Jane Salodof MacNeil

NICE, FRANCE — German investigators significantly reduced radiation exposures without causing complications in 64 women undergoing uterine fibroid embolization.

Bilateral embolization was possible in 63 patients, Dr. Dierk Vorwerk reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Embolization failed in a single uterine artery in just one woman.

No “specific complications” were found, according to Dr. Vorwerk of the Klinikum Ingolstadt (Germany).

“Strict adherence to simple radiation protection rules decreases dose area product significantly. Dose reduction per image significantly decreases dose but does not increase fluoroscopy time,” he said.

From January 2004 through June 2005, he and his colleagues treated 64 patients 32–48 years of age with a unilateral, subradical embolization approach.

In the first consecutive group (group A) of 26 patients, Dr. Vorwerk used pulsed radiation at 7.5 images per second and digital subtraction angiography (DSA). Radiation doses were reduced by 1.2 μGy per image for group A; the protocol included collimation. Besides DSA runs before and after embolization on each side, aortography was done as the final run.

For a second group of 29 patients, the protocol was revised to a dose of 1.2 μGy per image and maximum collimation with a 40-cm intensifier. DSA runs were only done before catheter placement for group B. There was no aortography.

For the final group of nine patients, the dose was further reduced by 0.48 μGy per image. The investigators also avoided oblique runs.

The physicians maintained average fluoroscopy time at 20.2 minutes, 21.3 minutes, and 19.8 minutes. Area dose product declined significantly from 52.7 Gy cm

Published studies cited by Dr. Vorwerk had reported mean fluoroscopy times of 11.8 and 22.5 minutes and average dose area product of 59.5 Gy cm

NICE, FRANCE — German investigators significantly reduced radiation exposures without causing complications in 64 women undergoing uterine fibroid embolization.

Bilateral embolization was possible in 63 patients, Dr. Dierk Vorwerk reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Embolization failed in a single uterine artery in just one woman.

No “specific complications” were found, according to Dr. Vorwerk of the Klinikum Ingolstadt (Germany).

“Strict adherence to simple radiation protection rules decreases dose area product significantly. Dose reduction per image significantly decreases dose but does not increase fluoroscopy time,” he said.

From January 2004 through June 2005, he and his colleagues treated 64 patients 32–48 years of age with a unilateral, subradical embolization approach.

In the first consecutive group (group A) of 26 patients, Dr. Vorwerk used pulsed radiation at 7.5 images per second and digital subtraction angiography (DSA). Radiation doses were reduced by 1.2 μGy per image for group A; the protocol included collimation. Besides DSA runs before and after embolization on each side, aortography was done as the final run.

For a second group of 29 patients, the protocol was revised to a dose of 1.2 μGy per image and maximum collimation with a 40-cm intensifier. DSA runs were only done before catheter placement for group B. There was no aortography.

For the final group of nine patients, the dose was further reduced by 0.48 μGy per image. The investigators also avoided oblique runs.

The physicians maintained average fluoroscopy time at 20.2 minutes, 21.3 minutes, and 19.8 minutes. Area dose product declined significantly from 52.7 Gy cm

Published studies cited by Dr. Vorwerk had reported mean fluoroscopy times of 11.8 and 22.5 minutes and average dose area product of 59.5 Gy cm

NICE, FRANCE — German investigators significantly reduced radiation exposures without causing complications in 64 women undergoing uterine fibroid embolization.

Bilateral embolization was possible in 63 patients, Dr. Dierk Vorwerk reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Embolization failed in a single uterine artery in just one woman.

No “specific complications” were found, according to Dr. Vorwerk of the Klinikum Ingolstadt (Germany).

“Strict adherence to simple radiation protection rules decreases dose area product significantly. Dose reduction per image significantly decreases dose but does not increase fluoroscopy time,” he said.

From January 2004 through June 2005, he and his colleagues treated 64 patients 32–48 years of age with a unilateral, subradical embolization approach.

In the first consecutive group (group A) of 26 patients, Dr. Vorwerk used pulsed radiation at 7.5 images per second and digital subtraction angiography (DSA). Radiation doses were reduced by 1.2 μGy per image for group A; the protocol included collimation. Besides DSA runs before and after embolization on each side, aortography was done as the final run.

For a second group of 29 patients, the protocol was revised to a dose of 1.2 μGy per image and maximum collimation with a 40-cm intensifier. DSA runs were only done before catheter placement for group B. There was no aortography.

For the final group of nine patients, the dose was further reduced by 0.48 μGy per image. The investigators also avoided oblique runs.

The physicians maintained average fluoroscopy time at 20.2 minutes, 21.3 minutes, and 19.8 minutes. Area dose product declined significantly from 52.7 Gy cm

Published studies cited by Dr. Vorwerk had reported mean fluoroscopy times of 11.8 and 22.5 minutes and average dose area product of 59.5 Gy cm

NICE, FRANCE — Uterine artery embolization should not be withheld from women with adenomyosis, according to investigators who conducted a prospective, multicenter study in 42 symptomatic patients.

At a median clinical follow-up of 17 months, 37 women had avoided hysterectomy, Dr. Paul N.M. Lohle reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Pain, bleeding, and mass-related symptoms were improved or resolved in nearly all patients, said Dr. Lohle of St. Elisabeth Hospital in Tilburg, the Netherlands.

Magnetic resonance imaging attested to the effectiveness of embolization in these patients at a median of 12 months. The data presented included median decreases of 45% for uterine volume, 72% for fibroid volume, and 23% for adenomyosis junctional zone thickness.

Investigators claimed a technical success rate of 100% for all 42 bilateral embolizations.

Speaking on behalf of collaborators at St. Elisabeth Hospital and at Charité University Hospital in Berlin, Dr. Lohle said they conducted the study because they were not convinced by reports of poor clinical outcomes from embolization in the presence of adenomyosis.

Among possible explanations for poor experiences, Dr. Lohle said, is the fact that magnetic resonance imaging is not always used to diagnose adenomyosis, nor are contrast MRIs always used to check the infarction rate. In addition, he said many clinics use polyvinyl alcohol particles instead of microspheres.

For their study, Dr. Lohle and his collaborators used 500- to 700-μm, calibrated trisacryl gelatine microspheres. They set the angiographic embolization end point as complete stasis in the ascending distal part of the uterine artery.

The investigators were able to detect adenomyosis infarctions in 10 women. Dr. Lohle reported the median infarction rate as 100% and the average as 76.5% with a range of 10%–100%.

The trial enrolled consecutive patients from January 1998 to November 2004. All the women, median age 46 years, were premenopausal. Symptoms included menorrhagia in 41 women, pain in 36, and mass effects in 17.

Seventeen women had adenomyosis without fibroids. For this group, the investigators reported three hysterectomies and one surgical resection subsequent to the embolization procedure. Bleeding was improved in 12 of 13 women with that symptom. Pain and mass effects were improved in all women with those symptoms.

Adenomyosis was the dominant disorder in a second group of 16 women, who also suffered from fibroids. Despite improvements in bleeding and pain, two women subsequently underwent hysterectomy. Among the remaining women, pain and mass symptoms were resolved and bleeding improved or resolved for all the women with those complaints.

No hysterectomies were reported in a third group of nine women with adenomyosis for whom fibroids were the dominant disorder. Pain was resolved in seven of eight patients. Otherwise, mass-related symptoms were completely resolved, and bleeding improved or resolved in all women where they occurred.

Dr. Lohle reported that 34 of the 42 women were satisfied with their procedure's outcomes.

NICE, FRANCE — Uterine artery embolization should not be withheld from women with adenomyosis, according to investigators who conducted a prospective, multicenter study in 42 symptomatic patients.

At a median clinical follow-up of 17 months, 37 women had avoided hysterectomy, Dr. Paul N.M. Lohle reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Pain, bleeding, and mass-related symptoms were improved or resolved in nearly all patients, said Dr. Lohle of St. Elisabeth Hospital in Tilburg, the Netherlands.

Magnetic resonance imaging attested to the effectiveness of embolization in these patients at a median of 12 months. The data presented included median decreases of 45% for uterine volume, 72% for fibroid volume, and 23% for adenomyosis junctional zone thickness.

Investigators claimed a technical success rate of 100% for all 42 bilateral embolizations.

