Kerri Wachter

Dr. Meng Law of the departments of radiology and neurosurgery at Mount Sinai Medical Center in New York and his colleagues have been investigating the use of dynamic susceptibility-weighted contrast-enhanced perfusion MRI to gather physiologic information about vascular endothelial proliferation, vascular density, and angiogenesis. In particular, they hypothesized that this technique can provide a means of characterizing tumor biology and predicting tumor progression. They retrospectively evaluated whether relative cerebral blood volume (CBV) measurements could be used to predict clinical outcomes in patients with malignant high-grade gliomas and low-grade gliomas. Specifically, they looked at whether patients who have gliomas with high initial relative CBV have more rapid progression than do those who have gliomas with low relative CBV.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI takes advantage of signal changes that take place with the passage of paramagnetic contrast agents—such as gadopentetate dimeglumine—through the cerebrovasculature. Dynamic susceptibility-weighted contrast-enhanced perfusion MRI results in a drop in signal intensity due to the susceptibility of the gadolinium that is proportional to the blood volume.

The technique “can be utilized and translated to the clinic pretty readily and that really provides us with a new way to predict tumor biology—one that is much needed, given the limitations that we have” with current classification systems, said Dr. Law.

The study included 189 patients (65% male, mean age 43) with pathologically proved gliomas, using the World Health Organization four-tier classification of gliomas (Radiology 2008;247:490–8). Patients were referred for preoperative assessment of intracranial tumors. They could not have any evidence of systemic malignancy or immune status compromise. In all, 28 patients had low-grade fibrillary astrocytomas (WHO II), 11 had low-grade oligoastrocytomas (WHO II), 14 had low-grade oligodendrogliomas (WHO II), 72 had anaplastic astrocytomas (WHO III), 12 had anaplastic oligoastrocytomas (WHO III), and 52 had glioblastoma multiforme (WHO IV).

Patients were followed up a median of 334 days and assessed clinically and with MRI—1.5 T conventional, single-dimension measurements of contrast-enhanced T1 enhancement and T2 signal hyperintensity (for tumor size), and serial relative CBV measurements.

Each patient was assigned to one of four response categories, based on clinical chart review and MR findings: complete response (4 patients), stable disease (41 patients), progressive disease (130 patients), and death (14 patients). Complete response was defined as no visible tumor on MRI and no new neurologic deficit. Stable disease was defined as no change in the patient's neurologic examination results and Karnofsky score, and less than 25% change in tumor size on MRI. Progressive disease was defined as a decline in neurologic status and Karnofsky score, or an increase in tumor size of more than 25% on MRI. Patients were assessed at 3-month intervals by their neuro-oncologist. MRIs were performed at the same time.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI does not give an absolute measure of CBV. Instead, CBV in the area of interest is expressed as a ratio relative to the CBV measured in standard tissue—typically normal contralateral white or gray matter. The researchers developed color overlay maps of relative CBV. Regions of interest were placed in regions of greatest perfusion on the color overlay maps for each patient. A constant radius of 3.6 mm was used for all regions of interest. Four separate CBV measurements were made in these regions of interest and the maximal value was recorded.

The researchers calculated means, standard deviations, and medians of relative CBV measurements in the regions of interest for all patients in a clinical response category. Mean relative CBV values were 1.41, 2.36, 4.84, and 3.82 for the complete response, stable disease, progressive disease, and death groups, respectively.

Patients were also classified in groups with low or high relative CBV, using a threshold of 1.75. Dr. Law and his colleagues previously identified this threshold value to provide optimal sensitivity and specificity for differentiating low-grade gliomas from high-grade gliomas in a study of 160 patients (Am. J. Neuroradiol. 2003;24:1989–98).

Median time to progression for patients with relative CBV values less than 1.75 was 3,585 days. In comparison, median time to progression for patients with relative CBV values greater than 1.75 was 265 days, regardless of histopathologic tumor type. Use of the 1.75 threshold was significantly associated with time to progression among all patients, with or without adjustment for pathologic status. Age and relative CBV—but not gender—were significant predictors of disease progression and death, based on binary logistic regression. However, using the 1.75 CBV threshold was not significantly associated with survival.

The relative CBV measurement might provide an important imaging biomarker of glioma malignancy that could potentially affect therapeutic choices.

Glioma seen on conventional MRI (arrow) did not progress with time, indicated by susceptibility-weighted contrast-enhanced perfusion MR images (color slices). Courtesy Dr. Meng Law

Dr. Meng Law of the departments of radiology and neurosurgery at Mount Sinai Medical Center in New York and his colleagues have been investigating the use of dynamic susceptibility-weighted contrast-enhanced perfusion MRI to gather physiologic information about vascular endothelial proliferation, vascular density, and angiogenesis. In particular, they hypothesized that this technique can provide a means of characterizing tumor biology and predicting tumor progression. They retrospectively evaluated whether relative cerebral blood volume (CBV) measurements could be used to predict clinical outcomes in patients with malignant high-grade gliomas and low-grade gliomas. Specifically, they looked at whether patients who have gliomas with high initial relative CBV have more rapid progression than do those who have gliomas with low relative CBV.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI takes advantage of signal changes that take place with the passage of paramagnetic contrast agents—such as gadopentetate dimeglumine—through the cerebrovasculature. Dynamic susceptibility-weighted contrast-enhanced perfusion MRI results in a drop in signal intensity due to the susceptibility of the gadolinium that is proportional to the blood volume.

The technique “can be utilized and translated to the clinic pretty readily and that really provides us with a new way to predict tumor biology—one that is much needed, given the limitations that we have” with current classification systems, said Dr. Law.

The study included 189 patients (65% male, mean age 43) with pathologically proved gliomas, using the World Health Organization four-tier classification of gliomas (Radiology 2008;247:490–8). Patients were referred for preoperative assessment of intracranial tumors. They could not have any evidence of systemic malignancy or immune status compromise. In all, 28 patients had low-grade fibrillary astrocytomas (WHO II), 11 had low-grade oligoastrocytomas (WHO II), 14 had low-grade oligodendrogliomas (WHO II), 72 had anaplastic astrocytomas (WHO III), 12 had anaplastic oligoastrocytomas (WHO III), and 52 had glioblastoma multiforme (WHO IV).

Patients were followed up a median of 334 days and assessed clinically and with MRI—1.5 T conventional, single-dimension measurements of contrast-enhanced T1 enhancement and T2 signal hyperintensity (for tumor size), and serial relative CBV measurements.

Each patient was assigned to one of four response categories, based on clinical chart review and MR findings: complete response (4 patients), stable disease (41 patients), progressive disease (130 patients), and death (14 patients). Complete response was defined as no visible tumor on MRI and no new neurologic deficit. Stable disease was defined as no change in the patient's neurologic examination results and Karnofsky score, and less than 25% change in tumor size on MRI. Progressive disease was defined as a decline in neurologic status and Karnofsky score, or an increase in tumor size of more than 25% on MRI. Patients were assessed at 3-month intervals by their neuro-oncologist. MRIs were performed at the same time.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI does not give an absolute measure of CBV. Instead, CBV in the area of interest is expressed as a ratio relative to the CBV measured in standard tissue—typically normal contralateral white or gray matter. The researchers developed color overlay maps of relative CBV. Regions of interest were placed in regions of greatest perfusion on the color overlay maps for each patient. A constant radius of 3.6 mm was used for all regions of interest. Four separate CBV measurements were made in these regions of interest and the maximal value was recorded.

The researchers calculated means, standard deviations, and medians of relative CBV measurements in the regions of interest for all patients in a clinical response category. Mean relative CBV values were 1.41, 2.36, 4.84, and 3.82 for the complete response, stable disease, progressive disease, and death groups, respectively.

