Michele G. Sullivan

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – There is no one-size-fits-all method of transitioning hospitalized diabetic patients off intravenous insulin to subcutaneous insulin.

A combination of a basal bolus of insulin, plus a sliding scale dictated by the patient’s blood sugar, is usually the way to go, although the process varies slightly depending on the before- and after-nutritional mode, Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

"An important point to remember is that using sliding-scale insulin as a sole strategy for glucose control in someone who needs insulin every day is not a good idea," said Dr. MacIndoe of HealthPartners Medical Group and Clinics, Minneapolis.

There are no evidence-based guidelines to provide a framework for the process, he said. "There are several protocols with supportive data, but no head-to-head trials comparing one to the other. This is a fairly young area with much less evidence than we would really like."

The initial changeover is managed by a basal bolus insulin protocol. This consists of a single dose of basal insulin (usually glargine) given once per day, along with scheduled insulin according to meal pattern, and sliding-scale insulin given throughout the day as indicated by blood glucose.

"Generally speaking, half of the insulin one requires over 24 hours (half of the total daily dose) is a long-acting preparation which covers the continuous amount of glucose put out by the liver," Dr. MacIndoe said. "This is referred to as basal insulin. The other half is that which is needed to cover the carbohydrate ingested with meals. This is usually given in thirds, with each meal, as a rapid-acting insulin."

The subcutaneous insulin for the first 24 hours after transition is considered to be 80% of the total daily dose required on intravenous insulin, Dr. MacIndoe said. "The subcutaneous total daily dose (TDD) is also dependent on what kind of nutrition the patient was given during the time on IV insulin, and the [newly implemented] type of nutrition," he said. "We see three common patterns here: NPO to NPO; NPO to meals; and enteral to meals."

For the NPO patient who will remain NPO, "things are pretty straightforward. You give a dose of basal glargine that’s equal to the TDD calculated for the subcutaneous transition."

Because the patient isn’t eating, there’s no need for additional scheduled nutritional insulin. However, sliding-scale insulin will be given as needed every 4-6 hours, depending on whether the insulin is a rapid-acting analog or regular insulin.

For patients switching from NPO to meals, the basal insulin will also be equal to the dose-calculated TDD for subcutaneous transition. At mealtime, patients get additional rapid-acting insulin at a dose equal in amount to one-third of the basal insulin dose; thus, by the end of the day, 50% of all the insulin given will be the single dose of glargine and 50% will be a rapid-acting analog, divided into three doses.

These patients need a constant carbohydrate diet, "which is essential because we can then predict the amount of insulin they will need with every meal," Dr. MacIndoe said. "You’ll have a finger stick ordered at each meal and bedtime, and, until they’re stable, a 2-hour postprandial check and maybe even a 3 a.m. value if they receive bedtime sliding-scale [insulin]." The most commonly used scales call for insulin to be given if the blood sugar exceeds 150 mg/dL.

Patients switching from enteral to meals "are a little trickier," he said. "It is important to remember that half of the IV insulin was covering nutrition and half covering their true basal needs. So as you transfer to meals, the basal dose of glargine will be equal to half of the calculated TDD of subcutaneus insulin, and at each meal the patient receives rapid-acting insulin equivalent to one-third of the basal dose."

"One of the toughest things to gauge in a patient after transition is whether and how quickly they will begin to eat. The key point is that the patient should be getting blood sugar measurements at mealtime; if it’s above target, they should receive whatever sliding-scale dose is called for with the meal, even if they might not be hungry."

Hold the nutritional dose until after the patient has finished eating, Dr. MacIndoe said. "If they complete their full meal or at least 50%, they can get the full dose of insulin. But if they eat less than 50%, they should only get half of the nutritional dose. The assessment and the insulin dosing should occur within 15 minutes of the meal, if possible."

Dr. MacIndoe disclosed that he is on the speakers bureau of Sanofi-Aventis.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.

GRAPEVINE, TEX. – Hospitalists can safely perform fluid retrieval procedures with a high rate of success and no patient complications, according to the findings of a retrospective study.

A hospitalist procedure team had an overall success rate of 92% among 977 thoracenteses, paracenteses, and lumbar punctures that were performed over a 2-year period, Dr. Michelle Mourad reported at the annual meeting of the Society of Hospital Medicine. The results suggest that additional training can boost hospitalists’ success rates to nearly that of the subspecialists who routinely perform these procedures.

"Unfortunately, many hospitalists lack formal training in procedure skills because training during residency is decreasing," said Dr. Mourad, a hospitalist at the University of California, San Francisco. "We are graduating hospitalists without these skills and having to refer procedures to subspecialties and interventional radiology."

Having hospitalists who are competent in procedures "is becoming more important because advanced technologies like bedside ultrasounds are rapidly becoming the standard of care."

Dr. Mourad and her colleagues examined their database over a 2-year period to determine the success rate of the three common procedures. Aside from success or failure, the outcomes took into account patient characteristics that might contribute to the lack of success and any patient outcomes that were related to unsuccessful procedures.

The hospitalist procedure service at Dr. Mourad’s institution began in 2008 and includes five physicians who obtained additional procedure skills from emergency physicians and interventional radiologists.

Over the 2-year period, the team performed 977 of these procedures (408 paracenteses, 279 thoracenteses, and 290 lumbar punctures). Nonsuccess was defined as the failure to obtain adequate fluid despite several needle passes.

The failure rate among paracenteses was 1%. All four of the unsuccessful procedures had ultrasound corroboration of fluid. "All of these patients also had an abdominal wall greater than 5 cm," Dr. Mourad said. "None sustained any complications," nor were any of these patients referred to another provider. All were treated empirically for spontaneous bacterial peritonitis.

Among the thoracenteses, 6% were unsuccessful. A CT scan corroborated the presence of more than 2 cm of fluid in each of the 16 cases. In all, 10 of the 16 patients had malignant effusions and 50% had pleural thickening. "We suspect that the pleural thickening" may have caused the procedures to be prematurely aborted "because the fluid was deeper than anticipated," Dr. Mourad said.

Nine patients were referred to interventional radiology and, although all radiologists agreed that the procedure was possible, they were unable to obtain fluid in three patients. "Of the six that were completed, three were more complicated than initially thought. Interventional radiology had to use CT guidance to complete the procedure." None of the failures resulted in any patient complications.