Speaking on behalf of collaborators at St. Elisabeth Hospital and at Charité University Hospital in Berlin, Dr. Lohle said they conducted the study because they were not convinced by reports of poor clinical outcomes from embolization in the presence of adenomyosis.

Among possible explanations for poor experiences, Dr. Lohle said, is the fact that magnetic resonance imaging is not always used to diagnose adenomyosis, nor are contrast MRIs always used to check the infarction rate. In addition, he said many clinics use polyvinyl alcohol particles instead of microspheres.

For their study, Dr. Lohle and his collaborators used 500- to 700-μm, calibrated trisacryl gelatine microspheres. They set the angiographic embolization end point as complete stasis in the ascending distal part of the uterine artery.

The investigators were able to detect adenomyosis infarctions in 10 women. Dr. Lohle reported the median infarction rate as 100% and the average as 76.5% with a range of 10%–100%.

The trial enrolled consecutive patients from January 1998 to November 2004. All the women, median age 46 years, were premenopausal. Symptoms included menorrhagia in 41 women, pain in 36, and mass effects in 17.

Seventeen women had adenomyosis without fibroids. For this group, the investigators reported three hysterectomies and one surgical resection subsequent to the embolization procedure. Bleeding was improved in 12 of 13 women with that symptom. Pain and mass effects were improved in all women with those symptoms.

Adenomyosis was the dominant disorder in a second group of 16 women, who also suffered from fibroids. Despite improvements in bleeding and pain, two women subsequently underwent hysterectomy. Among the remaining women, pain and mass symptoms were resolved and bleeding improved or resolved for all the women with those complaints.

No hysterectomies were reported in a third group of nine women with adenomyosis for whom fibroids were the dominant disorder. Pain was resolved in seven of eight patients. Otherwise, mass-related symptoms were completely resolved, and bleeding improved or resolved in all women where they occurred.

Dr. Lohle reported that 34 of the 42 women were satisfied with their procedure's outcomes.

NICE, FRANCE — Uterine artery embolization should not be withheld from women with adenomyosis, according to investigators who conducted a prospective, multicenter study in 42 symptomatic patients.

At a median clinical follow-up of 17 months, 37 women had avoided hysterectomy, Dr. Paul N.M. Lohle reported at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

Pain, bleeding, and mass-related symptoms were improved or resolved in nearly all patients, said Dr. Lohle of St. Elisabeth Hospital in Tilburg, the Netherlands.

Magnetic resonance imaging attested to the effectiveness of embolization in these patients at a median of 12 months. The data presented included median decreases of 45% for uterine volume, 72% for fibroid volume, and 23% for adenomyosis junctional zone thickness.

Investigators claimed a technical success rate of 100% for all 42 bilateral embolizations.

Speaking on behalf of collaborators at St. Elisabeth Hospital and at Charité University Hospital in Berlin, Dr. Lohle said they conducted the study because they were not convinced by reports of poor clinical outcomes from embolization in the presence of adenomyosis.

Among possible explanations for poor experiences, Dr. Lohle said, is the fact that magnetic resonance imaging is not always used to diagnose adenomyosis, nor are contrast MRIs always used to check the infarction rate. In addition, he said many clinics use polyvinyl alcohol particles instead of microspheres.

For their study, Dr. Lohle and his collaborators used 500- to 700-μm, calibrated trisacryl gelatine microspheres. They set the angiographic embolization end point as complete stasis in the ascending distal part of the uterine artery.

The investigators were able to detect adenomyosis infarctions in 10 women. Dr. Lohle reported the median infarction rate as 100% and the average as 76.5% with a range of 10%–100%.

The trial enrolled consecutive patients from January 1998 to November 2004. All the women, median age 46 years, were premenopausal. Symptoms included menorrhagia in 41 women, pain in 36, and mass effects in 17.

Seventeen women had adenomyosis without fibroids. For this group, the investigators reported three hysterectomies and one surgical resection subsequent to the embolization procedure. Bleeding was improved in 12 of 13 women with that symptom. Pain and mass effects were improved in all women with those symptoms.

Adenomyosis was the dominant disorder in a second group of 16 women, who also suffered from fibroids. Despite improvements in bleeding and pain, two women subsequently underwent hysterectomy. Among the remaining women, pain and mass symptoms were resolved and bleeding improved or resolved for all the women with those complaints.

No hysterectomies were reported in a third group of nine women with adenomyosis for whom fibroids were the dominant disorder. Pain was resolved in seven of eight patients. Otherwise, mass-related symptoms were completely resolved, and bleeding improved or resolved in all women where they occurred.

Dr. Lohle reported that 34 of the 42 women were satisfied with their procedure's outcomes.

SANTA ANA PUEBLO, N.M. — Residents and nurse practitioners are better at spotting anxiety than depression in patients recovering from acute myocardial infarction—but both disorders are underdiagnosed and undertreated, Dr. Felicia A. Smith reported at the annual meeting of the Academy of Psychosomatic Medicine.

In a study conducted at Massachusetts General Hospital in Boston, house staff and nurses identified three (4%) of 74 patients in cardiac units as having a major depressive disorder, Dr. Smith reported.

The researchers flagged 11 depressed patients (15%) in the same population.

The clinical teams treating these patients were better at identifying anxiety, but they still recognized only half as many cases as did the researchers: 8 (11%) vs. 16 (22%).

“The results of this study suggest it may be unrealistic for these busy, front-line clinicians to adequately diagnose depression in the post-MI period in the absence of systematic screening,” said Dr. Smith, a fellow on a psychiatric consultation service at the hospital. She suggested better education of clinical teams and the development of new screening tools for them to use in this setting.

Depression and anxiety are common after myocardial infarction, according to Dr. Smith, and both disorders are associated with higher mortality and complications. “This has clearly been shown to be a major issue,” she said.

To gauge the ability of house staff and nurse practitioners to recognize and treat the two psychiatric disorders in high-risk cardiac patients, Dr. Smith and her colleagues compared assessments of patients being treated in a cardiac intensive care or step-down unit 72 hours after a myocardial infarction.

The average age of the largely male population was about 64 years. Dr. Smith said 22% had had a prior depressive episode.

The investigators used a screening battery that included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the DMS-IV Structured Clinical Interview (SCID) for major and minor depression.

The house staff's impressions correlated with the SCID, BAI, and a psychiatric evaluation for anxiety, but did not correlate with the SCID, BDI, and a psychiatric evaluation for depression, Dr. Smith said.

About 26% of the patients had a BDI score higher than 10; the mean BDI was 8, Dr. Smith said. The same proportion, 26%, of patients scored above 10 on the BAI, but the average anxiety score was more than twice as high, at 18.5.

As for treatment, Dr. Smith reported only one patient of the three identified as depressed by the house staff was started on antidepressant medication. “Some patients were started on antidepressants who did not meet criteria for depression and the study team did not identify as depressed,” she said.

Anxiety was more likely to be treated, and seven of the patients flagged by the house staff were started on benzodiazepines.

Dr. Smith said she did not know why residents and nurses were better at spotting anxiety, but offered a theory. “Maybe patients who are anxious call more attention to themselves,” she said, citing more frequent use of the call bell and physical manifestations of anxiety, such as dyspnea and nausea.

“Depressed patients may be anergic and withdrawn, and don't call much attention to themselves,” she continued. “Less interaction with the team makes the diagnosis more difficult.”

SANTA ANA PUEBLO, N.M. — Residents and nurse practitioners are better at spotting anxiety than depression in patients recovering from acute myocardial infarction—but both disorders are underdiagnosed and undertreated, Dr. Felicia A. Smith reported at the annual meeting of the Academy of Psychosomatic Medicine.

In a study conducted at Massachusetts General Hospital in Boston, house staff and nurses identified three (4%) of 74 patients in cardiac units as having a major depressive disorder, Dr. Smith reported.

The researchers flagged 11 depressed patients (15%) in the same population.

The clinical teams treating these patients were better at identifying anxiety, but they still recognized only half as many cases as did the researchers: 8 (11%) vs. 16 (22%).

“The results of this study suggest it may be unrealistic for these busy, front-line clinicians to adequately diagnose depression in the post-MI period in the absence of systematic screening,” said Dr. Smith, a fellow on a psychiatric consultation service at the hospital. She suggested better education of clinical teams and the development of new screening tools for them to use in this setting.