Patients were also classified in groups with low or high relative CBV, using a threshold of 1.75. Dr. Law and his colleagues previously identified this threshold value to provide optimal sensitivity and specificity for differentiating low-grade gliomas from high-grade gliomas in a study of 160 patients (Am. J. Neuroradiol. 2003;24:1989–98).

Median time to progression for patients with relative CBV values less than 1.75 was 3,585 days. In comparison, median time to progression for patients with relative CBV values greater than 1.75 was 265 days, regardless of histopathologic tumor type. Use of the 1.75 threshold was significantly associated with time to progression among all patients, with or without adjustment for pathologic status. Age and relative CBV—but not gender—were significant predictors of disease progression and death, based on binary logistic regression. However, using the 1.75 CBV threshold was not significantly associated with survival.

The relative CBV measurement might provide an important imaging biomarker of glioma malignancy that could potentially affect therapeutic choices.

Glioma seen on conventional MRI (arrow) did not progress with time, indicated by susceptibility-weighted contrast-enhanced perfusion MR images (color slices). Courtesy Dr. Meng Law

Dr. Meng Law of the departments of radiology and neurosurgery at Mount Sinai Medical Center in New York and his colleagues have been investigating the use of dynamic susceptibility-weighted contrast-enhanced perfusion MRI to gather physiologic information about vascular endothelial proliferation, vascular density, and angiogenesis. In particular, they hypothesized that this technique can provide a means of characterizing tumor biology and predicting tumor progression. They retrospectively evaluated whether relative cerebral blood volume (CBV) measurements could be used to predict clinical outcomes in patients with malignant high-grade gliomas and low-grade gliomas. Specifically, they looked at whether patients who have gliomas with high initial relative CBV have more rapid progression than do those who have gliomas with low relative CBV.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI takes advantage of signal changes that take place with the passage of paramagnetic contrast agents—such as gadopentetate dimeglumine—through the cerebrovasculature. Dynamic susceptibility-weighted contrast-enhanced perfusion MRI results in a drop in signal intensity due to the susceptibility of the gadolinium that is proportional to the blood volume.

The technique “can be utilized and translated to the clinic pretty readily and that really provides us with a new way to predict tumor biology—one that is much needed, given the limitations that we have” with current classification systems, said Dr. Law.

The study included 189 patients (65% male, mean age 43) with pathologically proved gliomas, using the World Health Organization four-tier classification of gliomas (Radiology 2008;247:490–8). Patients were referred for preoperative assessment of intracranial tumors. They could not have any evidence of systemic malignancy or immune status compromise. In all, 28 patients had low-grade fibrillary astrocytomas (WHO II), 11 had low-grade oligoastrocytomas (WHO II), 14 had low-grade oligodendrogliomas (WHO II), 72 had anaplastic astrocytomas (WHO III), 12 had anaplastic oligoastrocytomas (WHO III), and 52 had glioblastoma multiforme (WHO IV).

Patients were followed up a median of 334 days and assessed clinically and with MRI—1.5 T conventional, single-dimension measurements of contrast-enhanced T1 enhancement and T2 signal hyperintensity (for tumor size), and serial relative CBV measurements.

Each patient was assigned to one of four response categories, based on clinical chart review and MR findings: complete response (4 patients), stable disease (41 patients), progressive disease (130 patients), and death (14 patients). Complete response was defined as no visible tumor on MRI and no new neurologic deficit. Stable disease was defined as no change in the patient's neurologic examination results and Karnofsky score, and less than 25% change in tumor size on MRI. Progressive disease was defined as a decline in neurologic status and Karnofsky score, or an increase in tumor size of more than 25% on MRI. Patients were assessed at 3-month intervals by their neuro-oncologist. MRIs were performed at the same time.

Dynamic susceptibility-weighted contrast-enhanced perfusion MRI does not give an absolute measure of CBV. Instead, CBV in the area of interest is expressed as a ratio relative to the CBV measured in standard tissue—typically normal contralateral white or gray matter. The researchers developed color overlay maps of relative CBV. Regions of interest were placed in regions of greatest perfusion on the color overlay maps for each patient. A constant radius of 3.6 mm was used for all regions of interest. Four separate CBV measurements were made in these regions of interest and the maximal value was recorded.

The researchers calculated means, standard deviations, and medians of relative CBV measurements in the regions of interest for all patients in a clinical response category. Mean relative CBV values were 1.41, 2.36, 4.84, and 3.82 for the complete response, stable disease, progressive disease, and death groups, respectively.

Patients were also classified in groups with low or high relative CBV, using a threshold of 1.75. Dr. Law and his colleagues previously identified this threshold value to provide optimal sensitivity and specificity for differentiating low-grade gliomas from high-grade gliomas in a study of 160 patients (Am. J. Neuroradiol. 2003;24:1989–98).

Median time to progression for patients with relative CBV values less than 1.75 was 3,585 days. In comparison, median time to progression for patients with relative CBV values greater than 1.75 was 265 days, regardless of histopathologic tumor type. Use of the 1.75 threshold was significantly associated with time to progression among all patients, with or without adjustment for pathologic status. Age and relative CBV—but not gender—were significant predictors of disease progression and death, based on binary logistic regression. However, using the 1.75 CBV threshold was not significantly associated with survival.

The relative CBV measurement might provide an important imaging biomarker of glioma malignancy that could potentially affect therapeutic choices.

Glioma seen on conventional MRI (arrow) did not progress with time, indicated by susceptibility-weighted contrast-enhanced perfusion MR images (color slices). Courtesy Dr. Meng Law

BALTIMORE — Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, according to a study involving almost 11,000 children.

The findings, which were presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group.

In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said. The data provide evidence that “there are eating behavior traits that have long been implicated in obesity that show a gradient association with weight.”

Dr. Wardle suggested that individuals with higher-risk eating behavior traits—less sensitivity to satiety signals and greater response to external food cues—are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

BALTIMORE — Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, according to a study involving almost 11,000 children.

The findings, which were presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group.

In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said. The data provide evidence that “there are eating behavior traits that have long been implicated in obesity that show a gradient association with weight.”

Dr. Wardle suggested that individuals with higher-risk eating behavior traits—less sensitivity to satiety signals and greater response to external food cues—are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

BALTIMORE — Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, according to a study involving almost 11,000 children.

The findings, which were presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group.

In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said. The data provide evidence that “there are eating behavior traits that have long been implicated in obesity that show a gradient association with weight.”

Dr. Wardle suggested that individuals with higher-risk eating behavior traits—less sensitivity to satiety signals and greater response to external food cues—are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

PHILADELPHIA — Testing for hemoglobin A_1c could be an effective means of screening children not only for type 2 diabetes but also for impaired glucose tolerance, according to the results of a study of 74 children.

“Type 2 diabetes was effectively excluded by hemoglobin A_1c [HbA_1c] below 6.0%,” said Dr. Alisa Schiffman of Children's Hospital of Philadelphia. Using this cut-off, HbA_1c was 100% sensitive and 80% specific in identifying children with type 2 diabetes.

In its 2008 position statement on the standards of medical care in diabetes, the American Diabetes Association stated that the fasting plasma glucose test is the preferred means to diagnose diabetes in children and nonpregnant adults. The use of the HbA_1c level for the diagnosis of diabetes is not recommended at this time (Diabetes Care 2008;31:S12–54).

However, “oral glucose tolerance tests and fasting plasma glucose have logistical challenges in children” because of the overnight fasting requirement and multiple blood draws, Dr. Schiffman said at the annual meeting of the Eastern Society for Pediatric Research. HbA_1c testing can be performed with just a finger stick at any time of day regardless of fasting status.

The researchers performed a retrospective chart review of 74 children (mean age 12 years) who were referred for the evaluation of type 2 diabetes. The children were assigned to one of three groups based on their fasting plasma glucose level and 2-hour plasma glucose level.