The largest failure rate occurred among the lumbar punctures, in which 19% (56) were unsuccessful. Most of the patients with unsuccessful procedures were overweight or obese, Dr. Mourad said; 53% had a body mass index of more than 25 kg/m² and 36% had a BMI of more than 30. "We need to compare this to our total population of procedures to determine if BMI is a true risk factor or not," she said.

Of the unsuccessful procedures, 28 were referred to neuroradiology, where they were all successfully completed, although some required CT guidance. There were no complications among any of the patients with a failed procedure.

The findings have prompted some changes in the way procedures are managed, Dr. Mourad said. "For instance, for paracentesis we now routinely measure the abdominal wall thickness, and we have [a larger] range of needles available because we know that the problems of not getting fluid are often a problem of needle length."

Dr. Mourad reported having no conflicts of interest.

Energy drinks have no place in a young person's diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

“The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg,” lead authors Dr. Marcie B. Schneider of Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. “This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided.” Sports drinks are also often highly acidic, with a pH of 3-4.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial. Young people should be taught that water is the best beverage before, during, and after exercise. Even “muscle recovery” sports drinks, which contain forms of protein, are not really beneficial. “Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials,” according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. “The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature,” the report stated.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. “Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined,” according to the report.

Energy drinks may also contain other stimulants touted as “natural,” including guarana, a plant extract that itself contains caffeine. “The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage,” according to the report.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Energy drinks have no place in a young person's diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

“The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg,” lead authors Dr. Marcie B. Schneider of Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. “This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided.” Sports drinks are also often highly acidic, with a pH of 3-4.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial. Young people should be taught that water is the best beverage before, during, and after exercise. Even “muscle recovery” sports drinks, which contain forms of protein, are not really beneficial. “Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials,” according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. “The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature,” the report stated.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. “Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined,” according to the report.

Energy drinks may also contain other stimulants touted as “natural,” including guarana, a plant extract that itself contains caffeine. “The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage,” according to the report.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Energy drinks have no place in a young person's diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

“The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg,” lead authors Dr. Marcie B. Schneider of Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. “This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided.” Sports drinks are also often highly acidic, with a pH of 3-4.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial. Young people should be taught that water is the best beverage before, during, and after exercise. Even “muscle recovery” sports drinks, which contain forms of protein, are not really beneficial. “Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials,” according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. “The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature,” the report stated.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. “Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined,” according to the report.

Energy drinks may also contain other stimulants touted as “natural,” including guarana, a plant extract that itself contains caffeine. “The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage,” according to the report.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Major Finding: The 5-year disease-free survival rate was significantly better when breast tumors were detected by mammography (94% vs. 71% when tumors presented clinically), as was 5-year overall survival (97% vs. 78%).

Data Source: A 10-year retrospective study of 311 women aged 40–49 years who were treated for breast cancer.

Disclosures: Dr. Dale said he had no relevant financial disclosures.

WASHINGTON – Younger women may suffer under new national mammography screening guidelines that recommend that the procedure become biennial and begin at age 50 years, according to investigators who conducted a retrospective study of breast cancer patients in the 40- to 49-year age group.

Breast tumors that arise in this group may not be discovered until they present clinically, at which time treatment will be more expensive and curative therapy perhaps impossible, Dr. Paul Dale said.

“Our study found that tumors identified through mammography generally had better outcomes after treatment [than did] those found through clinical exam,” he said at a press briefing.

The 10-year retrospective study found that women aged 40–49 years who presented with a breast cancer through clinical symptoms or palpation had significantly larger tumor size, more nodal involvement, and lower 5-year survival rates than did a similarly aged group whose cancers were detected through mammography.

The study comprised 311 women aged 40–49 years who were treated for breast cancer at a single center in 2004–2008. Of these, 145 (47%) had undergone a screening mammography that detected the tumor, whereas 166 (53%) had a tumor that presented clinically, either by symptoms or by physician- or self-exam of the breast. Tumors in the mammography group were significantly smaller than those among the clinically presenting group (median, 2 cm vs. 3 cm). The 5-year disease-free survival rate was significantly better in the mammographically detected group (94% vs. 71%); their 5-year overall survival was also significantly greater (97% vs. 78%). These advantages occurred despite the fact that significantly more women in the mammographically detected group had a family history of breast cancer (25% vs. 15%).

A multivariate analysis found that mammographic cancer detection, node negativity, and smaller tumor size were all significantly associated with an increase overall survival.

“In our institution, we find that 20% of the women diagnosed with breast cancer are younger than age 50,” said Dr. Dale, chief of surgical oncology at the University of Missouri–Columbia. Both the findings of this study and his own clinical experience have convinced him that annual mammographic screening has “great value” to this younger set of women, despite the 2010 U.S. Preventive Services Task Force (USPSTF) recommendation that biennial screening mammograms begin at age 50.

The agency recommended this screening regimen for women aged 50–75 years, but said that for women aged 40–49 years the benefit of screening is small and is balanced by “moderate harms,” including false positives that lead to unnecessary invasive interventions, anxiety, and the small impact of pain from biopsy and radiation exposure. The statement was largely informed by a 2009 review of the SEER (Surveillance Epidemiology and End Results) database. That review concluded that among women aged 40–49, the number needed to treat to prevent one breast cancer death was 1,904, compared with 1,339 for women aged 50–59.

“Although the relative risk reduction is nearly identical (15% and 14%) for these two age groups, the risk for breast cancer increases steeply with age starting at age 40 years,” the document stated. “Thus, the absolute risk reduction from screening … is greater for women aged 50–59 years than for those aged 40–49 years.”

However, the USPSTF document did not recommend against earlier screening, saying that the decision should be based on a woman's family history of the disease and her individual desires, and only after a discussion about the relative risks and benefits.

In an interview, Dr. Dale debated this approach, saying that “when it's your cancer, it matters a lot. I have been doing this for 20 years, and of all the women I have put through a breast biopsy because of something suspicious identified on a screening mammogram, I can tell you that 100% of those with a negative result were glad they did it. The woman's level of comfort in hearing that is huge,” he added.