Depression and anxiety are common after myocardial infarction, according to Dr. Smith, and both disorders are associated with higher mortality and complications. “This has clearly been shown to be a major issue,” she said.

To gauge the ability of house staff and nurse practitioners to recognize and treat the two psychiatric disorders in high-risk cardiac patients, Dr. Smith and her colleagues compared assessments of patients being treated in a cardiac intensive care or step-down unit 72 hours after a myocardial infarction.

The average age of the largely male population was about 64 years. Dr. Smith said 22% had had a prior depressive episode.

The investigators used a screening battery that included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the DMS-IV Structured Clinical Interview (SCID) for major and minor depression.

The house staff's impressions correlated with the SCID, BAI, and a psychiatric evaluation for anxiety, but did not correlate with the SCID, BDI, and a psychiatric evaluation for depression, Dr. Smith said.

About 26% of the patients had a BDI score higher than 10; the mean BDI was 8, Dr. Smith said. The same proportion, 26%, of patients scored above 10 on the BAI, but the average anxiety score was more than twice as high, at 18.5.

As for treatment, Dr. Smith reported only one patient of the three identified as depressed by the house staff was started on antidepressant medication. “Some patients were started on antidepressants who did not meet criteria for depression and the study team did not identify as depressed,” she said.

Anxiety was more likely to be treated, and seven of the patients flagged by the house staff were started on benzodiazepines.

Dr. Smith said she did not know why residents and nurses were better at spotting anxiety, but offered a theory. “Maybe patients who are anxious call more attention to themselves,” she said, citing more frequent use of the call bell and physical manifestations of anxiety, such as dyspnea and nausea.

“Depressed patients may be anergic and withdrawn, and don't call much attention to themselves,” she continued. “Less interaction with the team makes the diagnosis more difficult.”

SANTA ANA PUEBLO, N.M. — Residents and nurse practitioners are better at spotting anxiety than depression in patients recovering from acute myocardial infarction—but both disorders are underdiagnosed and undertreated, Dr. Felicia A. Smith reported at the annual meeting of the Academy of Psychosomatic Medicine.

In a study conducted at Massachusetts General Hospital in Boston, house staff and nurses identified three (4%) of 74 patients in cardiac units as having a major depressive disorder, Dr. Smith reported.

The researchers flagged 11 depressed patients (15%) in the same population.

The clinical teams treating these patients were better at identifying anxiety, but they still recognized only half as many cases as did the researchers: 8 (11%) vs. 16 (22%).

“The results of this study suggest it may be unrealistic for these busy, front-line clinicians to adequately diagnose depression in the post-MI period in the absence of systematic screening,” said Dr. Smith, a fellow on a psychiatric consultation service at the hospital. She suggested better education of clinical teams and the development of new screening tools for them to use in this setting.

Depression and anxiety are common after myocardial infarction, according to Dr. Smith, and both disorders are associated with higher mortality and complications. “This has clearly been shown to be a major issue,” she said.

To gauge the ability of house staff and nurse practitioners to recognize and treat the two psychiatric disorders in high-risk cardiac patients, Dr. Smith and her colleagues compared assessments of patients being treated in a cardiac intensive care or step-down unit 72 hours after a myocardial infarction.

The average age of the largely male population was about 64 years. Dr. Smith said 22% had had a prior depressive episode.

The investigators used a screening battery that included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the DMS-IV Structured Clinical Interview (SCID) for major and minor depression.

The house staff's impressions correlated with the SCID, BAI, and a psychiatric evaluation for anxiety, but did not correlate with the SCID, BDI, and a psychiatric evaluation for depression, Dr. Smith said.

About 26% of the patients had a BDI score higher than 10; the mean BDI was 8, Dr. Smith said. The same proportion, 26%, of patients scored above 10 on the BAI, but the average anxiety score was more than twice as high, at 18.5.

As for treatment, Dr. Smith reported only one patient of the three identified as depressed by the house staff was started on antidepressant medication. “Some patients were started on antidepressants who did not meet criteria for depression and the study team did not identify as depressed,” she said.

Anxiety was more likely to be treated, and seven of the patients flagged by the house staff were started on benzodiazepines.

Dr. Smith said she did not know why residents and nurses were better at spotting anxiety, but offered a theory. “Maybe patients who are anxious call more attention to themselves,” she said, citing more frequent use of the call bell and physical manifestations of anxiety, such as dyspnea and nausea.

“Depressed patients may be anergic and withdrawn, and don't call much attention to themselves,” she continued. “Less interaction with the team makes the diagnosis more difficult.”

SANTA ANA PUEBLO, N.M. – The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act–a sense of control–should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University, Portland. “And we need to let this goal start driving how they should be cared for–whether they get assisted suicide or not.”

The findings gained new currency last month, when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors anticipated in the political debate over the law were significant to the terminally ill in determining who chose assisted suicide. Most patients who requested lethal prescriptions were no more depressed, poor, poorly educated, from minority groups, or in worse physical condition than were those who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Often, those who requested assisted suicide had highly successful careers and worked as school superintendents, teachers, lawyers, and dentists, Dr. Ganzini said. Overcoming adversity early in life was another common experience for many who requested assisted suicide.

“Many had parents who were neglectful or incompetent,” she said. “They learned to be very self-sufficient and to prize their independence.”

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it,” she said.

Amyotrophic lateral sclerosis (ALS) is the disease tied to the highest number of assisted suicide requests, Dr. Ganzini said. Compared with other patients, ALS patients in Oregon have an odds ratio above 20 for dying by assisted suicide.

A study she and her associates conducted with 100 ALS patients showed that a sense of hopelessness was an important predictor of interest in obtaining a lethal prescription.

Dr. Ganzini is now studying patients who are in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living when it happens,” she said. She noted that no patient complained of physical symptoms worse than 2 on a scale of 1–5 when they made their requests, but that they feared worsening symptoms as the disease progressed.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

Depression was expected to be the biggest risk factor for assisted suicide requests, Dr. Ganzini said. In addition to the patient having to provide two oral requests and one written request, Oregon's law requires that patients be screened by a psychiatrist or psychologist if depression is suspected.

Yet physicians surveyed by Dr. Ganzini ranked the prevalence of depression at about 20% of patients making a request (N. Engl. J. Med. 2000;342:557–63). Hospice social workers and nurses also put depression among the least important reasons for requests (N. Engl. J. Med. 2002;347:582–8).

In her current study, she reported that only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories that might explain why investigators don't find more depression. “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern that arose before the passage of the Death with Dignity Act was that the act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

“Even though they oppose suicide, their moral feelings about abandoning the patient are stronger,” she said, adding that the chaplains said providing nonjudgmental support was the most effective way to help change a person's mind.

The Oregon experience highlights “a very rarified group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded. As an example, she cited Annie, who stopped hospice services after 13 days, saying, “They [the staff] are really nice, but I just hate it when other people tell me what to do.”

The one-size-fits-all hospice care model actually does not fit everyone, Dr. Ganzini said. “I think hospice and palliative care have to change to individualize the treatment they offer.”

'Some people want to leave this world in the driver's seat. That's their major goal.' DR. GANZINI

SANTA ANA PUEBLO, N.M. – The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act–a sense of control–should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University, Portland. “And we need to let this goal start driving how they should be cared for–whether they get assisted suicide or not.”

The findings gained new currency last month, when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors anticipated in the political debate over the law were significant to the terminally ill in determining who chose assisted suicide. Most patients who requested lethal prescriptions were no more depressed, poor, poorly educated, from minority groups, or in worse physical condition than were those who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Often, those who requested assisted suicide had highly successful careers and worked as school superintendents, teachers, lawyers, and dentists, Dr. Ganzini said. Overcoming adversity early in life was another common experience for many who requested assisted suicide.

“Many had parents who were neglectful or incompetent,” she said. “They learned to be very self-sufficient and to prize their independence.”

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it,” she said.

Amyotrophic lateral sclerosis (ALS) is the disease tied to the highest number of assisted suicide requests, Dr. Ganzini said. Compared with other patients, ALS patients in Oregon have an odds ratio above 20 for dying by assisted suicide.

A study she and her associates conducted with 100 ALS patients showed that a sense of hopelessness was an important predictor of interest in obtaining a lethal prescription.

