. 7 (Disaster Med. Public Health Prep. 2011 [doi:10.1001/dmp.2011.48]). "Our work shows that the association between experiencing trauma and PTSD may persist well beyond that time frame."

Ms. Soo and her associates examined data from 11,006 uniformed New York City firefighters who completed 40,672 questionnaires during the 9 years after 9/11. Respondents were categorized into four groups: those who arrived during the morning of Sept. 11 (arrival group 1), those who arrived during the afternoon of Sept. 11 (arrival group 2), those who arrived on day 2 (arrival group 3), and those who arrived between days 3-14 (arrival group 4).

In years 1-4, the researchers evaluated PTSD with a modified version of the PTSD CheckList – Civilian Version (PCL), a 14-item self-reported survey that corresponds to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Respondents answered on a binary scale. In years 6-9, PTSD was evaluated with the original version of the PCL-C, which contains 17 items and which respondents answered on Likert scale.

The respondents also were asked about their change in alcohol intake since Sept. 11, change in exercise (since the individual’s last questionnaire), smoking status (at the time of the questionnaire), as well as the presence of wheeze, shortness of breath, or other aerodigestive symptoms.

Ms. Soo and her associates reported that 7.4% of the respondents met criteria for probable PTSD. By comparison, the National Comorbidity Survey Replication, administered from 2001-2003, estimated the prevalence of PTSD in the United States population to be 1.8%. Firefighters in arrival group 1 had the highest prevalence in all years, ending at 13.4% in year 9.

Longitudinal analyses revealed that a lower likelihood of recovery from probable PTSD was associated with an increasing number of aerodigestive symptoms (hazard ratio, 0.89/symptom) and reporting a decrease in exercise, whether the result of health (HR, 0.56 vs. no change in exercise) or other reasons (0.76 vs. no change in exercise).

Delayed onset of probable PTSD was associated with early arrival at the WTC (HR, 1.38 vs. later arrival), an increasing number of aerodigestive symptoms (HR, 1.45/symptoms), and reporting an increase in alcohol intake since Sept. 11 (HR 3.43 vs. no alcohol intake).

"PTSD may thus persist or may arise not solely because of the intensity of the event experienced but also because of physical injuries or illnesses sustained during the event and changes in health behaviors after the event," the researchers concluded. "A full comprehensive treatment approach that addresses the physical, behavioral, and mental health consequences of WTC exposure is of critical importance."

The researchers acknowledged certain limitations of the study, including the fact that they used two different screening instruments to establish probable PTSD: one in years 1-4 after the attacks and one in years 6-9. "Although the agreement (as measured by the kappa statistic) was high, we cannot rule out the possibility that the two versions may have produced minor inconsistencies in probable PTSD prevalence," they wrote. "In addition, because feasibility concerns required a screening rather than a diagnostic instrument for PTSD, there may be some lack of correspondence between ‘probable’ and actual PTSD."

The study also lacked information on the treatment of PTSD, "which could have influenced recovery or delayed onset of symptoms."

The study was funded by the National Institute for Occupational Safety and Health.

The researchers stated that they had no relevant financial conflicts to disclose.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

SAN DIEGO – Before you formally assess patients who present with back and neck pain, listen carefully to how they characterize their discomfort, Dr. Robert K. Eastlack advised at a meeting on primary care medicine sponsored by Scripps Clinic.

"The history is the critical part of the evaluation," said Dr. Eastlack, fellowship and spine research director in the division of orthopedic surgery at Scripps Clinic, La Jolla, Calif. "It’s like putting a puzzle together. If you sit and listen to your patients – you let them isolate where the problem is – they’ll usually lead you right to the money."

©ugurhan/iStockphoto.com

The location of the pain will help you home in on your differential. Is it neck pain or back pain? Both? What’s the character of the pain? Is it radiating into extremities? Is it a burning pain? Does it occur at night? Does it worsen with certain activities?

"Refer the patient immediately if they have acute weakness, bowel or bladder dysfunction, or unmitigated severe pain," Dr. Eastlack emphasized. "Having said that, 95% of people with back pain and neck pain will get better in 4-6 weeks. The hard part is holding their hand through that period. Everybody wants to know what the best treatment is. The reality is, it usually just takes time."

In the primary care setting, his recommended examination of the lumbar spine includes inspection while the patient is standing, sitting, and walking, as well as palpation of the midline, flank, paraspinal, and gluteal areas to screen for abnormalities. He also recommends a motion assessment to help differentiate potential sources of pain.