A 2011 study supports the idea that screening more women will save more lives, Dr. Dale said, referring to another analysis of the same SEER data. Dr. Edward Hendrick of the University of Colorado at Denver and colleagues, concluded that annual screening for women aged 40–84 years would result in a 71% greater mortality reduction than the USPSTF recommendation of biennial screening in those aged 50–74 years. An annual screening for women aged 40–84 years would save almost 100,000 more lives, the authors argued (AJR 2011;196:W112-6).

Dr. Dale also suggested that resource allocation and federal funding concerns may have at least partially motivated the government study. “The government is paying the brunt of this, and annual screening runs into the billions,” he said. “But if you really look at the economics of it, and the years of life it can save – the fact that these women are not undergoing the much more expensive therapies [of treating more advanced cancer], and the economic benefit their productive lives give our economy – the economic picture doesn't look that bad.”

Another 2011 study supports this conclusion, he said. Dr. Blake Cady of the Cambridge (Mass.) Breast Center and associates suggested that financial resources were a driving point of the recommendations. The annual cost of an additional 25,000 mammograms could well be offset by an estimated $50,000-$100,000 per life saved, they said. “Why the USPSTF deliberately chose a less effective method of preventing mortality in the most frequent and feared cancer of women is a puzzle, especially as cost considerations may not be a major adverse factor, although resource allocation is increased,” they concluded (Ann. Surg. Oncol. 2011;18:903-6).

The American Cancer Society, American College of Surgeons, and American College of Obstetricians and Gynecologists still recommend either annual or biennial screening for women, beginning at age 40.

'Our study found that tumors identified through mammography generally had better outcomes.'

Source DR. DALE

Major Finding: The 5-year disease-free survival rate was significantly better when breast tumors were detected by mammography (94% vs. 71% when tumors presented clinically), as was 5-year overall survival (97% vs. 78%).

Data Source: A 10-year retrospective study of 311 women aged 40–49 years who were treated for breast cancer.

Disclosures: Dr. Dale said he had no relevant financial disclosures.

WASHINGTON – Younger women may suffer under new national mammography screening guidelines that recommend that the procedure become biennial and begin at age 50 years, according to investigators who conducted a retrospective study of breast cancer patients in the 40- to 49-year age group.

Breast tumors that arise in this group may not be discovered until they present clinically, at which time treatment will be more expensive and curative therapy perhaps impossible, Dr. Paul Dale said.

“Our study found that tumors identified through mammography generally had better outcomes after treatment [than did] those found through clinical exam,” he said at a press briefing.

The 10-year retrospective study found that women aged 40–49 years who presented with a breast cancer through clinical symptoms or palpation had significantly larger tumor size, more nodal involvement, and lower 5-year survival rates than did a similarly aged group whose cancers were detected through mammography.

The study comprised 311 women aged 40–49 years who were treated for breast cancer at a single center in 2004–2008. Of these, 145 (47%) had undergone a screening mammography that detected the tumor, whereas 166 (53%) had a tumor that presented clinically, either by symptoms or by physician- or self-exam of the breast. Tumors in the mammography group were significantly smaller than those among the clinically presenting group (median, 2 cm vs. 3 cm). The 5-year disease-free survival rate was significantly better in the mammographically detected group (94% vs. 71%); their 5-year overall survival was also significantly greater (97% vs. 78%). These advantages occurred despite the fact that significantly more women in the mammographically detected group had a family history of breast cancer (25% vs. 15%).

A multivariate analysis found that mammographic cancer detection, node negativity, and smaller tumor size were all significantly associated with an increase overall survival.

“In our institution, we find that 20% of the women diagnosed with breast cancer are younger than age 50,” said Dr. Dale, chief of surgical oncology at the University of Missouri–Columbia. Both the findings of this study and his own clinical experience have convinced him that annual mammographic screening has “great value” to this younger set of women, despite the 2010 U.S. Preventive Services Task Force (USPSTF) recommendation that biennial screening mammograms begin at age 50.

The agency recommended this screening regimen for women aged 50–75 years, but said that for women aged 40–49 years the benefit of screening is small and is balanced by “moderate harms,” including false positives that lead to unnecessary invasive interventions, anxiety, and the small impact of pain from biopsy and radiation exposure. The statement was largely informed by a 2009 review of the SEER (Surveillance Epidemiology and End Results) database. That review concluded that among women aged 40–49, the number needed to treat to prevent one breast cancer death was 1,904, compared with 1,339 for women aged 50–59.

“Although the relative risk reduction is nearly identical (15% and 14%) for these two age groups, the risk for breast cancer increases steeply with age starting at age 40 years,” the document stated. “Thus, the absolute risk reduction from screening … is greater for women aged 50–59 years than for those aged 40–49 years.”

However, the USPSTF document did not recommend against earlier screening, saying that the decision should be based on a woman's family history of the disease and her individual desires, and only after a discussion about the relative risks and benefits.

In an interview, Dr. Dale debated this approach, saying that “when it's your cancer, it matters a lot. I have been doing this for 20 years, and of all the women I have put through a breast biopsy because of something suspicious identified on a screening mammogram, I can tell you that 100% of those with a negative result were glad they did it. The woman's level of comfort in hearing that is huge,” he added.

A 2011 study supports the idea that screening more women will save more lives, Dr. Dale said, referring to another analysis of the same SEER data. Dr. Edward Hendrick of the University of Colorado at Denver and colleagues, concluded that annual screening for women aged 40–84 years would result in a 71% greater mortality reduction than the USPSTF recommendation of biennial screening in those aged 50–74 years. An annual screening for women aged 40–84 years would save almost 100,000 more lives, the authors argued (AJR 2011;196:W112-6).

Dr. Dale also suggested that resource allocation and federal funding concerns may have at least partially motivated the government study. “The government is paying the brunt of this, and annual screening runs into the billions,” he said. “But if you really look at the economics of it, and the years of life it can save – the fact that these women are not undergoing the much more expensive therapies [of treating more advanced cancer], and the economic benefit their productive lives give our economy – the economic picture doesn't look that bad.”

Another 2011 study supports this conclusion, he said. Dr. Blake Cady of the Cambridge (Mass.) Breast Center and associates suggested that financial resources were a driving point of the recommendations. The annual cost of an additional 25,000 mammograms could well be offset by an estimated $50,000-$100,000 per life saved, they said. “Why the USPSTF deliberately chose a less effective method of preventing mortality in the most frequent and feared cancer of women is a puzzle, especially as cost considerations may not be a major adverse factor, although resource allocation is increased,” they concluded (Ann. Surg. Oncol. 2011;18:903-6).