Dr. Ganzini is now studying patients who are in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living when it happens,” she said. She noted that no patient complained of physical symptoms worse than 2 on a scale of 1–5 when they made their requests, but that they feared worsening symptoms as the disease progressed.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

Depression was expected to be the biggest risk factor for assisted suicide requests, Dr. Ganzini said. In addition to the patient having to provide two oral requests and one written request, Oregon's law requires that patients be screened by a psychiatrist or psychologist if depression is suspected.

Yet physicians surveyed by Dr. Ganzini ranked the prevalence of depression at about 20% of patients making a request (N. Engl. J. Med. 2000;342:557–63). Hospice social workers and nurses also put depression among the least important reasons for requests (N. Engl. J. Med. 2002;347:582–8).

In her current study, she reported that only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories that might explain why investigators don't find more depression. “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern that arose before the passage of the Death with Dignity Act was that the act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

“Even though they oppose suicide, their moral feelings about abandoning the patient are stronger,” she said, adding that the chaplains said providing nonjudgmental support was the most effective way to help change a person's mind.

The Oregon experience highlights “a very rarified group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded. As an example, she cited Annie, who stopped hospice services after 13 days, saying, “They [the staff] are really nice, but I just hate it when other people tell me what to do.”

The one-size-fits-all hospice care model actually does not fit everyone, Dr. Ganzini said. “I think hospice and palliative care have to change to individualize the treatment they offer.”

'Some people want to leave this world in the driver's seat. That's their major goal.' DR. GANZINI

SANTA ANA PUEBLO, N.M. – The key factor motivating the terminally ill to seek assisted suicide under Oregon's Death with Dignity Act–a sense of control–should prompt a rethinking of end-of-life care, Dr. Linda Ganzini said at the annual meeting of the Academy of Psychosomatic Medicine.

Studies of terminally ill patients in Oregon showed that “some people want to leave this world in the driver's seat. That's their major goal,” said Dr. Ganzini, director of the geriatric psychiatry fellowship program at Oregon Health and Science University, Portland. “And we need to let this goal start driving how they should be cared for–whether they get assisted suicide or not.”

The findings gained new currency last month, when the U.S. Supreme Court ruled that the Bush administration improperly tried to use a federal drug law to stop physicians from prescribing lethal drugs to terminally ill patients under the Oregon law.

The studies, which also included physicians, nurses, hospice chaplains, and family members, showed that few of the factors anticipated in the political debate over the law were significant to the terminally ill in determining who chose assisted suicide. Most patients who requested lethal prescriptions were no more depressed, poor, poorly educated, from minority groups, or in worse physical condition than were those who opted not to make such a request.

“These were individuals who wanted to control their lives,” Dr. Ganzini said. Relatively few people go through with assisted suicide, but those who do are determined to remain self-reliant until the end.

Often, those who requested assisted suicide had highly successful careers and worked as school superintendents, teachers, lawyers, and dentists, Dr. Ganzini said. Overcoming adversity early in life was another common experience for many who requested assisted suicide.

“Many had parents who were neglectful or incompetent,” she said. “They learned to be very self-sufficient and to prize their independence.”

Oregon's voters passed its Death with Dignity Act by a slim majority in 1994, making Oregon the first and only state to approve assisted suicide. The act was delayed by a legal injunction until 1997, when 60% of voters refused to repeal it.

Since 1997, Oregon has had 208 deaths by assisted suicide, said Dr. Ganzini, also a senior scholar at the university's center for ethics in health care. “For every 1,000 patients in Oregon who die, 100 will seriously consider assisted suicide, 10 will make an explicit request, and 1 will die by it,” she said.

Amyotrophic lateral sclerosis (ALS) is the disease tied to the highest number of assisted suicide requests, Dr. Ganzini said. Compared with other patients, ALS patients in Oregon have an odds ratio above 20 for dying by assisted suicide.

A study she and her associates conducted with 100 ALS patients showed that a sense of hopelessness was an important predictor of interest in obtaining a lethal prescription.

Dr. Ganzini is now studying patients who are in the process of making legal requests. “They are really focused on what is coming down the road, how intolerable it will be, and how it will make their lives not worth living when it happens,” she said. She noted that no patient complained of physical symptoms worse than 2 on a scale of 1–5 when they made their requests, but that they feared worsening symptoms as the disease progressed.

In another study with cancer patients, growing dissatisfaction with medical care was a leading predictor of interest in assisted suicide, and perhaps the interest reflected hopelessness, she added.

Depression was expected to be the biggest risk factor for assisted suicide requests, Dr. Ganzini said. In addition to the patient having to provide two oral requests and one written request, Oregon's law requires that patients be screened by a psychiatrist or psychologist if depression is suspected.

Yet physicians surveyed by Dr. Ganzini ranked the prevalence of depression at about 20% of patients making a request (N. Engl. J. Med. 2000;342:557–63). Hospice social workers and nurses also put depression among the least important reasons for requests (N. Engl. J. Med. 2002;347:582–8).

In her current study, she reported that only 6 of 46 patients requesting assisted suicide met criteria for a major depressive disorder in structured clinical interviews. Even patients who felt hopeless were not depressed.

“I remain very perplexed. I still don't know why there are not more depressed people making a request,” Dr. Ganzini said. But she has a few theories that might explain why investigators don't find more depression. “I have no empirical data to support it, but people who go through this process have to be very physically fit, determined, convincing, and articulate. I think depressed people, particularly if they are physically ill people, may get left behind in this process.”

Another concern that arose before the passage of the Death with Dignity Act was that the act might undermine efforts to improve hospice or palliative care. Instead, 86% of assisted suicides occurred in hospice patients, Dr. Ganzini said.

Opposition to the law remains fairly strong. About 42% of hospice chaplains and a third of hospice nurses oppose the law, she said. Yet few said they would actively oppose it with a patient, and no chaplain would seek transfer of a patient who requested assisted suicide.

“Even though they oppose suicide, their moral feelings about abandoning the patient are stronger,” she said, adding that the chaplains said providing nonjudgmental support was the most effective way to help change a person's mind.

The Oregon experience highlights “a very rarified group” of people whose needs are not generalizable but should not be ignored, Dr. Ganzini concluded. As an example, she cited Annie, who stopped hospice services after 13 days, saying, “They [the staff] are really nice, but I just hate it when other people tell me what to do.”

The one-size-fits-all hospice care model actually does not fit everyone, Dr. Ganzini said. “I think hospice and palliative care have to change to individualize the treatment they offer.”

'Some people want to leave this world in the driver's seat. That's their major goal.' DR. GANZINI

SANTA ANA PUEBLO, N.M. – Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

As many adult diagnostic techniques cannot be used with very young children, she suggested asking pediatric hospital patients where they are.

“If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, Dr. Turkel said she gives the child a small dose of an atypical antipsychotic medication.

Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SANTA ANA PUEBLO, N.M. – Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

As many adult diagnostic techniques cannot be used with very young children, she suggested asking pediatric hospital patients where they are.

“If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, Dr. Turkel said she gives the child a small dose of an atypical antipsychotic medication.

Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SANTA ANA PUEBLO, N.M. – Pediatric delirium is rarely discussed in the medical literature and hardly ever diagnosed in practice, but Dr. Susan Beckwitt Turkel contends that children may be as vulnerable as elderly patients.

“I think when we say that children don't get delirium, it is because it is very rarely diagnosed by pediatricians, and most consultation-liaison psychiatrists don't bump into it,” Dr. Turkel said at the annual meeting of the Academy of Psychosomatic Medicine.

Pediatric delirium “is probably very common, and when it does occur, it is typically mistreated,” said Dr. Turkel, chief of neuropsychiatry and child adolescent psychiatry at Childrens Hospital Los Angeles.

She speculated that age-related changes in the cholinergic systems may put children and the elderly at risk for delirium. “It may have something to do with the development of the cholinergic system in the brain and then the decline of cholinergic system in the brain,” she said.

Children present with many of the characteristic symptoms in the DSM-IV, but, because pediatricians think in a developmental context, they describe “behavioral regression,” according to Dr. Turkel.

She suggested many children become delirious while running high fevers from common conditions such as ear infections that are treated at home.

At Childrens Hospital, a tertiary care referral center, she and a colleague reviewed 84 cases involving very sick children who were the subject of psychiatric-liaison consultations from 1991 through 1995 (J. Neuropsychiatry Clin. Neurosci. 2003;15:431–5).