"For instance, somebody who has pain when they’re leaning back will sometimes have facet arthritis," Dr. Eastlack said. "They can be managed with NSAIDs, activity management, physical therapy, and sometimes, we’ll send them off to pain management to get injections. Someone who has flexion-related pain can be more problematic in terms of disk abnormalities and associated nerve pinching. By getting a sense of how much motion they have, you get a sense of what they may be able to achieve or improve upon in physical therapy."

Straight leg lifts and internal rotation of the hip can be helpful in assessing knee and hip pain, respectively, while part of his neurological assessment includes a stair step with each leg, toe and heel walk, and great toe dorsiflexion. "If you push down on the great toes of your patients during attempted resistance, they should be able to hold their toes up against your finger strength," Dr. Eastlack said. "If they can’t, they probably have a neurological issue that would probably otherwise go unrecognized. It’s a rapid way for you to recognize that they may have something going on in their spinal canal. Always look for asymmetry, as well."

Rather than fuss with formal neurological motor testing, Dr. Eastlack advises primary care physicians to "boil it down to what’s easy to do. Orthopedic surgeons and neurosurgeons tend to use graded scales. That’s more for study and objective evaluations that we can assess serially." The key is to look for any change from normal. "See whether they can go against your resistance or not. They can either use it fully or they can’t, or they can provide resistance against you that seems normal and symmetric or they can’t. Use that as your parameter."

Sensory evaluation should be focused on light touch, he continued. "You’ll also want to understand the dermatomal regions you’re considering," he said. Deep tendon reflexes of the biceps, brachioradialis, triceps, patella, and Achilles are helpful; however, people with diabetes or thyroid issues are generally not going to have reflexes. Having said that, remember to look for asymmetry.

Standing x-rays of the lumbar spine "are critical," he said. "So many patients who show up in my office have had a CT scan or an MRI scan but no plain x-rays. Instability of the spine can often be better detected on upright or standing x-ray."

CT scans expose patients to far more radiation than x-rays or MRI do, "and they’re not that helpful," Dr. Eastlack said. "Generally speaking, the only time I get a CT scan is if I have an acute trauma patient or if I’m looking for small bone defects that are not well visualized on a radiograph."

Dr. Eastlack said that he had no relevant financial disclosures.

Major Finding: Some 61% of children and adolescents initially diagnosed with type 2 diabetes maintained a diagnosis of type 2 diabetes over a median of 7 years, while 39% were reclassified as having type 1 diabetes.

Data Source: A study of 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006.

Disclosures: Dr. Tripathi said that he had no relevant financial disclosures.

SAN DIEGO – More than a third of type 1 diabetes cases in a large pediatric Medicaid population were misdiagnosed as having type 2 early in management, results from a 10-year analysis showed.

Such misclassification “may be associated with significantly increased risk of life-threatening, but potentially preventable, acute complications such as diabetic ketoacidosis,” Dr. Avnish Tripathi said at the meeting. “These findings have implications for primary health care of diabetes and reiterate the importance of performing laboratory tests such as autoantibody titers and C-peptide levels for establishing type 1 diabetes pathology earlier in the clinical management process,” said Dr. Tripathi, a doctoral candidate in public health at the University of South Carolina, Columbia.

Misclassification can occur both ways, he added. Pediatric diabetes is usually assumed to be type 1, so “it may be diagnosed as such even if characteristics point to type 2 diabetes.” But increased awareness of type 2 diabetes in the pediatric population means that “type 1 diabetes in overweight or obese patients may be diagnosed as type 2 diabetes.”

The researchers analyzed data from 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006. They also evaluated ICD-9 codes for comorbid medical complications such as obesity and dyslipidemia, and for vascular and other complications such as diabetic ketoacidosis.

Of the 4,070 children and adolescents, more than half (57%) were female, 56% were non-Hispanic black, their median age was 8 years, and they were followed for a median of 7 years. Dr. Tripathi reported that 2,489 of the subjects (61%) maintained a diagnosis of type 2 diabetes over time, whereas 39% were later reclassified as having type 1. After adjustment for variables, older age at diagnosis increased the risk of misclassification (odds ratio, 1.66), while being obese or overweight decreased the risk of being in the misclassification group (OR, 0.79).