The American Cancer Society, American College of Surgeons, and American College of Obstetricians and Gynecologists still recommend either annual or biennial screening for women, beginning at age 40.

'Our study found that tumors identified through mammography generally had better outcomes.'

Source DR. DALE

Major Finding: The 5-year disease-free survival rate was significantly better when breast tumors were detected by mammography (94% vs. 71% when tumors presented clinically), as was 5-year overall survival (97% vs. 78%).

Data Source: A 10-year retrospective study of 311 women aged 40–49 years who were treated for breast cancer.

Disclosures: Dr. Dale said he had no relevant financial disclosures.

WASHINGTON – Younger women may suffer under new national mammography screening guidelines that recommend that the procedure become biennial and begin at age 50 years, according to investigators who conducted a retrospective study of breast cancer patients in the 40- to 49-year age group.

Breast tumors that arise in this group may not be discovered until they present clinically, at which time treatment will be more expensive and curative therapy perhaps impossible, Dr. Paul Dale said.

“Our study found that tumors identified through mammography generally had better outcomes after treatment [than did] those found through clinical exam,” he said at a press briefing.

The 10-year retrospective study found that women aged 40–49 years who presented with a breast cancer through clinical symptoms or palpation had significantly larger tumor size, more nodal involvement, and lower 5-year survival rates than did a similarly aged group whose cancers were detected through mammography.

The study comprised 311 women aged 40–49 years who were treated for breast cancer at a single center in 2004–2008. Of these, 145 (47%) had undergone a screening mammography that detected the tumor, whereas 166 (53%) had a tumor that presented clinically, either by symptoms or by physician- or self-exam of the breast. Tumors in the mammography group were significantly smaller than those among the clinically presenting group (median, 2 cm vs. 3 cm). The 5-year disease-free survival rate was significantly better in the mammographically detected group (94% vs. 71%); their 5-year overall survival was also significantly greater (97% vs. 78%). These advantages occurred despite the fact that significantly more women in the mammographically detected group had a family history of breast cancer (25% vs. 15%).

A multivariate analysis found that mammographic cancer detection, node negativity, and smaller tumor size were all significantly associated with an increase overall survival.

“In our institution, we find that 20% of the women diagnosed with breast cancer are younger than age 50,” said Dr. Dale, chief of surgical oncology at the University of Missouri–Columbia. Both the findings of this study and his own clinical experience have convinced him that annual mammographic screening has “great value” to this younger set of women, despite the 2010 U.S. Preventive Services Task Force (USPSTF) recommendation that biennial screening mammograms begin at age 50.

The agency recommended this screening regimen for women aged 50–75 years, but said that for women aged 40–49 years the benefit of screening is small and is balanced by “moderate harms,” including false positives that lead to unnecessary invasive interventions, anxiety, and the small impact of pain from biopsy and radiation exposure. The statement was largely informed by a 2009 review of the SEER (Surveillance Epidemiology and End Results) database. That review concluded that among women aged 40–49, the number needed to treat to prevent one breast cancer death was 1,904, compared with 1,339 for women aged 50–59.

“Although the relative risk reduction is nearly identical (15% and 14%) for these two age groups, the risk for breast cancer increases steeply with age starting at age 40 years,” the document stated. “Thus, the absolute risk reduction from screening … is greater for women aged 50–59 years than for those aged 40–49 years.”

However, the USPSTF document did not recommend against earlier screening, saying that the decision should be based on a woman's family history of the disease and her individual desires, and only after a discussion about the relative risks and benefits.

In an interview, Dr. Dale debated this approach, saying that “when it's your cancer, it matters a lot. I have been doing this for 20 years, and of all the women I have put through a breast biopsy because of something suspicious identified on a screening mammogram, I can tell you that 100% of those with a negative result were glad they did it. The woman's level of comfort in hearing that is huge,” he added.

A 2011 study supports the idea that screening more women will save more lives, Dr. Dale said, referring to another analysis of the same SEER data. Dr. Edward Hendrick of the University of Colorado at Denver and colleagues, concluded that annual screening for women aged 40–84 years would result in a 71% greater mortality reduction than the USPSTF recommendation of biennial screening in those aged 50–74 years. An annual screening for women aged 40–84 years would save almost 100,000 more lives, the authors argued (AJR 2011;196:W112-6).

Dr. Dale also suggested that resource allocation and federal funding concerns may have at least partially motivated the government study. “The government is paying the brunt of this, and annual screening runs into the billions,” he said. “But if you really look at the economics of it, and the years of life it can save – the fact that these women are not undergoing the much more expensive therapies [of treating more advanced cancer], and the economic benefit their productive lives give our economy – the economic picture doesn't look that bad.”

Another 2011 study supports this conclusion, he said. Dr. Blake Cady of the Cambridge (Mass.) Breast Center and associates suggested that financial resources were a driving point of the recommendations. The annual cost of an additional 25,000 mammograms could well be offset by an estimated $50,000-$100,000 per life saved, they said. “Why the USPSTF deliberately chose a less effective method of preventing mortality in the most frequent and feared cancer of women is a puzzle, especially as cost considerations may not be a major adverse factor, although resource allocation is increased,” they concluded (Ann. Surg. Oncol. 2011;18:903-6).

The American Cancer Society, American College of Surgeons, and American College of Obstetricians and Gynecologists still recommend either annual or biennial screening for women, beginning at age 40.

'Our study found that tumors identified through mammography generally had better outcomes.'

Source DR. DALE

Energy drinks have no place in a young person’s diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics on May 30.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

(c) Alexander Mirokhin/Fotolia.com.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

"The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg," lead authors Dr. Marcie B. Schneider of in a private adolescent medicine practice in Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy’s Committee on Nutrition and Council on Sports Medicine and Fitness.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. "This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided." Sports drinks are also often highly acidic, with a pH of 3-4. Continuous consumption of acidic drinks can contribute to dental erosion, the report stated.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial, especially during, and after, exercise. Although these may benefit some student athletes engaged in prolonged, vigorous exercise, most don’t need such replenishment, the report said. "For most children and adolescents, daily electrolyte requirements are met sufficiently by a healthy balanced diet; therefore, sports drinks offer little to no advantage over plain water."