Delirium was identified in 45 males and 39 females, ranging in age from 6 months to 18 years. Their length of stay ranged from 1 to 255 days, with an average of 41 days.

Infection was the most common cause of delirium, but mortality was higher in children with organ failure, autoimmune diseases, or a recent transplant. Overall, the mortality rate was 20%.

All of the children had impaired attention and fluctuating symptoms, often described as “waxing and waning.” Nearly all had impaired alertness, confusion, sleep disturbance, and impaired responsiveness. Exacerbation at night and disorientation also were common.

Apathy and agitation were documented in more than two-thirds of the children. Only about half had memory impairment. Fewer than half hallucinated, and none had perceptual disturbance, delusion, paranoia, or hypervigilance.

“These are not things you see in children,” Dr. Turkel said, adding that when children do hallucinate, the experience is more likely to be auditory than visual.

Dr. Turkel said she has since compared the children with 968 adults, aged 30–100 years, in 10 published delirium studies. “Overall, you see the same symptoms in toddlers, children, adolescents and adults, but maybe at different rates,” she said, noting that the articles concerning adults were not consistent with each other in reporting data.

As many adult diagnostic techniques cannot be used with very young children, she suggested asking pediatric hospital patients where they are.

“If they tell you they are at home or at school, you can tell they are disoriented,” she said. “They don't have the same specificity you get from an adult.”

Sometimes a child will talk to someone who is not there, she said. Mood changes, irritability, and sleep changes also are clues.

“The inattention may not be picked up, but we get the consult because they are not sleeping,” she said. “They nap a little while, and wake up really cranky.”

Dr. Turkel described her approach to delirium treatment as multifactorial. Physicians treat the underlying condition, she said, but also look for sedating and anticholinergic medications that may be playing a role.

She said she works closely with the child's family, advising parents that their job is to tell children where they are each time they wake up irritable and confused. “You tell them … 'You are in the hospital, you are sick, and mommy is here.' That is often enough to calm them down,” she said.

Positioning the children near a window can help them distinguish day from night, she added.

If these interventions do not work, Dr. Turkel said she gives the child a small dose of an atypical antipsychotic medication.

Benzodiazepines and anticholinergic agents should be avoided, she said, as they can make delirium worse and even precipitate delirium.

SCOTTSDALE, ARIZ. — A telephone survey of 66 physicians, each representing an obstetric group in Wisconsin, found that most groups did not have formal rules regarding call responsibilities or provisions for physicians to recover after being on call.

Yet 16 groups delivered babies at more than one hospital, leaving open the possibility that there would be simultaneous call at different locations, according to a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Most of [the respondents] said, 'We just call one of our colleagues if we need extra help, and they will come on in. We help each other,'” one of the investigators, Dr. Charles W. Schauberger, said in an interview. “There is a real brotherhood and sisterhood of obstetricians who will cover for one another.”

Avoiding call at multiple locations was the first of three “call best practices” recommended by Dr. Schauberger, medical director for quality and performance improvement at Gundersen Lutheran Medical Center in La Crosse, Wisc., and his coauthors.

The second and third best practices were, respectively, having a formal backup system and restricting work after being on call “to avoid difficult or complicated surgery or medical care,” he said.

The survey found a wide variety of ways of handling call, but no perfect call system. Dr. Schauberger and coauthor Dr. Robert K. Gribble, of Marshfield Clinic in Marshfield, Wisc., conducted the physician-to-physician survey by telephone. Working with third coauthor Brenda Rooney, Ph.D., of Gundersen Lutheran, they identified 70 “call pools” and obstetric groups in the state. After accounting for two physicians who declined to participate and those who did not return calls, there was a total of 66 participants.

The size of call pools ranged from 1 to 11 physicians, with 5 physicians being the median staffing, according to the investigators. Physicians were usually on call for 24 hours, but many groups had longer call duties on weekends.

Everyone provided obstetric care and emergency department consults on call. A large majority also did regular office work (82%) and provided backup for family physicians (68%). Others (24%) provided backup for midwives, but none performed home deliveries. Separately, more than 30% taught residents and about 25% taught students while on call.

Only 23% of the groups had formal rules governing call responsibilities. Just 26% had provisions for recovery after call, and 21% had decreased call with age. Some physicians said they did not do surgery on the day after being on call.

Asked how often they questioned their ability to provide safe care due to too many call responsibilities, 8% of respondents said occasionally. When asked the same question due to sleep deprivation, 1% said frequently and 11% said occasionally.

Although most physicians delivered at only one hospital, the survey found 10 physicians delivering at two hospitals, 4 physicians at three hospitals, and 2 physicians at four hospitals. Initially, Dr. Schauberger was surprised to find physicians providing multiple coverage.

“After I got to talking to the doctors, the rationale for it became apparent,” he said. “When you have patients that have insurance and can deliver in any hospital they want, they may choose to deliver in [a particular] hospital because they had a friend who had a good experience there. And if you want to keep that patient, you will have privileges in that hospital also.”

Nonetheless, Dr. Schauberger expressed concern about the risk that a physician might not be available in an emergency. “The problem is if you are trying to deliver a baby in one hospital and have a patient in another hospital, you can't provide emergency care for that patient,” he said. “If you are in the same physical proximity, you can manage more than one patient at a time.”

Another concern related to the contrast between call as experienced by residents and the real-world experience of obstetric groups. The investigators described resident call as being more intense and highly focused, occurring in-house, and carrying a higher likelihood of no sleep. They said private practitioners spend longer hours on call (sometimes over 2 or 3 days), have multiple responsibilities, and may cover in multiple hospitals.

“I'm not sure residents who are being trained these days have a very good understanding … that what their call is in residency will be significantly different from what it will be in private practice,” Dr. Schauberger said.

SCOTTSDALE, ARIZ. — A telephone survey of 66 physicians, each representing an obstetric group in Wisconsin, found that most groups did not have formal rules regarding call responsibilities or provisions for physicians to recover after being on call.

Yet 16 groups delivered babies at more than one hospital, leaving open the possibility that there would be simultaneous call at different locations, according to a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Most of [the respondents] said, 'We just call one of our colleagues if we need extra help, and they will come on in. We help each other,'” one of the investigators, Dr. Charles W. Schauberger, said in an interview. “There is a real brotherhood and sisterhood of obstetricians who will cover for one another.”

Avoiding call at multiple locations was the first of three “call best practices” recommended by Dr. Schauberger, medical director for quality and performance improvement at Gundersen Lutheran Medical Center in La Crosse, Wisc., and his coauthors.

The second and third best practices were, respectively, having a formal backup system and restricting work after being on call “to avoid difficult or complicated surgery or medical care,” he said.

The survey found a wide variety of ways of handling call, but no perfect call system. Dr. Schauberger and coauthor Dr. Robert K. Gribble, of Marshfield Clinic in Marshfield, Wisc., conducted the physician-to-physician survey by telephone. Working with third coauthor Brenda Rooney, Ph.D., of Gundersen Lutheran, they identified 70 “call pools” and obstetric groups in the state. After accounting for two physicians who declined to participate and those who did not return calls, there was a total of 66 participants.

The size of call pools ranged from 1 to 11 physicians, with 5 physicians being the median staffing, according to the investigators. Physicians were usually on call for 24 hours, but many groups had longer call duties on weekends.

Everyone provided obstetric care and emergency department consults on call. A large majority also did regular office work (82%) and provided backup for family physicians (68%). Others (24%) provided backup for midwives, but none performed home deliveries. Separately, more than 30% taught residents and about 25% taught students while on call.

Only 23% of the groups had formal rules governing call responsibilities. Just 26% had provisions for recovery after call, and 21% had decreased call with age. Some physicians said they did not do surgery on the day after being on call.

Asked how often they questioned their ability to provide safe care due to too many call responsibilities, 8% of respondents said occasionally. When asked the same question due to sleep deprivation, 1% said frequently and 11% said occasionally.

Although most physicians delivered at only one hospital, the survey found 10 physicians delivering at two hospitals, 4 physicians at three hospitals, and 2 physicians at four hospitals. Initially, Dr. Schauberger was surprised to find physicians providing multiple coverage.

“After I got to talking to the doctors, the rationale for it became apparent,” he said. “When you have patients that have insurance and can deliver in any hospital they want, they may choose to deliver in [a particular] hospital because they had a friend who had a good experience there. And if you want to keep that patient, you will have privileges in that hospital also.”