Compared with those who maintained a type 2 diagnosis, a significantly higher proportion of misclassified youth were treated with insulin (82% vs. 2%, respectively), and went on to develop dyslipidemia (P less than .001) and hypertension (P = .0001). Misclassified youth also had a 50-fold increased risk of at least one incidence of diabetic ketoacidosis (OR, 49.5), nearly a 4-fold increased risk of developing cumulative diabetic neuropathy (OR, 3.75), a higher risk of cumulative renal complications (OR, 1.27), and a lower risk of developing cardiac conditions (OR, 0.81).

View on The News

New Criteria Needed for Type 2 Dx

This concept is not new, and there have been a number of publications over the past decade regarding the difficulty in clinically separating type 1 and type 2 diabetes, as at least one-third of type 1 patients in our series are overweight or obese at diagnosis (Pediatr. Diabetes 2003;4:110-3; Diabetes Care 2003;26:2876-82; Diabetes Care 2003;26:2871-5). These findings have since been confirmed by the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study and the SEARCH for Diabetes in Youth study. In the current study, I found it difficult to evaluate what the criteria for the reclassification were.

The message to pediatricians, general practitioners, and diabetologists should be that being obese does not protect the patient from type 1 diabetes, and thus, there need to be other criteria to make the diagnosis of type 2 in children.

DOROTHY BECKER, M.D., is professor of pediatrics and director of endocrinology and diabetes at Children's Hospital of Pittsburgh and the University of Pittsburgh, who was asked to comment on Dr. Tripathi's findings. Dr. Becker said she had no relevant financial disclosures. Her 2003 series of diabetes studies was funded by the National Institutes of Health.

Major Finding: Some 61% of children and adolescents initially diagnosed with type 2 diabetes maintained a diagnosis of type 2 diabetes over a median of 7 years, while 39% were reclassified as having type 1 diabetes.

Data Source: A study of 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006.

Disclosures: Dr. Tripathi said that he had no relevant financial disclosures.

SAN DIEGO – More than a third of type 1 diabetes cases in a large pediatric Medicaid population were misdiagnosed as having type 2 early in management, results from a 10-year analysis showed.

Such misclassification “may be associated with significantly increased risk of life-threatening, but potentially preventable, acute complications such as diabetic ketoacidosis,” Dr. Avnish Tripathi said at the meeting. “These findings have implications for primary health care of diabetes and reiterate the importance of performing laboratory tests such as autoantibody titers and C-peptide levels for establishing type 1 diabetes pathology earlier in the clinical management process,” said Dr. Tripathi, a doctoral candidate in public health at the University of South Carolina, Columbia.

Misclassification can occur both ways, he added. Pediatric diabetes is usually assumed to be type 1, so “it may be diagnosed as such even if characteristics point to type 2 diabetes.” But increased awareness of type 2 diabetes in the pediatric population means that “type 1 diabetes in overweight or obese patients may be diagnosed as type 2 diabetes.”

The researchers analyzed data from 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006. They also evaluated ICD-9 codes for comorbid medical complications such as obesity and dyslipidemia, and for vascular and other complications such as diabetic ketoacidosis.

Of the 4,070 children and adolescents, more than half (57%) were female, 56% were non-Hispanic black, their median age was 8 years, and they were followed for a median of 7 years. Dr. Tripathi reported that 2,489 of the subjects (61%) maintained a diagnosis of type 2 diabetes over time, whereas 39% were later reclassified as having type 1. After adjustment for variables, older age at diagnosis increased the risk of misclassification (odds ratio, 1.66), while being obese or overweight decreased the risk of being in the misclassification group (OR, 0.79).

Compared with those who maintained a type 2 diagnosis, a significantly higher proportion of misclassified youth were treated with insulin (82% vs. 2%, respectively), and went on to develop dyslipidemia (P less than .001) and hypertension (P = .0001). Misclassified youth also had a 50-fold increased risk of at least one incidence of diabetic ketoacidosis (OR, 49.5), nearly a 4-fold increased risk of developing cumulative diabetic neuropathy (OR, 3.75), a higher risk of cumulative renal complications (OR, 1.27), and a lower risk of developing cardiac conditions (OR, 0.81).

View on The News

New Criteria Needed for Type 2 Dx

This concept is not new, and there have been a number of publications over the past decade regarding the difficulty in clinically separating type 1 and type 2 diabetes, as at least one-third of type 1 patients in our series are overweight or obese at diagnosis (Pediatr. Diabetes 2003;4:110-3; Diabetes Care 2003;26:2876-82; Diabetes Care 2003;26:2871-5). These findings have since been confirmed by the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study and the SEARCH for Diabetes in Youth study. In the current study, I found it difficult to evaluate what the criteria for the reclassification were.