Young people should be taught that water is the best beverage before, during, and after exercise. Even "muscle recovery" sports drinks, which contain forms of protein, are not really beneficial. "Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials," according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. "The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature," the report stated. Sleep disturbance and anxiety are also side effects of caffeine consumption.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. "Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined," according to the report.

Energy drinks may also contain other stimulants touted as "natural," including guarana, a plant extract that itself contains caffeine. "The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage," according to the report.

Some studies have even suggested a link between energy drink consumption in children and the risk of substance abuse or other health-compromising behaviors, the authors noted.

Unfortunately, while banning the sale of soft drinks, many schools now offer sports and energy drinks for sale. "The trade group representing beverage manufacturers reported that sports drinks increased their market share in schools from 14.6% in 2004 to 20% in the 2006-2007 school year." During the same period, the market share for full-calorie sodas decreased from 40% to 30%.

Pediatricians are in a unique place educate both children and parents about the health issues associated with the beverages. "As part of each yearly check-up, it is important for pediatric health care providers to review a patient’s nutritional status and quantify physical activity. Routine questions that specifically address the use of sports and energy drinks are recommended," the report said.

This is also an opportunity to educate parents. "Parents may be unaware [that their children are drinking these beverages] or they may in fact, promote their use, which opens the door to provide education about these drinks for both patients and their parents," according to the report.

Dr. Lillian Beard, a pediatrician at the National Children’s Medical Center in Washington, and who also has a private practice in Silver Spring, Md., firmly agrees with the screening recommendation.

"Simply inquiring about beverage choices during the annual physical examination discussion offers a tremendous opportunity to inform our patient families on the real deal with sports and energy drinks," she said in an interview.

Continuous consumption of caffeinated beverages could compel young people to keep on drinking – even if they are unaware of the caffeine content, Dr. Beard noted in a 2007 commentary for Pediatric News, a publication of Elsevier, after she surveyed 108 of her patients ("Do Kids Crave Caffeine? Let’s Ask Them.")

"Those who want caffeinated drinks will seek them out, but many others don’t know the caffeine content of their favorite drinks. I think the popularity of [such drinks] reflects savvy marketing. Although adolescents are aware of how some beverages change their alertness, there seems to be a perception of these drinks as healthier choices regardless of whether they contain caffeine," Dr. Beard related concerning her survey findings.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Dr. Beard said she had no relevant financial disclosures.

Energy drinks have no place in a young person’s diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics on May 30.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

(c) Alexander Mirokhin/Fotolia.com.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

"The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg," lead authors Dr. Marcie B. Schneider of in a private adolescent medicine practice in Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy’s Committee on Nutrition and Council on Sports Medicine and Fitness.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. "This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided." Sports drinks are also often highly acidic, with a pH of 3-4. Continuous consumption of acidic drinks can contribute to dental erosion, the report stated.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial, especially during, and after, exercise. Although these may benefit some student athletes engaged in prolonged, vigorous exercise, most don’t need such replenishment, the report said. "For most children and adolescents, daily electrolyte requirements are met sufficiently by a healthy balanced diet; therefore, sports drinks offer little to no advantage over plain water."

Young people should be taught that water is the best beverage before, during, and after exercise. Even "muscle recovery" sports drinks, which contain forms of protein, are not really beneficial. "Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials," according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. "The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature," the report stated. Sleep disturbance and anxiety are also side effects of caffeine consumption.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. "Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined," according to the report.

Energy drinks may also contain other stimulants touted as "natural," including guarana, a plant extract that itself contains caffeine. "The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage," according to the report.

Some studies have even suggested a link between energy drink consumption in children and the risk of substance abuse or other health-compromising behaviors, the authors noted.

Unfortunately, while banning the sale of soft drinks, many schools now offer sports and energy drinks for sale. "The trade group representing beverage manufacturers reported that sports drinks increased their market share in schools from 14.6% in 2004 to 20% in the 2006-2007 school year." During the same period, the market share for full-calorie sodas decreased from 40% to 30%.

Pediatricians are in a unique place educate both children and parents about the health issues associated with the beverages. "As part of each yearly check-up, it is important for pediatric health care providers to review a patient’s nutritional status and quantify physical activity. Routine questions that specifically address the use of sports and energy drinks are recommended," the report said.

This is also an opportunity to educate parents. "Parents may be unaware [that their children are drinking these beverages] or they may in fact, promote their use, which opens the door to provide education about these drinks for both patients and their parents," according to the report.

Dr. Lillian Beard, a pediatrician at the National Children’s Medical Center in Washington, and who also has a private practice in Silver Spring, Md., firmly agrees with the screening recommendation.

"Simply inquiring about beverage choices during the annual physical examination discussion offers a tremendous opportunity to inform our patient families on the real deal with sports and energy drinks," she said in an interview.

Continuous consumption of caffeinated beverages could compel young people to keep on drinking – even if they are unaware of the caffeine content, Dr. Beard noted in a 2007 commentary for Pediatric News, a publication of Elsevier, after she surveyed 108 of her patients ("Do Kids Crave Caffeine? Let’s Ask Them.")

"Those who want caffeinated drinks will seek them out, but many others don’t know the caffeine content of their favorite drinks. I think the popularity of [such drinks] reflects savvy marketing. Although adolescents are aware of how some beverages change their alertness, there seems to be a perception of these drinks as healthier choices regardless of whether they contain caffeine," Dr. Beard related concerning her survey findings.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Dr. Beard said she had no relevant financial disclosures.

Energy drinks have no place in a young person’s diet, and sport drinks are useful only to student athletes who engage in prolonged, rigorous activity, according to a clinical report issued by the American Academy of Pediatrics on May 30.

Water should be encouraged as the principal source of hydration for children and adolescents, the report concluded.

(c) Alexander Mirokhin/Fotolia.com.

Too many children and adolescents consume both types of drinks without any knowledge of their potentially deleterious health effects (Pediatrics 2011;127:1182-9). Carbohydrates and caffeine are the chief concerns in the beverages, according to the report.

"The total amount of caffeine contained in some cans or bottles of energy drinks can exceed 500 mg – equivalent to 14 cans of common caffeinated soft drinks – and is clearly high enough to result in caffeine toxicity. A lethal dose of caffeine is considered to be 200-400 mg/kg," lead authors Dr. Marcie B. Schneider of in a private adolescent medicine practice in Greenwich, Conn., and Dr. Holly J. Benjamin of the University of Chicago wrote on behalf of the academy’s Committee on Nutrition and Council on Sports Medicine and Fitness.