There was a significant trend for increasing HbA_1c along the continuum from normal glucose tolerance to type 2 diabetes. Mean HbA_1c was 5.4% for those with normal glucose tolerance, 6.1% for those with impaired glucose tolerance, and 6.8% for those with type 2 diabetes. A threshold HbA_1c of 5.7% was 91% sensitive and 80% specific in identifying children with abnormal glucose tolerance.

“Hemoglobin A_1c can be used to screen for type 2 diabetes and even impaired glucose tolerance [in children],” said Dr. Schiffman.

Likewise, there was a significant trend for decreasing mean β-cell function along the continuum from normal glucose tolerance to impaired glucose tolerance to type 2 diabetes.

There were no significant differences between the groups in terms of gender, age, race, or body mass index. HbA_1c was adjusted for age, gender, ethnicity, and body mass index.

PHILADELPHIA — Testing for hemoglobin A_1c could be an effective means of screening children not only for type 2 diabetes but also for impaired glucose tolerance, according to the results of a study of 74 children.

“Type 2 diabetes was effectively excluded by hemoglobin A_1c [HbA_1c] below 6.0%,” said Dr. Alisa Schiffman of Children's Hospital of Philadelphia. Using this cut-off, HbA_1c was 100% sensitive and 80% specific in identifying children with type 2 diabetes.

In its 2008 position statement on the standards of medical care in diabetes, the American Diabetes Association stated that the fasting plasma glucose test is the preferred means to diagnose diabetes in children and nonpregnant adults. The use of the HbA_1c level for the diagnosis of diabetes is not recommended at this time (Diabetes Care 2008;31:S12–54).

However, “oral glucose tolerance tests and fasting plasma glucose have logistical challenges in children” because of the overnight fasting requirement and multiple blood draws, Dr. Schiffman said at the annual meeting of the Eastern Society for Pediatric Research. HbA_1c testing can be performed with just a finger stick at any time of day regardless of fasting status.

The researchers performed a retrospective chart review of 74 children (mean age 12 years) who were referred for the evaluation of type 2 diabetes. The children were assigned to one of three groups based on their fasting plasma glucose level and 2-hour plasma glucose level.

There was a significant trend for increasing HbA_1c along the continuum from normal glucose tolerance to type 2 diabetes. Mean HbA_1c was 5.4% for those with normal glucose tolerance, 6.1% for those with impaired glucose tolerance, and 6.8% for those with type 2 diabetes. A threshold HbA_1c of 5.7% was 91% sensitive and 80% specific in identifying children with abnormal glucose tolerance.

“Hemoglobin A_1c can be used to screen for type 2 diabetes and even impaired glucose tolerance [in children],” said Dr. Schiffman.

Likewise, there was a significant trend for decreasing mean β-cell function along the continuum from normal glucose tolerance to impaired glucose tolerance to type 2 diabetes.

There were no significant differences between the groups in terms of gender, age, race, or body mass index. HbA_1c was adjusted for age, gender, ethnicity, and body mass index.

PHILADELPHIA — Testing for hemoglobin A_1c could be an effective means of screening children not only for type 2 diabetes but also for impaired glucose tolerance, according to the results of a study of 74 children.

“Type 2 diabetes was effectively excluded by hemoglobin A_1c [HbA_1c] below 6.0%,” said Dr. Alisa Schiffman of Children's Hospital of Philadelphia. Using this cut-off, HbA_1c was 100% sensitive and 80% specific in identifying children with type 2 diabetes.

In its 2008 position statement on the standards of medical care in diabetes, the American Diabetes Association stated that the fasting plasma glucose test is the preferred means to diagnose diabetes in children and nonpregnant adults. The use of the HbA_1c level for the diagnosis of diabetes is not recommended at this time (Diabetes Care 2008;31:S12–54).

However, “oral glucose tolerance tests and fasting plasma glucose have logistical challenges in children” because of the overnight fasting requirement and multiple blood draws, Dr. Schiffman said at the annual meeting of the Eastern Society for Pediatric Research. HbA_1c testing can be performed with just a finger stick at any time of day regardless of fasting status.

The researchers performed a retrospective chart review of 74 children (mean age 12 years) who were referred for the evaluation of type 2 diabetes. The children were assigned to one of three groups based on their fasting plasma glucose level and 2-hour plasma glucose level.

There was a significant trend for increasing HbA_1c along the continuum from normal glucose tolerance to type 2 diabetes. Mean HbA_1c was 5.4% for those with normal glucose tolerance, 6.1% for those with impaired glucose tolerance, and 6.8% for those with type 2 diabetes. A threshold HbA_1c of 5.7% was 91% sensitive and 80% specific in identifying children with abnormal glucose tolerance.

“Hemoglobin A_1c can be used to screen for type 2 diabetes and even impaired glucose tolerance [in children],” said Dr. Schiffman.

Likewise, there was a significant trend for decreasing mean β-cell function along the continuum from normal glucose tolerance to impaired glucose tolerance to type 2 diabetes.

There were no significant differences between the groups in terms of gender, age, race, or body mass index. HbA_1c was adjusted for age, gender, ethnicity, and body mass index.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008;117:1478–97).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique. Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those found in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was deemed appropriate if the expected incremental information, combined with clinical judgement, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” they wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed for definitive classification.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008;117:1478–97).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique. Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those found in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was deemed appropriate if the expected incremental information, combined with clinical judgement, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” they wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed for definitive classification.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008;117:1478–97).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique. Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those found in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was deemed appropriate if the expected incremental information, combined with clinical judgement, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” they wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed for definitive classification.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

BALTIMORE – African American women with high levels of hostility show increased levels of fasting glucose. In addition, patients' proportion of trunk fat appears to play a role in the association between hostility and glucose metabolism, results from two posters presented at the annual meeting of the American Psychosomatic Society show.

In the first poster, Anastasia Georgiades, Ph.D., a research associate in the department of psychiatry and behavioral science at Duke University, Durham, N.C., and her colleagues recruited 400 healthy, nondiabetic individuals–101 African American women, 118 white women, 82 African American men, and 99 white men. Mean age was 33 years. Hostility was measured using the 27-item Cook Medley hostility questionnaire. Fasting and postprandial glucose and insulin levels were measured with an oral glucose tolerance test.

General linear modeling showed that African American women had consistent positive associations between hostility and fasting glucose, postprandial glucose, and postprandial insulin. In contrast, African American men showed negative associations. Stratified correlation analysis revealed that only African American women showed a significant positive association between hostility and fasting glucose.

The results indicate that hostility may have a greater impact on glucose metabolism in African American women, which could help explain racial and gender-based health disparities.

The second poster study built on these results, showing a consistent hostility/glucose metabolism association among African American women. Dr. Georgiades and her colleagues hypothesized that this relationship might be mediated by trunk fat, given that abdominal fat has been associated with both fasting glucose levels and insulin resistance.

For the study, the researchers recruited 44 African American and 77 white nondiabetic women. The women had either high (greater than 12) or low (less than 9) scores on the 27-item Cook Medley hostility questionnaire. The women underwent several assessments, including an oral fasting glucose tolerance test and dual-energy x-ray absorptiometry (DXA) scan. The researchers included DXA scans because body mass index is a rather imprecise measure of body fat and does not take into account the distribution of body fat. DXA technology gives a highly accurate estimate of percent body fat, and its distribution, Dr. Georgiades said in an interview.

After the researchers controlled for age and race, hostility was significantly associated with greater fasting glucose levels and greater percentage trunk fat but not BMI or fasting insulin for the entire cohort. The association between hostility and fasting glucose was significant for African American women and white women. No significant association was found between race and hostility with respect to fasting glucose. However, there was a significant interaction between race and trunk fat with respect to fasting glucose. In other words, there was a significant correlation between fasting glucose and trunk fat in African American women but not in white women.

“It was clear that the African American women had higher percentage of trunk fat as compared to the [white] women, and that the association between trunk fat and fasting glucose was very strong in African American women, but was not evident in the [white] women,” Dr. Georgiades said.