Nonetheless, Dr. Schauberger expressed concern about the risk that a physician might not be available in an emergency. “The problem is if you are trying to deliver a baby in one hospital and have a patient in another hospital, you can't provide emergency care for that patient,” he said. “If you are in the same physical proximity, you can manage more than one patient at a time.”

Another concern related to the contrast between call as experienced by residents and the real-world experience of obstetric groups. The investigators described resident call as being more intense and highly focused, occurring in-house, and carrying a higher likelihood of no sleep. They said private practitioners spend longer hours on call (sometimes over 2 or 3 days), have multiple responsibilities, and may cover in multiple hospitals.

“I'm not sure residents who are being trained these days have a very good understanding … that what their call is in residency will be significantly different from what it will be in private practice,” Dr. Schauberger said.

SCOTTSDALE, ARIZ. — A telephone survey of 66 physicians, each representing an obstetric group in Wisconsin, found that most groups did not have formal rules regarding call responsibilities or provisions for physicians to recover after being on call.

Yet 16 groups delivered babies at more than one hospital, leaving open the possibility that there would be simultaneous call at different locations, according to a poster presentation at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Most of [the respondents] said, 'We just call one of our colleagues if we need extra help, and they will come on in. We help each other,'” one of the investigators, Dr. Charles W. Schauberger, said in an interview. “There is a real brotherhood and sisterhood of obstetricians who will cover for one another.”

Avoiding call at multiple locations was the first of three “call best practices” recommended by Dr. Schauberger, medical director for quality and performance improvement at Gundersen Lutheran Medical Center in La Crosse, Wisc., and his coauthors.

The second and third best practices were, respectively, having a formal backup system and restricting work after being on call “to avoid difficult or complicated surgery or medical care,” he said.

The survey found a wide variety of ways of handling call, but no perfect call system. Dr. Schauberger and coauthor Dr. Robert K. Gribble, of Marshfield Clinic in Marshfield, Wisc., conducted the physician-to-physician survey by telephone. Working with third coauthor Brenda Rooney, Ph.D., of Gundersen Lutheran, they identified 70 “call pools” and obstetric groups in the state. After accounting for two physicians who declined to participate and those who did not return calls, there was a total of 66 participants.

The size of call pools ranged from 1 to 11 physicians, with 5 physicians being the median staffing, according to the investigators. Physicians were usually on call for 24 hours, but many groups had longer call duties on weekends.

Everyone provided obstetric care and emergency department consults on call. A large majority also did regular office work (82%) and provided backup for family physicians (68%). Others (24%) provided backup for midwives, but none performed home deliveries. Separately, more than 30% taught residents and about 25% taught students while on call.

Only 23% of the groups had formal rules governing call responsibilities. Just 26% had provisions for recovery after call, and 21% had decreased call with age. Some physicians said they did not do surgery on the day after being on call.

Asked how often they questioned their ability to provide safe care due to too many call responsibilities, 8% of respondents said occasionally. When asked the same question due to sleep deprivation, 1% said frequently and 11% said occasionally.

Although most physicians delivered at only one hospital, the survey found 10 physicians delivering at two hospitals, 4 physicians at three hospitals, and 2 physicians at four hospitals. Initially, Dr. Schauberger was surprised to find physicians providing multiple coverage.

“After I got to talking to the doctors, the rationale for it became apparent,” he said. “When you have patients that have insurance and can deliver in any hospital they want, they may choose to deliver in [a particular] hospital because they had a friend who had a good experience there. And if you want to keep that patient, you will have privileges in that hospital also.”

Nonetheless, Dr. Schauberger expressed concern about the risk that a physician might not be available in an emergency. “The problem is if you are trying to deliver a baby in one hospital and have a patient in another hospital, you can't provide emergency care for that patient,” he said. “If you are in the same physical proximity, you can manage more than one patient at a time.”

Another concern related to the contrast between call as experienced by residents and the real-world experience of obstetric groups. The investigators described resident call as being more intense and highly focused, occurring in-house, and carrying a higher likelihood of no sleep. They said private practitioners spend longer hours on call (sometimes over 2 or 3 days), have multiple responsibilities, and may cover in multiple hospitals.

“I'm not sure residents who are being trained these days have a very good understanding … that what their call is in residency will be significantly different from what it will be in private practice,” Dr. Schauberger said.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

SANTA ANA PUEBLO, N.M. — Elderly people with depression and arthritis experienced significant pain relief with duloxetine in a placebo-controlled trial reported at the annual meeting of the Academy of Psychosomatic Medicine.

Conducted by investigators from Eli Lilly & Co., the research findings also documented significant improvement in cognitive functions, primarily verbal learning and memory, for depressed patients treated with duloxetine (Cymbalta) in the 8-week, multicenter study.

“I think (these findings are) very encouraging,” investigator Dr. Michael J. Robinson, a clinical research physician at Lilly's medical division in Indianapolis, said in an interview. “Duloxetine may be advantageous for those specific cognitive symptoms.”

The results suggest duloxetine can alleviate arthritis pain, a common comorbidity in depressed elderly patients. An inhibitor of serotonin and norepinephrine reuptake, duloxetine is known to have analgesic properties and is approved for treatment of peripheral neuropathic pain in patients with diabetes.

Cognition was a primary outcome in the trial, which randomized 207 depressed elderly patients to 60 mg daily of duloxetine and 104 to placebo. The two cohorts were similar, with an average age of 73 years, slightly more women than men, and more than three-fourths the population being white. All patients were at least 65 years old and had previous episodes of depression.

Similar proportions of patients withdrew because of adverse events. The most common in the duloxetine group were dry mouth, nausea, and constipation.

Duloxetine produced faster and more significant reductions than placebo on the Geriatric Depression Scale (GDS) and the Hamilton Rating Scale for Depression (HAMD 17). On average, the GDS fell 4.07 in patients on duloxetine vs. 1.34 in the placebo cohort. HAMD 17 scores declined 6.49 with duloxetine and 3.72 with placebo.

The duloxetine cohort demonstrated significantly greater improvement in a composite score based on four cognitive tests: a mean change of +1.95 vs. +0.76 for the placebo group.

At baseline, the mean composite cognitive scores were 22.70 for the duloxetine group and 23.17 for the placebo group. Most of the improvement could be due to changes in scores on verbal learning and recall tests.

Visual analog scale scores for all 311 patients in the trial demonstrated greater improvement in back pain and “time in pain while awake” for the duloxetine cohort. In a subgroup analysis limited to patients with comorbid arthritis, 117 patients on duloxetine had significantly greater improvement in four of six pain measures, compared with 55 placebo patient scores.

At the outset, all patients with arthritis had significantly higher baseline scores on five of six pain categories assessed with visual analog scales. Overall severity was 38.3 for patients with arthritis vs. 22.5 in patients who did not have arthritis.

Arthritis patients in the duloxetine cohort had greater improvements in overall pain, back pain, time in pain while awake, and interference with daily activities. Arthritis patients in the placebo group had more headache and shoulder pain; the difference was not significant.

The mean change in overall pain scores was −6.70 for arthritis patients on duloxetine vs. −1.89 for arthritis patients on placebo. The most dramatic effect was for back pain, which fell by a mean of more than 20% with duloxetine while increasing more than 10% with placebo.

“We don't know if this is their pain due to arthritis or their pain due to depression,” Dr. Robinson said. “This is just looking at general pain outcomes.”

Baseline scores for depression and improvements in mood were similar for arthritis patients in the two arms of the trial.

In another poster at the meeting, analysis of pooled data from seven randomized, multicenter, double-blind trials of duloxetine showed symptom improvement to be similar for white, Hispanic, and African American patients. Dr. John M. Plewes of Eli Lilly was the principal investigator.

SANTA ANA PUEBLO, N.M. — Elderly people with depression and arthritis experienced significant pain relief with duloxetine in a placebo-controlled trial reported at the annual meeting of the Academy of Psychosomatic Medicine.

Conducted by investigators from Eli Lilly & Co., the research findings also documented significant improvement in cognitive functions, primarily verbal learning and memory, for depressed patients treated with duloxetine (Cymbalta) in the 8-week, multicenter study.