Marketing of these products aims to convince young people that sports drinks containing electrolytes and carbohydrates are superior to water for hydration during exercise. Companies also advertise energy drinks as a providing a healthy boost to physical and mental energy in children and teens. Neither claim is accurate, according to the report.

In assessing the composition of these drinks and their potential health effects, the authors reviewed literature published from 2000 through 2009. They concluded that carbohydrates are the chief concern in sports drinks.

The average sports beverage contains 2-19 grams of carbohydrate, yielding up to 270 calories per serving. "This excessive caloric intake can substantially increase the risk for overweight and obesity in children and adolescents and should be avoided." Sports drinks are also often highly acidic, with a pH of 3-4. Continuous consumption of acidic drinks can contribute to dental erosion, the report stated.

Proponents of sports drinks tout the electrolyte, vitamin, and mineral content as beneficial, especially during, and after, exercise. Although these may benefit some student athletes engaged in prolonged, vigorous exercise, most don’t need such replenishment, the report said. "For most children and adolescents, daily electrolyte requirements are met sufficiently by a healthy balanced diet; therefore, sports drinks offer little to no advantage over plain water."

Young people should be taught that water is the best beverage before, during, and after exercise. Even "muscle recovery" sports drinks, which contain forms of protein, are not really beneficial. "Heavily marketed effects of specific amino acids in sports drinks have not been supported by appropriate clinical trials," according to the report.

While sports drinks may simply be unhelpful sources of added calories, energy drinks may actually be dangerous if consumed in large quantities, they said. Caffeine is molecularly similar to adenosine and can replace it in cell receptors. "The effects of caffeine on various organ systems include increases in heart rate, blood pressure, speech rate, motor activity, attentiveness, gastric secretion, diuresis, and temperature," the report stated. Sleep disturbance and anxiety are also side effects of caffeine consumption.

The American Association of Poison Control Centers confirms these findings. In 2005, the association reported that its centers had fielded more than 4,600 calls about caffeine. "Of these calls, 2,600 included patients younger than 19 years, and 2,345 patients required treatment, although the number of pediatric patients who required treatment was not defined," according to the report.

Energy drinks may also contain other stimulants touted as "natural," including guarana, a plant extract that itself contains caffeine. "The presence of guarana in an energy drink is a cause for concern, because it increases the total caffeine level in the beverage," according to the report.

Some studies have even suggested a link between energy drink consumption in children and the risk of substance abuse or other health-compromising behaviors, the authors noted.

Unfortunately, while banning the sale of soft drinks, many schools now offer sports and energy drinks for sale. "The trade group representing beverage manufacturers reported that sports drinks increased their market share in schools from 14.6% in 2004 to 20% in the 2006-2007 school year." During the same period, the market share for full-calorie sodas decreased from 40% to 30%.

Pediatricians are in a unique place educate both children and parents about the health issues associated with the beverages. "As part of each yearly check-up, it is important for pediatric health care providers to review a patient’s nutritional status and quantify physical activity. Routine questions that specifically address the use of sports and energy drinks are recommended," the report said.

This is also an opportunity to educate parents. "Parents may be unaware [that their children are drinking these beverages] or they may in fact, promote their use, which opens the door to provide education about these drinks for both patients and their parents," according to the report.

Dr. Lillian Beard, a pediatrician at the National Children’s Medical Center in Washington, and who also has a private practice in Silver Spring, Md., firmly agrees with the screening recommendation.

"Simply inquiring about beverage choices during the annual physical examination discussion offers a tremendous opportunity to inform our patient families on the real deal with sports and energy drinks," she said in an interview.

Continuous consumption of caffeinated beverages could compel young people to keep on drinking – even if they are unaware of the caffeine content, Dr. Beard noted in a 2007 commentary for Pediatric News, a publication of Elsevier, after she surveyed 108 of her patients ("Do Kids Crave Caffeine? Let’s Ask Them.")

"Those who want caffeinated drinks will seek them out, but many others don’t know the caffeine content of their favorite drinks. I think the popularity of [such drinks] reflects savvy marketing. Although adolescents are aware of how some beverages change their alertness, there seems to be a perception of these drinks as healthier choices regardless of whether they contain caffeine," Dr. Beard related concerning her survey findings.

All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors.

Dr. Beard said she had no relevant financial disclosures.

GRAPEVINE, TEX. – Researchers found no evidence that the length of resident-covered inpatient rotations – whether 2 or 4 weeks – significantly detracts from hospitalists’ quality of life, or from the quality of care they provide.

However, although nonhospitalists’ patients did just as well as did those of hospitalists, their work/life balance suffered significantly when they worked 4-week inpatient shifts, Dr. Brian Lucas said at the annual meeting of the Society of Hospital Medicine.

Dr. Lucas’s randomized controlled trial on a general medicine teaching ward service was not powered to detect a difference in outcomes between hospitalists and nonhospitalists. Nonetheless, his findings suggest that hospitalists and nonhospitalists experience rotation duration differently, Dr. Lucas said in an interview. It simply may have to do with being accustomed to the rhythm of a hospitalist’s professional life.

"My sense is that hospitalists have the chance to return to a more ‘normal’ schedule after their rotations are over and regain their composure," said Dr. Lucas, chief of hospital medicine at the John H. Stroger Hospital of Cook County, Chicago. "The nonhospitalists don’t experience that. They work at the hospital for 2 or 4 weeks, put their clinic on hold, and at the end, go back to a clinic that has become overburdened. There’s a lot of stress dealing with that."

Dr. Lucas presented the overall findings of the same study at the Society of General Internal Medicine meeting in Phoenix the week earlier. The subanalysis explored at SHM examined work/life balance between the two rotation durations and among the different providers.

The study randomized 62 physicians – 18 hospitalists and 44 nonhospitalists – to sequences of 2- and 4-week rotations, with a total of 130 2-week shifts and 76 4-week shifts. The investigators examined 30-day outcomes in 12,352 patients discharged during these rotations, as well as physicians’ life stressors.