Controlling for trunk fat reduced the association between hostility and fasting glucose in African American women. A formal test of mediation revealed a significant mediating effect of trunk fat in the association between hostility and fasting glucose among African American women.

“We are not sure exactly why trunk fat mediated the association between hostility and glucose only in African American females. However, a previous study found that African American women have a higher density of β receptor in the fat tissue located around the inner organs as compared to [white] women,” Dr. Georgiades said.

This could potentially make African American women more susceptible to the effects of adrenergic stimulation through stress hormones such as epinephrine and norepinephrine. Epinephrine stimulation of visceral fat tissue has been shown to induce lipolysis, bathing the liver with nonesterified fatty acids, and rendering it insulin resistant.

BALTIMORE – African American women with high levels of hostility show increased levels of fasting glucose. In addition, patients' proportion of trunk fat appears to play a role in the association between hostility and glucose metabolism, results from two posters presented at the annual meeting of the American Psychosomatic Society show.

In the first poster, Anastasia Georgiades, Ph.D., a research associate in the department of psychiatry and behavioral science at Duke University, Durham, N.C., and her colleagues recruited 400 healthy, nondiabetic individuals–101 African American women, 118 white women, 82 African American men, and 99 white men. Mean age was 33 years. Hostility was measured using the 27-item Cook Medley hostility questionnaire. Fasting and postprandial glucose and insulin levels were measured with an oral glucose tolerance test.

General linear modeling showed that African American women had consistent positive associations between hostility and fasting glucose, postprandial glucose, and postprandial insulin. In contrast, African American men showed negative associations. Stratified correlation analysis revealed that only African American women showed a significant positive association between hostility and fasting glucose.

The results indicate that hostility may have a greater impact on glucose metabolism in African American women, which could help explain racial and gender-based health disparities.

The second poster study built on these results, showing a consistent hostility/glucose metabolism association among African American women. Dr. Georgiades and her colleagues hypothesized that this relationship might be mediated by trunk fat, given that abdominal fat has been associated with both fasting glucose levels and insulin resistance.

For the study, the researchers recruited 44 African American and 77 white nondiabetic women. The women had either high (greater than 12) or low (less than 9) scores on the 27-item Cook Medley hostility questionnaire. The women underwent several assessments, including an oral fasting glucose tolerance test and dual-energy x-ray absorptiometry (DXA) scan. The researchers included DXA scans because body mass index is a rather imprecise measure of body fat and does not take into account the distribution of body fat. DXA technology gives a highly accurate estimate of percent body fat, and its distribution, Dr. Georgiades said in an interview.

After the researchers controlled for age and race, hostility was significantly associated with greater fasting glucose levels and greater percentage trunk fat but not BMI or fasting insulin for the entire cohort. The association between hostility and fasting glucose was significant for African American women and white women. No significant association was found between race and hostility with respect to fasting glucose. However, there was a significant interaction between race and trunk fat with respect to fasting glucose. In other words, there was a significant correlation between fasting glucose and trunk fat in African American women but not in white women.

“It was clear that the African American women had higher percentage of trunk fat as compared to the [white] women, and that the association between trunk fat and fasting glucose was very strong in African American women, but was not evident in the [white] women,” Dr. Georgiades said.

Controlling for trunk fat reduced the association between hostility and fasting glucose in African American women. A formal test of mediation revealed a significant mediating effect of trunk fat in the association between hostility and fasting glucose among African American women.

“We are not sure exactly why trunk fat mediated the association between hostility and glucose only in African American females. However, a previous study found that African American women have a higher density of β receptor in the fat tissue located around the inner organs as compared to [white] women,” Dr. Georgiades said.

This could potentially make African American women more susceptible to the effects of adrenergic stimulation through stress hormones such as epinephrine and norepinephrine. Epinephrine stimulation of visceral fat tissue has been shown to induce lipolysis, bathing the liver with nonesterified fatty acids, and rendering it insulin resistant.

BALTIMORE – African American women with high levels of hostility show increased levels of fasting glucose. In addition, patients' proportion of trunk fat appears to play a role in the association between hostility and glucose metabolism, results from two posters presented at the annual meeting of the American Psychosomatic Society show.

In the first poster, Anastasia Georgiades, Ph.D., a research associate in the department of psychiatry and behavioral science at Duke University, Durham, N.C., and her colleagues recruited 400 healthy, nondiabetic individuals–101 African American women, 118 white women, 82 African American men, and 99 white men. Mean age was 33 years. Hostility was measured using the 27-item Cook Medley hostility questionnaire. Fasting and postprandial glucose and insulin levels were measured with an oral glucose tolerance test.

General linear modeling showed that African American women had consistent positive associations between hostility and fasting glucose, postprandial glucose, and postprandial insulin. In contrast, African American men showed negative associations. Stratified correlation analysis revealed that only African American women showed a significant positive association between hostility and fasting glucose.

The results indicate that hostility may have a greater impact on glucose metabolism in African American women, which could help explain racial and gender-based health disparities.

The second poster study built on these results, showing a consistent hostility/glucose metabolism association among African American women. Dr. Georgiades and her colleagues hypothesized that this relationship might be mediated by trunk fat, given that abdominal fat has been associated with both fasting glucose levels and insulin resistance.

For the study, the researchers recruited 44 African American and 77 white nondiabetic women. The women had either high (greater than 12) or low (less than 9) scores on the 27-item Cook Medley hostility questionnaire. The women underwent several assessments, including an oral fasting glucose tolerance test and dual-energy x-ray absorptiometry (DXA) scan. The researchers included DXA scans because body mass index is a rather imprecise measure of body fat and does not take into account the distribution of body fat. DXA technology gives a highly accurate estimate of percent body fat, and its distribution, Dr. Georgiades said in an interview.

After the researchers controlled for age and race, hostility was significantly associated with greater fasting glucose levels and greater percentage trunk fat but not BMI or fasting insulin for the entire cohort. The association between hostility and fasting glucose was significant for African American women and white women. No significant association was found between race and hostility with respect to fasting glucose. However, there was a significant interaction between race and trunk fat with respect to fasting glucose. In other words, there was a significant correlation between fasting glucose and trunk fat in African American women but not in white women.

“It was clear that the African American women had higher percentage of trunk fat as compared to the [white] women, and that the association between trunk fat and fasting glucose was very strong in African American women, but was not evident in the [white] women,” Dr. Georgiades said.

Controlling for trunk fat reduced the association between hostility and fasting glucose in African American women. A formal test of mediation revealed a significant mediating effect of trunk fat in the association between hostility and fasting glucose among African American women.

“We are not sure exactly why trunk fat mediated the association between hostility and glucose only in African American females. However, a previous study found that African American women have a higher density of β receptor in the fat tissue located around the inner organs as compared to [white] women,” Dr. Georgiades said.

This could potentially make African American women more susceptible to the effects of adrenergic stimulation through stress hormones such as epinephrine and norepinephrine. Epinephrine stimulation of visceral fat tissue has been shown to induce lipolysis, bathing the liver with nonesterified fatty acids, and rendering it insulin resistant.

BALTIMORE – The anticonvulsant lamotrigine shows promise for reducing pain and improving mood symptoms associated with chronic pelvic pain, particularly in women with the vulvovaginal subtype.

In a study of 43 women with chronic pelvic pain, researchers at the University of North Carolina found that treatment with lamotrigine resulted in significant reductions in total pain, overall pain intensity, and depressive symptoms at 8 weeks, compared with baseline.

There were slightly greater reductions in those measures at 12 weeks that achieved significance. The study, which was presented as a poster at the annual meeting of the American Psychosomatic Society, was funded by GlaxoSmithKline Inc., maker of Lamictal (lamotrigine).