“I think (these findings are) very encouraging,” investigator Dr. Michael J. Robinson, a clinical research physician at Lilly's medical division in Indianapolis, said in an interview. “Duloxetine may be advantageous for those specific cognitive symptoms.”

The results suggest duloxetine can alleviate arthritis pain, a common comorbidity in depressed elderly patients. An inhibitor of serotonin and norepinephrine reuptake, duloxetine is known to have analgesic properties and is approved for treatment of peripheral neuropathic pain in patients with diabetes.

Cognition was a primary outcome in the trial, which randomized 207 depressed elderly patients to 60 mg daily of duloxetine and 104 to placebo. The two cohorts were similar, with an average age of 73 years, slightly more women than men, and more than three-fourths the population being white. All patients were at least 65 years old and had previous episodes of depression.

Similar proportions of patients withdrew because of adverse events. The most common in the duloxetine group were dry mouth, nausea, and constipation.

Duloxetine produced faster and more significant reductions than placebo on the Geriatric Depression Scale (GDS) and the Hamilton Rating Scale for Depression (HAMD 17). On average, the GDS fell 4.07 in patients on duloxetine vs. 1.34 in the placebo cohort. HAMD 17 scores declined 6.49 with duloxetine and 3.72 with placebo.

The duloxetine cohort demonstrated significantly greater improvement in a composite score based on four cognitive tests: a mean change of +1.95 vs. +0.76 for the placebo group.

At baseline, the mean composite cognitive scores were 22.70 for the duloxetine group and 23.17 for the placebo group. Most of the improvement could be due to changes in scores on verbal learning and recall tests.

Visual analog scale scores for all 311 patients in the trial demonstrated greater improvement in back pain and “time in pain while awake” for the duloxetine cohort. In a subgroup analysis limited to patients with comorbid arthritis, 117 patients on duloxetine had significantly greater improvement in four of six pain measures, compared with 55 placebo patient scores.

At the outset, all patients with arthritis had significantly higher baseline scores on five of six pain categories assessed with visual analog scales. Overall severity was 38.3 for patients with arthritis vs. 22.5 in patients who did not have arthritis.

Arthritis patients in the duloxetine cohort had greater improvements in overall pain, back pain, time in pain while awake, and interference with daily activities. Arthritis patients in the placebo group had more headache and shoulder pain; the difference was not significant.

The mean change in overall pain scores was −6.70 for arthritis patients on duloxetine vs. −1.89 for arthritis patients on placebo. The most dramatic effect was for back pain, which fell by a mean of more than 20% with duloxetine while increasing more than 10% with placebo.

“We don't know if this is their pain due to arthritis or their pain due to depression,” Dr. Robinson said. “This is just looking at general pain outcomes.”

Baseline scores for depression and improvements in mood were similar for arthritis patients in the two arms of the trial.

In another poster at the meeting, analysis of pooled data from seven randomized, multicenter, double-blind trials of duloxetine showed symptom improvement to be similar for white, Hispanic, and African American patients. Dr. John M. Plewes of Eli Lilly was the principal investigator.

SANTA ANA PUEBLO, N.M. — Elderly people with depression and arthritis experienced significant pain relief with duloxetine in a placebo-controlled trial reported at the annual meeting of the Academy of Psychosomatic Medicine.

Conducted by investigators from Eli Lilly & Co., the research findings also documented significant improvement in cognitive functions, primarily verbal learning and memory, for depressed patients treated with duloxetine (Cymbalta) in the 8-week, multicenter study.

“I think (these findings are) very encouraging,” investigator Dr. Michael J. Robinson, a clinical research physician at Lilly's medical division in Indianapolis, said in an interview. “Duloxetine may be advantageous for those specific cognitive symptoms.”

The results suggest duloxetine can alleviate arthritis pain, a common comorbidity in depressed elderly patients. An inhibitor of serotonin and norepinephrine reuptake, duloxetine is known to have analgesic properties and is approved for treatment of peripheral neuropathic pain in patients with diabetes.

Cognition was a primary outcome in the trial, which randomized 207 depressed elderly patients to 60 mg daily of duloxetine and 104 to placebo. The two cohorts were similar, with an average age of 73 years, slightly more women than men, and more than three-fourths the population being white. All patients were at least 65 years old and had previous episodes of depression.

Similar proportions of patients withdrew because of adverse events. The most common in the duloxetine group were dry mouth, nausea, and constipation.

Duloxetine produced faster and more significant reductions than placebo on the Geriatric Depression Scale (GDS) and the Hamilton Rating Scale for Depression (HAMD 17). On average, the GDS fell 4.07 in patients on duloxetine vs. 1.34 in the placebo cohort. HAMD 17 scores declined 6.49 with duloxetine and 3.72 with placebo.

The duloxetine cohort demonstrated significantly greater improvement in a composite score based on four cognitive tests: a mean change of +1.95 vs. +0.76 for the placebo group.

At baseline, the mean composite cognitive scores were 22.70 for the duloxetine group and 23.17 for the placebo group. Most of the improvement could be due to changes in scores on verbal learning and recall tests.

Visual analog scale scores for all 311 patients in the trial demonstrated greater improvement in back pain and “time in pain while awake” for the duloxetine cohort. In a subgroup analysis limited to patients with comorbid arthritis, 117 patients on duloxetine had significantly greater improvement in four of six pain measures, compared with 55 placebo patient scores.

At the outset, all patients with arthritis had significantly higher baseline scores on five of six pain categories assessed with visual analog scales. Overall severity was 38.3 for patients with arthritis vs. 22.5 in patients who did not have arthritis.

Arthritis patients in the duloxetine cohort had greater improvements in overall pain, back pain, time in pain while awake, and interference with daily activities. Arthritis patients in the placebo group had more headache and shoulder pain; the difference was not significant.

The mean change in overall pain scores was −6.70 for arthritis patients on duloxetine vs. −1.89 for arthritis patients on placebo. The most dramatic effect was for back pain, which fell by a mean of more than 20% with duloxetine while increasing more than 10% with placebo.

“We don't know if this is their pain due to arthritis or their pain due to depression,” Dr. Robinson said. “This is just looking at general pain outcomes.”

Baseline scores for depression and improvements in mood were similar for arthritis patients in the two arms of the trial.

In another poster at the meeting, analysis of pooled data from seven randomized, multicenter, double-blind trials of duloxetine showed symptom improvement to be similar for white, Hispanic, and African American patients. Dr. John M. Plewes of Eli Lilly was the principal investigator.

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other errors were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8, compared with 2.5–7.2 for women who did not have these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data when making estimates.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network recently opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter laceration at vaginal delivery with women who underwent cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial.

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other errors were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8, compared with 2.5–7.2 for women who did not have these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data when making estimates.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network recently opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter laceration at vaginal delivery with women who underwent cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial.

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other errors were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8, compared with 2.5–7.2 for women who did not have these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data when making estimates.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network recently opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter laceration at vaginal delivery with women who underwent cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial.

NICE, FRANCE — When pulmonary embolism is suspected, clinicians also should be looking for thromboembolic disease in the venous system, Dr. Christian J. Herold said at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

“In my experience, there is limited awareness regarding the role of the lower extremity venous system as the prime source of pulmonary embolism,” said Dr. Herold, a radiologist at the University of Vienna Medical Center. Pulmonary embolism and deep venous thrombosis are components of the same thromboembolic disease complex, Dr. Herold stressed. He said as many as 70% of patients with proven pulmonary embolism also have proximal deep vein thrombosis.

Dr. Herold said the probability of pulmonary embolism should be assessed for every patient where the condition is suspected. Imaging studies must be done in every patient with a moderate to high probability of pulmonary embolism.

“Diagnosis is very important because mortality is very high in undiagnosed and untreated patients,” he warned, putting the death rate in these patients at 10%–30% and emphasizing that the first week can be critical. “Unfortunately … many patients go unrecognized.”

Clinicians at his institution last year examined 4,250 patients for venous thromboembolic disease, he reported. The process relies heavily on CT and an easy to follow algorithm that is taught to medical residents at the hospital.

He said alternative diagnoses should be considered since ruling out pulmonary embolism does not mean the patient is disease free. In one study, he noted, 70% of patients with suspicion of pulmonary embolism did not have pulmonary embolism.