At the end of the study, physicians completed a survey containing portions of three validated life stress measures. Items from the Human Services Survey of the Maslach Burnout Inventory assessed emotional exhaustion; items from the Cohen Perceived Stress Scale measured stress; and items from the Physicians Worklife Study II (Med. Care 1999;37:1140-54) assessed feelings of control in the workplace.

The median number of rotations per physician was three; there was a median of 10 weeks between rotations.

Rotation length did not affect 30-day unplanned patient revisits for either schedule; the rate was 25% for both 2- and 4-week rotations. Residents, who were asked to evaluate their attending physician at the end of the study, did not give significantly different scores according to whether their supervisor worked the 2- or 4-week schedule.

However, Dr. Lucas said, physicians overall did report a significant worsening of work/life balance during the 4-week rotation as opposed to the 2-week rotation. To explore this finding, the investigators first added five characteristics to the model: number of children, being a hospitalist, being an international medical graduate, being a woman, and years of experience.

Three factors significantly affected the overall model. For each child, the attending physician’s work/life became significantly worse, which Dr. Lucas, who has three children of his own, said "is certainly intuitive." Being a hospitalist or an international medical graduate also was significantly protective of work/life balance overall. But whether being a hospitalist limits the imbalance of 4-week rotations depended on which facet of work/life balance was examined.

When considering the entire cohort and both rotation durations combined, the median score in the emotional exhaustion measure was 22. In this measure, the higher the score, the more emotional exhaustion is present. The median life-stress score – which increases as stress increases – was 6. The median score of perceived control at work was 19; this score goes down as perceived control decreases.

All of the scores improved significantly when the physicians worked 2-week shifts rather than 4-week shifts. The difference appeared to be driven by nonhospitalists, however. Their summary scores – which included reactions to both shift schedules – were worse than those of the overall cohort. Working a 2-week shift significantly improved all of these scores, compared with a 4-week shift.

Among hospitalists, however, the summary scores for both schedules were better: 11.8 for emotional exhaustion, 4.6 for life stress, and 21.5 for perceived control. Working a 2-week shift did not significantly improve any of these scores, compared with a 4-week shift, showing, Dr. Lucas said, that hospitalists coped equally well with both rotation lengths.

"In a multivariate model, however, the only significant interaction was perceived control," Dr. Lucas said. "In other words, we found that being a hospitalist protects against loss of control during 4-week rotation, but not that being a hospitalist protects against worsened emotional exhaustion or life stress.

"Overall, these findings suggest that everyone has a little more work/life imbalance after a 4-week rotation, and that those feelings are greater for nonhospitalists," he said.

Before this study, Dr. Lucas said his hospital only offered 4-week rotations. Based on these data, it now allows physicians to choose which schedule might be the best fit. "Despite our findings, about a quarter of our attendings choose to do the 4-week rotation," he said. "My thought is that it works better for some people who don’t have some of these other personal or professional commitments."

As for trainee supervision, he expressed a different thought. "I think you have a better sense of your residents and medical students if you are with them for a full month at a time, rather than 2 weeks."

Dr. Lucas had no financial disclosures with regard to the study.

GRAPEVINE, TEX. – Researchers found no evidence that the length of resident-covered inpatient rotations – whether 2 or 4 weeks – significantly detracts from hospitalists’ quality of life, or from the quality of care they provide.

However, although nonhospitalists’ patients did just as well as did those of hospitalists, their work/life balance suffered significantly when they worked 4-week inpatient shifts, Dr. Brian Lucas said at the annual meeting of the Society of Hospital Medicine.

Dr. Lucas’s randomized controlled trial on a general medicine teaching ward service was not powered to detect a difference in outcomes between hospitalists and nonhospitalists. Nonetheless, his findings suggest that hospitalists and nonhospitalists experience rotation duration differently, Dr. Lucas said in an interview. It simply may have to do with being accustomed to the rhythm of a hospitalist’s professional life.

"My sense is that hospitalists have the chance to return to a more ‘normal’ schedule after their rotations are over and regain their composure," said Dr. Lucas, chief of hospital medicine at the John H. Stroger Hospital of Cook County, Chicago. "The nonhospitalists don’t experience that. They work at the hospital for 2 or 4 weeks, put their clinic on hold, and at the end, go back to a clinic that has become overburdened. There’s a lot of stress dealing with that."

Dr. Lucas presented the overall findings of the same study at the Society of General Internal Medicine meeting in Phoenix the week earlier. The subanalysis explored at SHM examined work/life balance between the two rotation durations and among the different providers.

The study randomized 62 physicians – 18 hospitalists and 44 nonhospitalists – to sequences of 2- and 4-week rotations, with a total of 130 2-week shifts and 76 4-week shifts. The investigators examined 30-day outcomes in 12,352 patients discharged during these rotations, as well as physicians’ life stressors.

At the end of the study, physicians completed a survey containing portions of three validated life stress measures. Items from the Human Services Survey of the Maslach Burnout Inventory assessed emotional exhaustion; items from the Cohen Perceived Stress Scale measured stress; and items from the Physicians Worklife Study II (Med. Care 1999;37:1140-54) assessed feelings of control in the workplace.

The median number of rotations per physician was three; there was a median of 10 weeks between rotations.

Rotation length did not affect 30-day unplanned patient revisits for either schedule; the rate was 25% for both 2- and 4-week rotations. Residents, who were asked to evaluate their attending physician at the end of the study, did not give significantly different scores according to whether their supervisor worked the 2- or 4-week schedule.

However, Dr. Lucas said, physicians overall did report a significant worsening of work/life balance during the 4-week rotation as opposed to the 2-week rotation. To explore this finding, the investigators first added five characteristics to the model: number of children, being a hospitalist, being an international medical graduate, being a woman, and years of experience.

Three factors significantly affected the overall model. For each child, the attending physician’s work/life became significantly worse, which Dr. Lucas, who has three children of his own, said "is certainly intuitive." Being a hospitalist or an international medical graduate also was significantly protective of work/life balance overall. But whether being a hospitalist limits the imbalance of 4-week rotations depended on which facet of work/life balance was examined.

When considering the entire cohort and both rotation durations combined, the median score in the emotional exhaustion measure was 22. In this measure, the higher the score, the more emotional exhaustion is present. The median life-stress score – which increases as stress increases – was 6. The median score of perceived control at work was 19; this score goes down as perceived control decreases.