Dr. Samantha Meltzer-Brody of the department of psychiatry at the University of North Carolina, Chapel Hill, and her colleagues recruited women from a tertiary care clinic. Participants had to have pelvic pain for at least 6 months. Women were excluded if they had active systemic disease or substance abuse, pelvic surgery in the previous 6 months, or initiation/change in psychiatric medications in the previous month.

After baseline assessments, the women were titrated up to a therapeutic dosage of 400 mg/day lamotrigine over 8 weeks. This dosage was continued for weeks 8–12. Patients then were slowly discontinued from the drug over a 2-week period. A total of 31 women completed the 8-week titration phase and 21 completed all 12 weeks of treatment.

The women completing 8 weeks of treatment were aged 41 years on average and were predominantly white (95%). The average dosage in that period was 340 mg/day. Most of the women had the vulvodynia/vulvar vestibulitis syndrome subtype (17). The remaining women were evenly split between diffuse abdominal pain (7) and neuropathic pain (7).

The researchers also analyzed the data by chronic pelvic pain subtype. Those with the vulvovaginal pain (VVS) subtype had significant reductions in McGill total pain and visual analog scale overall pain intensity scores at weeks 8 and 12. They also had a significant reduction in Hamilton Depression Rating Scale scores at 12 weeks. However, the investigators noted in the poster that “VVS patients have better mental health and decreased rates of sexual and/or physical abuse history compared to women with other chronic pelvic pain subtypes.”

BALTIMORE – The anticonvulsant lamotrigine shows promise for reducing pain and improving mood symptoms associated with chronic pelvic pain, particularly in women with the vulvovaginal subtype.

In a study of 43 women with chronic pelvic pain, researchers at the University of North Carolina found that treatment with lamotrigine resulted in significant reductions in total pain, overall pain intensity, and depressive symptoms at 8 weeks, compared with baseline.

There were slightly greater reductions in those measures at 12 weeks that achieved significance. The study, which was presented as a poster at the annual meeting of the American Psychosomatic Society, was funded by GlaxoSmithKline Inc., maker of Lamictal (lamotrigine).

Dr. Samantha Meltzer-Brody of the department of psychiatry at the University of North Carolina, Chapel Hill, and her colleagues recruited women from a tertiary care clinic. Participants had to have pelvic pain for at least 6 months. Women were excluded if they had active systemic disease or substance abuse, pelvic surgery in the previous 6 months, or initiation/change in psychiatric medications in the previous month.

After baseline assessments, the women were titrated up to a therapeutic dosage of 400 mg/day lamotrigine over 8 weeks. This dosage was continued for weeks 8–12. Patients then were slowly discontinued from the drug over a 2-week period. A total of 31 women completed the 8-week titration phase and 21 completed all 12 weeks of treatment.

The women completing 8 weeks of treatment were aged 41 years on average and were predominantly white (95%). The average dosage in that period was 340 mg/day. Most of the women had the vulvodynia/vulvar vestibulitis syndrome subtype (17). The remaining women were evenly split between diffuse abdominal pain (7) and neuropathic pain (7).

The researchers also analyzed the data by chronic pelvic pain subtype. Those with the vulvovaginal pain (VVS) subtype had significant reductions in McGill total pain and visual analog scale overall pain intensity scores at weeks 8 and 12. They also had a significant reduction in Hamilton Depression Rating Scale scores at 12 weeks. However, the investigators noted in the poster that “VVS patients have better mental health and decreased rates of sexual and/or physical abuse history compared to women with other chronic pelvic pain subtypes.”

BALTIMORE – The anticonvulsant lamotrigine shows promise for reducing pain and improving mood symptoms associated with chronic pelvic pain, particularly in women with the vulvovaginal subtype.

In a study of 43 women with chronic pelvic pain, researchers at the University of North Carolina found that treatment with lamotrigine resulted in significant reductions in total pain, overall pain intensity, and depressive symptoms at 8 weeks, compared with baseline.

There were slightly greater reductions in those measures at 12 weeks that achieved significance. The study, which was presented as a poster at the annual meeting of the American Psychosomatic Society, was funded by GlaxoSmithKline Inc., maker of Lamictal (lamotrigine).

Dr. Samantha Meltzer-Brody of the department of psychiatry at the University of North Carolina, Chapel Hill, and her colleagues recruited women from a tertiary care clinic. Participants had to have pelvic pain for at least 6 months. Women were excluded if they had active systemic disease or substance abuse, pelvic surgery in the previous 6 months, or initiation/change in psychiatric medications in the previous month.

After baseline assessments, the women were titrated up to a therapeutic dosage of 400 mg/day lamotrigine over 8 weeks. This dosage was continued for weeks 8–12. Patients then were slowly discontinued from the drug over a 2-week period. A total of 31 women completed the 8-week titration phase and 21 completed all 12 weeks of treatment.

The women completing 8 weeks of treatment were aged 41 years on average and were predominantly white (95%). The average dosage in that period was 340 mg/day. Most of the women had the vulvodynia/vulvar vestibulitis syndrome subtype (17). The remaining women were evenly split between diffuse abdominal pain (7) and neuropathic pain (7).

The researchers also analyzed the data by chronic pelvic pain subtype. Those with the vulvovaginal pain (VVS) subtype had significant reductions in McGill total pain and visual analog scale overall pain intensity scores at weeks 8 and 12. They also had a significant reduction in Hamilton Depression Rating Scale scores at 12 weeks. However, the investigators noted in the poster that “VVS patients have better mental health and decreased rates of sexual and/or physical abuse history compared to women with other chronic pelvic pain subtypes.”

TAMPA – Levorphanol appears to be an attractive option for the treatment of refractory pain that does not respond to other opioids, based on a case series of 31 patients presented at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Dr. John P. McNulty of the Palliative Care Institute of Southeast Louisiana presented a case series of 20 of 244 patients with chronic, nonmalignant pain from a palliative care clinic and 11 of 1,508 terminally ill patients with severe chronic pain enrolled in hospice care during a 5-year period. These patients were treated with levorphanol when pain did not respond adequately to other opioids, including methadone. Roughly half of the patients reported excellent relief (52%). Another 22% reported fair pain control, yielding a response rate of 74%.

Levorphanol has been reported to provide analgesia at doses that suggest it does not act like other pure agonist opioids. It has been proposed that levorphanol acts on both opioid receptors and N-methyl-D-aspartate (NMDA) receptors, which might account for this effect.

The drug has a number of advantages. It acts on mu, kappa, and delta opioid receptors and is an NMDA receptor antagonist. The drug relieves neuropathic pain, has a long half-life, and can be administered every 6–8 hours.

Levorphanol's disadvantages include the lack of a parenteral formulation. It is not actively marketed, so many physicians are not aware that it is available. “I would suggest, based on this, that if methadone works then levorphanol might be an option,” Dr. McNulty said. “We are using it for our hospice patients as a second-line drug.”

Dr. McNulty disclosed that he had no relevant financial relationships.

TAMPA – Levorphanol appears to be an attractive option for the treatment of refractory pain that does not respond to other opioids, based on a case series of 31 patients presented at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Dr. John P. McNulty of the Palliative Care Institute of Southeast Louisiana presented a case series of 20 of 244 patients with chronic, nonmalignant pain from a palliative care clinic and 11 of 1,508 terminally ill patients with severe chronic pain enrolled in hospice care during a 5-year period. These patients were treated with levorphanol when pain did not respond adequately to other opioids, including methadone. Roughly half of the patients reported excellent relief (52%). Another 22% reported fair pain control, yielding a response rate of 74%.

Levorphanol has been reported to provide analgesia at doses that suggest it does not act like other pure agonist opioids. It has been proposed that levorphanol acts on both opioid receptors and N-methyl-D-aspartate (NMDA) receptors, which might account for this effect.