The message to pediatricians, general practitioners, and diabetologists should be that being obese does not protect the patient from type 1 diabetes, and thus, there need to be other criteria to make the diagnosis of type 2 in children.

DOROTHY BECKER, M.D., is professor of pediatrics and director of endocrinology and diabetes at Children's Hospital of Pittsburgh and the University of Pittsburgh, who was asked to comment on Dr. Tripathi's findings. Dr. Becker said she had no relevant financial disclosures. Her 2003 series of diabetes studies was funded by the National Institutes of Health.

Major Finding: Some 61% of children and adolescents initially diagnosed with type 2 diabetes maintained a diagnosis of type 2 diabetes over a median of 7 years, while 39% were reclassified as having type 1 diabetes.

Data Source: A study of 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006.

Disclosures: Dr. Tripathi said that he had no relevant financial disclosures.

SAN DIEGO – More than a third of type 1 diabetes cases in a large pediatric Medicaid population were misdiagnosed as having type 2 early in management, results from a 10-year analysis showed.

Such misclassification “may be associated with significantly increased risk of life-threatening, but potentially preventable, acute complications such as diabetic ketoacidosis,” Dr. Avnish Tripathi said at the meeting. “These findings have implications for primary health care of diabetes and reiterate the importance of performing laboratory tests such as autoantibody titers and C-peptide levels for establishing type 1 diabetes pathology earlier in the clinical management process,” said Dr. Tripathi, a doctoral candidate in public health at the University of South Carolina, Columbia.

Misclassification can occur both ways, he added. Pediatric diabetes is usually assumed to be type 1, so “it may be diagnosed as such even if characteristics point to type 2 diabetes.” But increased awareness of type 2 diabetes in the pediatric population means that “type 1 diabetes in overweight or obese patients may be diagnosed as type 2 diabetes.”

The researchers analyzed data from 4,070 subjects aged 17 years and younger enrolled in the South Carolina State Medicaid Program who had at least two initial service encounters with an ICD-9 diagnosis of type 2 diabetes in 1996-2006. They also evaluated ICD-9 codes for comorbid medical complications such as obesity and dyslipidemia, and for vascular and other complications such as diabetic ketoacidosis.

Of the 4,070 children and adolescents, more than half (57%) were female, 56% were non-Hispanic black, their median age was 8 years, and they were followed for a median of 7 years. Dr. Tripathi reported that 2,489 of the subjects (61%) maintained a diagnosis of type 2 diabetes over time, whereas 39% were later reclassified as having type 1. After adjustment for variables, older age at diagnosis increased the risk of misclassification (odds ratio, 1.66), while being obese or overweight decreased the risk of being in the misclassification group (OR, 0.79).

Compared with those who maintained a type 2 diagnosis, a significantly higher proportion of misclassified youth were treated with insulin (82% vs. 2%, respectively), and went on to develop dyslipidemia (P less than .001) and hypertension (P = .0001). Misclassified youth also had a 50-fold increased risk of at least one incidence of diabetic ketoacidosis (OR, 49.5), nearly a 4-fold increased risk of developing cumulative diabetic neuropathy (OR, 3.75), a higher risk of cumulative renal complications (OR, 1.27), and a lower risk of developing cardiac conditions (OR, 0.81).

View on The News

New Criteria Needed for Type 2 Dx

This concept is not new, and there have been a number of publications over the past decade regarding the difficulty in clinically separating type 1 and type 2 diabetes, as at least one-third of type 1 patients in our series are overweight or obese at diagnosis (Pediatr. Diabetes 2003;4:110-3; Diabetes Care 2003;26:2876-82; Diabetes Care 2003;26:2871-5). These findings have since been confirmed by the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study and the SEARCH for Diabetes in Youth study. In the current study, I found it difficult to evaluate what the criteria for the reclassification were.

The message to pediatricians, general practitioners, and diabetologists should be that being obese does not protect the patient from type 1 diabetes, and thus, there need to be other criteria to make the diagnosis of type 2 in children.

DOROTHY BECKER, M.D., is professor of pediatrics and director of endocrinology and diabetes at Children's Hospital of Pittsburgh and the University of Pittsburgh, who was asked to comment on Dr. Tripathi's findings. Dr. Becker said she had no relevant financial disclosures. Her 2003 series of diabetes studies was funded by the National Institutes of Health.