All of the scores improved significantly when the physicians worked 2-week shifts rather than 4-week shifts. The difference appeared to be driven by nonhospitalists, however. Their summary scores – which included reactions to both shift schedules – were worse than those of the overall cohort. Working a 2-week shift significantly improved all of these scores, compared with a 4-week shift.

Among hospitalists, however, the summary scores for both schedules were better: 11.8 for emotional exhaustion, 4.6 for life stress, and 21.5 for perceived control. Working a 2-week shift did not significantly improve any of these scores, compared with a 4-week shift, showing, Dr. Lucas said, that hospitalists coped equally well with both rotation lengths.

"In a multivariate model, however, the only significant interaction was perceived control," Dr. Lucas said. "In other words, we found that being a hospitalist protects against loss of control during 4-week rotation, but not that being a hospitalist protects against worsened emotional exhaustion or life stress.

"Overall, these findings suggest that everyone has a little more work/life imbalance after a 4-week rotation, and that those feelings are greater for nonhospitalists," he said.

Before this study, Dr. Lucas said his hospital only offered 4-week rotations. Based on these data, it now allows physicians to choose which schedule might be the best fit. "Despite our findings, about a quarter of our attendings choose to do the 4-week rotation," he said. "My thought is that it works better for some people who don’t have some of these other personal or professional commitments."

As for trainee supervision, he expressed a different thought. "I think you have a better sense of your residents and medical students if you are with them for a full month at a time, rather than 2 weeks."

Dr. Lucas had no financial disclosures with regard to the study.

GRAPEVINE, TEX. – Researchers found no evidence that the length of resident-covered inpatient rotations – whether 2 or 4 weeks – significantly detracts from hospitalists’ quality of life, or from the quality of care they provide.

However, although nonhospitalists’ patients did just as well as did those of hospitalists, their work/life balance suffered significantly when they worked 4-week inpatient shifts, Dr. Brian Lucas said at the annual meeting of the Society of Hospital Medicine.

Dr. Lucas’s randomized controlled trial on a general medicine teaching ward service was not powered to detect a difference in outcomes between hospitalists and nonhospitalists. Nonetheless, his findings suggest that hospitalists and nonhospitalists experience rotation duration differently, Dr. Lucas said in an interview. It simply may have to do with being accustomed to the rhythm of a hospitalist’s professional life.

"My sense is that hospitalists have the chance to return to a more ‘normal’ schedule after their rotations are over and regain their composure," said Dr. Lucas, chief of hospital medicine at the John H. Stroger Hospital of Cook County, Chicago. "The nonhospitalists don’t experience that. They work at the hospital for 2 or 4 weeks, put their clinic on hold, and at the end, go back to a clinic that has become overburdened. There’s a lot of stress dealing with that."

Dr. Lucas presented the overall findings of the same study at the Society of General Internal Medicine meeting in Phoenix the week earlier. The subanalysis explored at SHM examined work/life balance between the two rotation durations and among the different providers.

The study randomized 62 physicians – 18 hospitalists and 44 nonhospitalists – to sequences of 2- and 4-week rotations, with a total of 130 2-week shifts and 76 4-week shifts. The investigators examined 30-day outcomes in 12,352 patients discharged during these rotations, as well as physicians’ life stressors.

At the end of the study, physicians completed a survey containing portions of three validated life stress measures. Items from the Human Services Survey of the Maslach Burnout Inventory assessed emotional exhaustion; items from the Cohen Perceived Stress Scale measured stress; and items from the Physicians Worklife Study II (Med. Care 1999;37:1140-54) assessed feelings of control in the workplace.

The median number of rotations per physician was three; there was a median of 10 weeks between rotations.

Rotation length did not affect 30-day unplanned patient revisits for either schedule; the rate was 25% for both 2- and 4-week rotations. Residents, who were asked to evaluate their attending physician at the end of the study, did not give significantly different scores according to whether their supervisor worked the 2- or 4-week schedule.

However, Dr. Lucas said, physicians overall did report a significant worsening of work/life balance during the 4-week rotation as opposed to the 2-week rotation. To explore this finding, the investigators first added five characteristics to the model: number of children, being a hospitalist, being an international medical graduate, being a woman, and years of experience.

Three factors significantly affected the overall model. For each child, the attending physician’s work/life became significantly worse, which Dr. Lucas, who has three children of his own, said "is certainly intuitive." Being a hospitalist or an international medical graduate also was significantly protective of work/life balance overall. But whether being a hospitalist limits the imbalance of 4-week rotations depended on which facet of work/life balance was examined.

When considering the entire cohort and both rotation durations combined, the median score in the emotional exhaustion measure was 22. In this measure, the higher the score, the more emotional exhaustion is present. The median life-stress score – which increases as stress increases – was 6. The median score of perceived control at work was 19; this score goes down as perceived control decreases.

All of the scores improved significantly when the physicians worked 2-week shifts rather than 4-week shifts. The difference appeared to be driven by nonhospitalists, however. Their summary scores – which included reactions to both shift schedules – were worse than those of the overall cohort. Working a 2-week shift significantly improved all of these scores, compared with a 4-week shift.

Among hospitalists, however, the summary scores for both schedules were better: 11.8 for emotional exhaustion, 4.6 for life stress, and 21.5 for perceived control. Working a 2-week shift did not significantly improve any of these scores, compared with a 4-week shift, showing, Dr. Lucas said, that hospitalists coped equally well with both rotation lengths.

"In a multivariate model, however, the only significant interaction was perceived control," Dr. Lucas said. "In other words, we found that being a hospitalist protects against loss of control during 4-week rotation, but not that being a hospitalist protects against worsened emotional exhaustion or life stress.

"Overall, these findings suggest that everyone has a little more work/life imbalance after a 4-week rotation, and that those feelings are greater for nonhospitalists," he said.

Before this study, Dr. Lucas said his hospital only offered 4-week rotations. Based on these data, it now allows physicians to choose which schedule might be the best fit. "Despite our findings, about a quarter of our attendings choose to do the 4-week rotation," he said. "My thought is that it works better for some people who don’t have some of these other personal or professional commitments."

As for trainee supervision, he expressed a different thought. "I think you have a better sense of your residents and medical students if you are with them for a full month at a time, rather than 2 weeks."

Dr. Lucas had no financial disclosures with regard to the study.