The drug has a number of advantages. It acts on mu, kappa, and delta opioid receptors and is an NMDA receptor antagonist. The drug relieves neuropathic pain, has a long half-life, and can be administered every 6–8 hours.

Levorphanol's disadvantages include the lack of a parenteral formulation. It is not actively marketed, so many physicians are not aware that it is available. “I would suggest, based on this, that if methadone works then levorphanol might be an option,” Dr. McNulty said. “We are using it for our hospice patients as a second-line drug.”

Dr. McNulty disclosed that he had no relevant financial relationships.

TAMPA – Levorphanol appears to be an attractive option for the treatment of refractory pain that does not respond to other opioids, based on a case series of 31 patients presented at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Dr. John P. McNulty of the Palliative Care Institute of Southeast Louisiana presented a case series of 20 of 244 patients with chronic, nonmalignant pain from a palliative care clinic and 11 of 1,508 terminally ill patients with severe chronic pain enrolled in hospice care during a 5-year period. These patients were treated with levorphanol when pain did not respond adequately to other opioids, including methadone. Roughly half of the patients reported excellent relief (52%). Another 22% reported fair pain control, yielding a response rate of 74%.

Levorphanol has been reported to provide analgesia at doses that suggest it does not act like other pure agonist opioids. It has been proposed that levorphanol acts on both opioid receptors and N-methyl-D-aspartate (NMDA) receptors, which might account for this effect.

The drug has a number of advantages. It acts on mu, kappa, and delta opioid receptors and is an NMDA receptor antagonist. The drug relieves neuropathic pain, has a long half-life, and can be administered every 6–8 hours.

Levorphanol's disadvantages include the lack of a parenteral formulation. It is not actively marketed, so many physicians are not aware that it is available. “I would suggest, based on this, that if methadone works then levorphanol might be an option,” Dr. McNulty said. “We are using it for our hospice patients as a second-line drug.”

Dr. McNulty disclosed that he had no relevant financial relationships.

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.

WASHINGTON — Mortality from hospital-acquired bloodstream infections is greater when the causal organism is not susceptible to initial antibiotic choice.

“We need to know the antibiogram and select broadly enough to cover the likely organism in the first 24 hours,” Dr. Richard Wenzel said at the annual meeting of the American College of Physicians.

He recommended using systemic inflammatory response syndrome (SIRS) criteria to identify sepsis patients early. SIRS is defined as the presence of two or more of these variables:

▸ A body temperature of more than 38° C or less than 36° C.

▸ A heart rate of more than 90 beats per minute.

▸ A respiratory rate of more than 20 breaths per minute (or an arterial partial pressure of carbon dioxide [PaCO₂] level of less than 32 mm Hg).

▸ An abnormal white blood cell count (greater than 12,000/mcL or less than 4,000/mcL, or greater than 10% bands).

Two SIRS criteria plus any evidence of infection define sepsis, he said. Severe sepsis involves any end-organ dysfunction plus sepsis. Septic shock is defined as severe sepsis with a blood pressure of less than 90 mm Hg after a 500-mL fluid bolus.

Coagulase-negative staphylococcus organisms are the No. 1 cause of crude mortality among patients with bloodstream infections. Other potentially deadly organisms include Staphylococcus aureus, enterococcus, Candida species, gram-negative rods, and Pseudomonas aeruginosa.

Two culprits—Candida species and P. aeruginosa—predict outcome after correction for the underlying disease, noted Dr. Wenzel, professor and chair of the department of internal medicine at Virginia Commonwealth University, Richmond.

The duration of hypotension prior to the initiation of effective treatment is another critical factor in survival. “Treat the patients early. Resuscitate them early. Move them to the ICU early,” Dr. Wenzel advised.

The use of five evidence-based interventions—hand hygiene, a skin preparation with chlorhexidine, barrier precautions, preferred use of the subclavian vein, and catheter removal as soon as possible—can reduce catheter-associated bloodstream infections by as much as two-thirds according to some studies, he said.

For skin antisepsis, 2% chlorhexidine is now preferred over alcohol to reduce bloodstream infections. Another important element of hand hygiene may be eradication of nasal carriage through use of mupirocin. “Forty to fifty percent of people who are nasal carriers have the same organism on their hands,” he said.

Technology-based approaches—including antibiotic-coated catheters, vancomycin lock solutions, chlorhexidine-impregnated dressings, and daily bathing of ICU patients with chlorhexidine—also show some promise, Dr. Wenzel added.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography in an ongoing effort to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008 March 3 [doi:10.1161/circulationaha.107.189097]).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed to be appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique.

Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was considered appropriate if the expected incremental information, combined with clinical judgment, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” the panel wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed to classify the indication definitively.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography in an ongoing effort to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008 March 3 [doi:10.1161/circulationaha.107.189097]).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed to be appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique.

Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was considered appropriate if the expected incremental information, combined with clinical judgment, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” the panel wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed to classify the indication definitively.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography in an ongoing effort to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008 March 3 [doi:10.1161/circulationaha.107.189097]).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed to be appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique.

Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was considered appropriate if the expected incremental information, combined with clinical judgment, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” the panel wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed to classify the indication definitively.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

TAMPA — It's possible to start practicing palliative care medicine, while still learning how to provide it, according to two physicians who have made successful switches from other specialties.

Dr. Tina L. Smusz was once an emergency medicine specialist, but is now the medical codirector of Carilion Hospice of New River Valley Medical Center in Christiansburg, Va. She and Dr. Christopher W. Pile of Carilion Roanoke (Va.) Memorial Hospital described their experiences last month at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Retraining might be one way to help ease the growing need for palliative care specialists, according to Dr. Edward Vandenberg of the department of geriatrics at the University of Nebraska, Omaha. “The need for palliative care services in rural areas will rapidly outpace the need in urban areas on a per-person basis. Rural nursing homes will carry a significant share of the burden,” he said in an interview. The percentage of individuals over age 65 years who live in rural areas and need chronic care exceeds the percentage in urban areas. In 2004, the proportion of the population over age 65 years in the United States was 12.1%, while the proportion in rural Nebraska, for example, was 17%.

Both Dr. Smusz and Dr. Pile said that they were able to start practicing palliative medicine—while still learning how to provide it—by establishing relationships with several facilities in Southwestern Virginia simultaneously.

Dr. Pile was a practicing family physician when he started as the volunteer director of palliative care at Wythe County Community Hospital and its Hospice of Southwest Virginia. The area served by the hospice and the 104-bed acute and subacute care hospital includes four counties that have a total population of about 120,000.

Dr. Pile became the hospice's medical director and chairman of the hospital's ethics committee. After becoming certified in palliative medicine by the American Board of Hospice and Palliative Medicine, he gained consulting privileges in palliative care at Smyth County Community Hospital in Marion, Va., and Johnston Memorial Hospital in Abingdon, Va., where he also had contracts for delivering palliative care and ethics administration. Setting up the contracts was important because they allowed him to be paid for administrative time. Dr. Pile advised his audience to ensure that they are compensated for administrative time. “Don't shortchange yourself. [About] $100 an hour is reasonable,” he said.

He also became medical director of Valley Health Care Center, a 180-bed nursing facility in Chilhowie, Va., which offers skilled, intermediate, and assisted living care. He also became an associate professor at the Virginia College of Osteopathic Medicine in Blacksburg.

All of these entities supported his training and contribute to his current compensation. “Really it's just a matter of being creative,” said Dr. Pile. For instance, when he travels to palliative care training symposia, one facility pays for airfare, another facility covers registration, and a third reimburses his hotel costs. In return, Dr. Pile said he brings what he has learned back to each facility and gives in-service training to every staff member.

Dr. Pile's training has included a course based on the Education on Palliative and End-of-Life Care project, the American Academy of Hospice and Palliative Medicine's hospice medical director course and current concepts in palliative care course, and Harvard Medical School's program in palliative care education and practice. He also received palliative care leadership training under the auspices of the Center to Advance Palliative Care.