“Many had alternative diagnoses, and CT provides you this information,” Dr. Herold advised, adding that “CT has evolved into an unofficial gold standard for analyzing pulmonary arteries.” He urged that CT angiography and CT venography both be used when venous disease is suspected. “There is information in the body that you can retrieve using the same examination, the same bolus,” he said.

His group does CT venography 3 minutes after the pulmonary artery exam. “We prefer to do discontinuous slices with 3− to 4-cm gaps,” he said. “In my experience we don't miss clots with this technique.”

According to the medical literature, he added, CT venography has a sensitivity of 95%–100% and specificity of 97%–100%. He said studies in more than 5,300 patients have shown CT angiography to have a negative predictive value of 99%–100%, and that, therefore, it can be used to rule out the need for treatment.

He cautioned, however, that some patients are exceptions to the rule. “All those guidelines and rules do not really account for 100% of patients. You may have individualized exceptions. And each patient has to be treated as an individual,” Dr. Herold advised.

Embolism Diagnosis: Keep It Simple

Many combinations of tests have been promoted as ideal algorithms for diagnosing pulmonary embolisms, Dr. Herold said.

Most are too complex. He urged institutions to develop their own simple approaches. As an example, he offered these guidelines:

▸ All patients with intermediate or high clinical probability (independent from any other clinical or laboratory result) must be imaged.

▸ Clinical symptoms determine the region to be imaged.

▸ No further imaging is required to institute treatment in a patient whose primary examination is positive.

▸ If the patient has a moderate or high clinical probability for pulmonary embolism and the primary imaging exam is negative, assess the complementary region with CT angiography, CT venography, and ultrasound.

▸ If the patient has a low clinical probability of pulmonary embolism, D-dimer tests can help determine whether imaging is necessary.

Dr. Herold noted that most algorithms involve CT angiography, D-dimer testing, and ultrasound; lung ventilation-perfusion scanning and pulmonary angiography are rarely used.

NICE, FRANCE — When pulmonary embolism is suspected, clinicians also should be looking for thromboembolic disease in the venous system, Dr. Christian J. Herold said at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

“In my experience, there is limited awareness regarding the role of the lower extremity venous system as the prime source of pulmonary embolism,” said Dr. Herold, a radiologist at the University of Vienna Medical Center. Pulmonary embolism and deep venous thrombosis are components of the same thromboembolic disease complex, Dr. Herold stressed. He said as many as 70% of patients with proven pulmonary embolism also have proximal deep vein thrombosis.

Dr. Herold said the probability of pulmonary embolism should be assessed for every patient where the condition is suspected. Imaging studies must be done in every patient with a moderate to high probability of pulmonary embolism.

“Diagnosis is very important because mortality is very high in undiagnosed and untreated patients,” he warned, putting the death rate in these patients at 10%–30% and emphasizing that the first week can be critical. “Unfortunately … many patients go unrecognized.”

Clinicians at his institution last year examined 4,250 patients for venous thromboembolic disease, he reported. The process relies heavily on CT and an easy to follow algorithm that is taught to medical residents at the hospital.

He said alternative diagnoses should be considered since ruling out pulmonary embolism does not mean the patient is disease free. In one study, he noted, 70% of patients with suspicion of pulmonary embolism did not have pulmonary embolism.

“Many had alternative diagnoses, and CT provides you this information,” Dr. Herold advised, adding that “CT has evolved into an unofficial gold standard for analyzing pulmonary arteries.” He urged that CT angiography and CT venography both be used when venous disease is suspected. “There is information in the body that you can retrieve using the same examination, the same bolus,” he said.

His group does CT venography 3 minutes after the pulmonary artery exam. “We prefer to do discontinuous slices with 3− to 4-cm gaps,” he said. “In my experience we don't miss clots with this technique.”

According to the medical literature, he added, CT venography has a sensitivity of 95%–100% and specificity of 97%–100%. He said studies in more than 5,300 patients have shown CT angiography to have a negative predictive value of 99%–100%, and that, therefore, it can be used to rule out the need for treatment.

He cautioned, however, that some patients are exceptions to the rule. “All those guidelines and rules do not really account for 100% of patients. You may have individualized exceptions. And each patient has to be treated as an individual,” Dr. Herold advised.

Embolism Diagnosis: Keep It Simple

Many combinations of tests have been promoted as ideal algorithms for diagnosing pulmonary embolisms, Dr. Herold said.

Most are too complex. He urged institutions to develop their own simple approaches. As an example, he offered these guidelines:

▸ All patients with intermediate or high clinical probability (independent from any other clinical or laboratory result) must be imaged.

▸ Clinical symptoms determine the region to be imaged.

▸ No further imaging is required to institute treatment in a patient whose primary examination is positive.

▸ If the patient has a moderate or high clinical probability for pulmonary embolism and the primary imaging exam is negative, assess the complementary region with CT angiography, CT venography, and ultrasound.

▸ If the patient has a low clinical probability of pulmonary embolism, D-dimer tests can help determine whether imaging is necessary.

Dr. Herold noted that most algorithms involve CT angiography, D-dimer testing, and ultrasound; lung ventilation-perfusion scanning and pulmonary angiography are rarely used.

NICE, FRANCE — When pulmonary embolism is suspected, clinicians also should be looking for thromboembolic disease in the venous system, Dr. Christian J. Herold said at the annual meeting of the Cardiovascular and Interventional Radiological Society of Europe.

“In my experience, there is limited awareness regarding the role of the lower extremity venous system as the prime source of pulmonary embolism,” said Dr. Herold, a radiologist at the University of Vienna Medical Center. Pulmonary embolism and deep venous thrombosis are components of the same thromboembolic disease complex, Dr. Herold stressed. He said as many as 70% of patients with proven pulmonary embolism also have proximal deep vein thrombosis.

Dr. Herold said the probability of pulmonary embolism should be assessed for every patient where the condition is suspected. Imaging studies must be done in every patient with a moderate to high probability of pulmonary embolism.

“Diagnosis is very important because mortality is very high in undiagnosed and untreated patients,” he warned, putting the death rate in these patients at 10%–30% and emphasizing that the first week can be critical. “Unfortunately … many patients go unrecognized.”

Clinicians at his institution last year examined 4,250 patients for venous thromboembolic disease, he reported. The process relies heavily on CT and an easy to follow algorithm that is taught to medical residents at the hospital.

He said alternative diagnoses should be considered since ruling out pulmonary embolism does not mean the patient is disease free. In one study, he noted, 70% of patients with suspicion of pulmonary embolism did not have pulmonary embolism.

“Many had alternative diagnoses, and CT provides you this information,” Dr. Herold advised, adding that “CT has evolved into an unofficial gold standard for analyzing pulmonary arteries.” He urged that CT angiography and CT venography both be used when venous disease is suspected. “There is information in the body that you can retrieve using the same examination, the same bolus,” he said.

His group does CT venography 3 minutes after the pulmonary artery exam. “We prefer to do discontinuous slices with 3− to 4-cm gaps,” he said. “In my experience we don't miss clots with this technique.”

According to the medical literature, he added, CT venography has a sensitivity of 95%–100% and specificity of 97%–100%. He said studies in more than 5,300 patients have shown CT angiography to have a negative predictive value of 99%–100%, and that, therefore, it can be used to rule out the need for treatment.

He cautioned, however, that some patients are exceptions to the rule. “All those guidelines and rules do not really account for 100% of patients. You may have individualized exceptions. And each patient has to be treated as an individual,” Dr. Herold advised.

Embolism Diagnosis: Keep It Simple

Many combinations of tests have been promoted as ideal algorithms for diagnosing pulmonary embolisms, Dr. Herold said.

Most are too complex. He urged institutions to develop their own simple approaches. As an example, he offered these guidelines:

▸ All patients with intermediate or high clinical probability (independent from any other clinical or laboratory result) must be imaged.

▸ Clinical symptoms determine the region to be imaged.

▸ No further imaging is required to institute treatment in a patient whose primary examination is positive.

▸ If the patient has a moderate or high clinical probability for pulmonary embolism and the primary imaging exam is negative, assess the complementary region with CT angiography, CT venography, and ultrasound.

▸ If the patient has a low clinical probability of pulmonary embolism, D-dimer tests can help determine whether imaging is necessary.

Dr. Herold noted that most algorithms involve CT angiography, D-dimer testing, and ultrasound; lung ventilation-perfusion scanning and pulmonary angiography are rarely used.