Dr. Smusz also works with several facilities in Virginia. Besides holding the post as medical codirector of Carilion Hospice of the New River Valley, she is a palliative medicine specialist there and does inpatient consultation for the larger network of facilities called Carilion Clinic. She also is on the faculty of Virginia College of Osteopathic Medicine. The area served by the Carilion Hospice includes four counties with a total population of more than 150,000.

Once Dr. Smusz realized that she had an interest in palliative medicine, she began volunteering with the hospice and doing home visits while continuing to work in emergency medicine. She became medical codirector of the hospice while she was still retraining. The following year she started to do palliative medicine consultations at Carilion New River Valley Medical Center.

Her training included a Center to Advance Palliative Care course on building a hospital-based palliative care program, training in one of the center's palliative care leadership programs, the same Education on Palliative and End-of-Life-Care course and Harvard program in palliative care education and practice that Dr. Pile attended. She also did extensive study on her own.

Dr. Smusz paid for her initial training herself, but made the money she needed by starting hospice work while in her retraining period.

“Dr. Pile and Dr. Smusz have demonstrated an innovative approach to delivery of palliative care by combining the roles of the practice of palliative medicine with medical directorships of hospices and nursing homes,” said Dr. Vandenberg. “For the nursing home, this approach would provide skills and knowledge along with leadership in an area that critically needs improved end-of-life care. Through the medical directorship position, these physicians will not only have the ability to provide expertise in palliative care but also make system changes through quality improvement activities in end-of-life care in the nursing home. Finally, to provide this expertise in a rural environment addresses the areas that need it most.”

For those interested in making the transition to palliative care, Dr. Smusz recommended starting at a hospice. “You need to learn frontline … care of dying people before you ever pretend that you know how to do palliative medicine,” she said. Her compensation and training have been supported by all the facilities with which she works.

“The thing that makes this work is the teams,” said Dr. Pile. At every facility, a palliative care specialist should assemble a team made up of interested people from various disciplines—respiratory therapists, social workers, administrators, physicians, and nurses. It's the support of these teams that has allowed Dr. Pile to cover a broad geographic area, he said.

Dr. Pile said it is important for a palliative care specialist to regularly reinforce his or her value to rural facilities. He recommended keeping records of the annual number of patient-days spent in hospice and the average number of referrals made to hospice per month for each facility. Data such as these can demonstrate to administrators that having a palliative care specialist available can generate income from hospice services.

Physicians interested in entering palliative medicine have a 5-year window in which they can become certified without the requirement for a formal fellowship. Beginning this year, cooperating boards within the American Board of Medical Specialties will offer a subspecialty certificate in hospice and palliative medicine. Through 2012, candidates without formal training may sit for examination if they have prior certification by the American Board of Hospice and Palliative Medicine or have had at least 800 hours of subspecialty-level practice in hospice and palliative medicine during the past 5 years.

Dr. Pile and Dr. Smusz said they have no financial relationships to disclose.

Places to Turn For Guidance

▸ American Academy of Hospice and Palliative Medicine (

www.aahpm.org

▸ Center to Advance Palliative Care (

www.capc.org

▸ Educating Physicians in End-of-Life Care (

www.epec.net/EPEC/webpages/index.cfm

▸ Program in Palliative Care Education and Practice, Harvard Medical School (

www.hms.harvard.edu/cdi/pallcare

TAMPA — It's possible to start practicing palliative care medicine, while still learning how to provide it, according to two physicians who have made successful switches from other specialties.

Dr. Tina L. Smusz was once an emergency medicine specialist, but is now the medical codirector of Carilion Hospice of New River Valley Medical Center in Christiansburg, Va. She and Dr. Christopher W. Pile of Carilion Roanoke (Va.) Memorial Hospital described their experiences last month at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Retraining might be one way to help ease the growing need for palliative care specialists, according to Dr. Edward Vandenberg of the department of geriatrics at the University of Nebraska, Omaha. “The need for palliative care services in rural areas will rapidly outpace the need in urban areas on a per-person basis. Rural nursing homes will carry a significant share of the burden,” he said in an interview. The percentage of individuals over age 65 years who live in rural areas and need chronic care exceeds the percentage in urban areas. In 2004, the proportion of the population over age 65 years in the United States was 12.1%, while the proportion in rural Nebraska, for example, was 17%.

Both Dr. Smusz and Dr. Pile said that they were able to start practicing palliative medicine—while still learning how to provide it—by establishing relationships with several facilities in Southwestern Virginia simultaneously.

Dr. Pile was a practicing family physician when he started as the volunteer director of palliative care at Wythe County Community Hospital and its Hospice of Southwest Virginia. The area served by the hospice and the 104-bed acute and subacute care hospital includes four counties that have a total population of about 120,000.

Dr. Pile became the hospice's medical director and chairman of the hospital's ethics committee. After becoming certified in palliative medicine by the American Board of Hospice and Palliative Medicine, he gained consulting privileges in palliative care at Smyth County Community Hospital in Marion, Va., and Johnston Memorial Hospital in Abingdon, Va., where he also had contracts for delivering palliative care and ethics administration. Setting up the contracts was important because they allowed him to be paid for administrative time. Dr. Pile advised his audience to ensure that they are compensated for administrative time. “Don't shortchange yourself. [About] $100 an hour is reasonable,” he said.

He also became medical director of Valley Health Care Center, a 180-bed nursing facility in Chilhowie, Va., which offers skilled, intermediate, and assisted living care. He also became an associate professor at the Virginia College of Osteopathic Medicine in Blacksburg.

All of these entities supported his training and contribute to his current compensation. “Really it's just a matter of being creative,” said Dr. Pile. For instance, when he travels to palliative care training symposia, one facility pays for airfare, another facility covers registration, and a third reimburses his hotel costs. In return, Dr. Pile said he brings what he has learned back to each facility and gives in-service training to every staff member.

Dr. Pile's training has included a course based on the Education on Palliative and End-of-Life Care project, the American Academy of Hospice and Palliative Medicine's hospice medical director course and current concepts in palliative care course, and Harvard Medical School's program in palliative care education and practice. He also received palliative care leadership training under the auspices of the Center to Advance Palliative Care.

Dr. Smusz also works with several facilities in Virginia. Besides holding the post as medical codirector of Carilion Hospice of the New River Valley, she is a palliative medicine specialist there and does inpatient consultation for the larger network of facilities called Carilion Clinic. She also is on the faculty of Virginia College of Osteopathic Medicine. The area served by the Carilion Hospice includes four counties with a total population of more than 150,000.

Once Dr. Smusz realized that she had an interest in palliative medicine, she began volunteering with the hospice and doing home visits while continuing to work in emergency medicine. She became medical codirector of the hospice while she was still retraining. The following year she started to do palliative medicine consultations at Carilion New River Valley Medical Center.

Her training included a Center to Advance Palliative Care course on building a hospital-based palliative care program, training in one of the center's palliative care leadership programs, the same Education on Palliative and End-of-Life-Care course and Harvard program in palliative care education and practice that Dr. Pile attended. She also did extensive study on her own.

Dr. Smusz paid for her initial training herself, but made the money she needed by starting hospice work while in her retraining period.

“Dr. Pile and Dr. Smusz have demonstrated an innovative approach to delivery of palliative care by combining the roles of the practice of palliative medicine with medical directorships of hospices and nursing homes,” said Dr. Vandenberg. “For the nursing home, this approach would provide skills and knowledge along with leadership in an area that critically needs improved end-of-life care. Through the medical directorship position, these physicians will not only have the ability to provide expertise in palliative care but also make system changes through quality improvement activities in end-of-life care in the nursing home. Finally, to provide this expertise in a rural environment addresses the areas that need it most.”

For those interested in making the transition to palliative care, Dr. Smusz recommended starting at a hospice. “You need to learn frontline … care of dying people before you ever pretend that you know how to do palliative medicine,” she said. Her compensation and training have been supported by all the facilities with which she works.

“The thing that makes this work is the teams,” said Dr. Pile. At every facility, a palliative care specialist should assemble a team made up of interested people from various disciplines—respiratory therapists, social workers, administrators, physicians, and nurses. It's the support of these teams that has allowed Dr. Pile to cover a broad geographic area, he said.

Dr. Pile said it is important for a palliative care specialist to regularly reinforce his or her value to rural facilities. He recommended keeping records of the annual number of patient-days spent in hospice and the average number of referrals made to hospice per month for each facility. Data such as these can demonstrate to administrators that having a palliative care specialist available can generate income from hospice services.

Physicians interested in entering palliative medicine have a 5-year window in which they can become certified without the requirement for a formal fellowship. Beginning this year, cooperating boards within the American Board of Medical Specialties will offer a subspecialty certificate in hospice and palliative medicine. Through 2012, candidates without formal training may sit for examination if they have prior certification by the American Board of Hospice and Palliative Medicine or have had at least 800 hours of subspecialty-level practice in hospice and palliative medicine during the past 5 years.

Dr. Pile and Dr. Smusz said they have no financial relationships to disclose.

Places to Turn For Guidance

▸ American Academy of Hospice and Palliative Medicine (

www.aahpm.org

▸ Center to Advance Palliative Care (

www.capc.org

▸ Educating Physicians in End-of-Life Care (

www.epec.net/EPEC/webpages/index.cfm

▸ Program in Palliative Care Education and Practice, Harvard Medical School (

www.hms.harvard.edu/cdi/pallcare

TAMPA — It's possible to start practicing palliative care medicine, while still learning how to provide it, according to two physicians who have made successful switches from other specialties.

Dr. Tina L. Smusz was once an emergency medicine specialist, but is now the medical codirector of Carilion Hospice of New River Valley Medical Center in Christiansburg, Va. She and Dr. Christopher W. Pile of Carilion Roanoke (Va.) Memorial Hospital described their experiences last month at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Retraining might be one way to help ease the growing need for palliative care specialists, according to Dr. Edward Vandenberg of the department of geriatrics at the University of Nebraska, Omaha. “The need for palliative care services in rural areas will rapidly outpace the need in urban areas on a per-person basis. Rural nursing homes will carry a significant share of the burden,” he said in an interview. The percentage of individuals over age 65 years who live in rural areas and need chronic care exceeds the percentage in urban areas. In 2004, the proportion of the population over age 65 years in the United States was 12.1%, while the proportion in rural Nebraska, for example, was 17%.

Both Dr. Smusz and Dr. Pile said that they were able to start practicing palliative medicine—while still learning how to provide it—by establishing relationships with several facilities in Southwestern Virginia simultaneously.

Dr. Pile was a practicing family physician when he started as the volunteer director of palliative care at Wythe County Community Hospital and its Hospice of Southwest Virginia. The area served by the hospice and the 104-bed acute and subacute care hospital includes four counties that have a total population of about 120,000.

Dr. Pile became the hospice's medical director and chairman of the hospital's ethics committee. After becoming certified in palliative medicine by the American Board of Hospice and Palliative Medicine, he gained consulting privileges in palliative care at Smyth County Community Hospital in Marion, Va., and Johnston Memorial Hospital in Abingdon, Va., where he also had contracts for delivering palliative care and ethics administration. Setting up the contracts was important because they allowed him to be paid for administrative time. Dr. Pile advised his audience to ensure that they are compensated for administrative time. “Don't shortchange yourself. [About] $100 an hour is reasonable,” he said.

He also became medical director of Valley Health Care Center, a 180-bed nursing facility in Chilhowie, Va., which offers skilled, intermediate, and assisted living care. He also became an associate professor at the Virginia College of Osteopathic Medicine in Blacksburg.

All of these entities supported his training and contribute to his current compensation. “Really it's just a matter of being creative,” said Dr. Pile. For instance, when he travels to palliative care training symposia, one facility pays for airfare, another facility covers registration, and a third reimburses his hotel costs. In return, Dr. Pile said he brings what he has learned back to each facility and gives in-service training to every staff member.

Dr. Pile's training has included a course based on the Education on Palliative and End-of-Life Care project, the American Academy of Hospice and Palliative Medicine's hospice medical director course and current concepts in palliative care course, and Harvard Medical School's program in palliative care education and practice. He also received palliative care leadership training under the auspices of the Center to Advance Palliative Care.

Dr. Smusz also works with several facilities in Virginia. Besides holding the post as medical codirector of Carilion Hospice of the New River Valley, she is a palliative medicine specialist there and does inpatient consultation for the larger network of facilities called Carilion Clinic. She also is on the faculty of Virginia College of Osteopathic Medicine. The area served by the Carilion Hospice includes four counties with a total population of more than 150,000.

Once Dr. Smusz realized that she had an interest in palliative medicine, she began volunteering with the hospice and doing home visits while continuing to work in emergency medicine. She became medical codirector of the hospice while she was still retraining. The following year she started to do palliative medicine consultations at Carilion New River Valley Medical Center.

Her training included a Center to Advance Palliative Care course on building a hospital-based palliative care program, training in one of the center's palliative care leadership programs, the same Education on Palliative and End-of-Life-Care course and Harvard program in palliative care education and practice that Dr. Pile attended. She also did extensive study on her own.

Dr. Smusz paid for her initial training herself, but made the money she needed by starting hospice work while in her retraining period.

“Dr. Pile and Dr. Smusz have demonstrated an innovative approach to delivery of palliative care by combining the roles of the practice of palliative medicine with medical directorships of hospices and nursing homes,” said Dr. Vandenberg. “For the nursing home, this approach would provide skills and knowledge along with leadership in an area that critically needs improved end-of-life care. Through the medical directorship position, these physicians will not only have the ability to provide expertise in palliative care but also make system changes through quality improvement activities in end-of-life care in the nursing home. Finally, to provide this expertise in a rural environment addresses the areas that need it most.”

For those interested in making the transition to palliative care, Dr. Smusz recommended starting at a hospice. “You need to learn frontline … care of dying people before you ever pretend that you know how to do palliative medicine,” she said. Her compensation and training have been supported by all the facilities with which she works.

“The thing that makes this work is the teams,” said Dr. Pile. At every facility, a palliative care specialist should assemble a team made up of interested people from various disciplines—respiratory therapists, social workers, administrators, physicians, and nurses. It's the support of these teams that has allowed Dr. Pile to cover a broad geographic area, he said.

Dr. Pile said it is important for a palliative care specialist to regularly reinforce his or her value to rural facilities. He recommended keeping records of the annual number of patient-days spent in hospice and the average number of referrals made to hospice per month for each facility. Data such as these can demonstrate to administrators that having a palliative care specialist available can generate income from hospice services.

Physicians interested in entering palliative medicine have a 5-year window in which they can become certified without the requirement for a formal fellowship. Beginning this year, cooperating boards within the American Board of Medical Specialties will offer a subspecialty certificate in hospice and palliative medicine. Through 2012, candidates without formal training may sit for examination if they have prior certification by the American Board of Hospice and Palliative Medicine or have had at least 800 hours of subspecialty-level practice in hospice and palliative medicine during the past 5 years.

Dr. Pile and Dr. Smusz said they have no financial relationships to disclose.

Places to Turn For Guidance

▸ American Academy of Hospice and Palliative Medicine (

www.aahpm.org

▸ Center to Advance Palliative Care (

www.capc.org

▸ Educating Physicians in End-of-Life Care (

www.epec.net/EPEC/webpages/index.cfm

▸ Program in Palliative Care Education and Practice, Harvard Medical School (

www.hms.harvard.edu/cdi/pallcare