A girl, age 13 years, 4 months, presented to her primary care provider’s office for a well visit. Among her concerns, she mentioned a “bump” she had had on her right leg “for the past six months, maybe longer.” The area felt irritated when touched or when the patient “ran too much.” She had seen no change in the bump since she first noticed it. The patient knew of no trauma or other preceding factors. She denied any fever or warmth, redness, or ecchymosis to the area.

Medical history was unremarkable except for familial short stature and myopia. The patient was the fifth of eight children born to nonconsanguinous parents. She denied any surgical history or hospitalizations and was premenarcheal. She was up to date on all age-appropriate vaccines, with her meningococcal vaccine administered at that visit.

The patient’s blood pressure was 99/58 mm Hg with an apical pulse rate of 82 beats/min. Her growth parameters were following her curve. Her height was 55” (0.3 percentile); weight, 81 lb (7.5 percentile); and BMI, 18.8 (48.6 percentile).

The physical exam was normal with the exception of the musculoskeletal exam. Examination of the lower extremities revealed a palpable, 4 cm x 5 cm lesion at the right distal medial thigh just proximal to the knee. The lesion could not be visualized but on palpation was tender and firm. There was some question as to whether the lesion itself or inflamed soft tissue overlying the lesion was mobile. No overlying warmth, induration, erythema, or ecchymosis was noted.

Passive and active range of motion was intact at the hip and knee. No lesions to the upper extremities were evident, and no scoliosis was seen.

Blood work was done to rule out certain diagnoses. Results from a complete blood count with differential, lactate dehydrogenase (LDH), parathyroid hormone, lipid profiles, thyroid function, and a comprehensive metabolic profile were unremarkable. A low level of vitamin D 25-OH was detected: 21.7 ng/mL (normal range, 32 to 100 ng/mL).

Distal femur x-rays with posteroanterior, lateral, and oblique views were ordered. The imaging revealed a 3 cm x 3 cm lesion projecting from the “distal, somewhat medial” femur, which was diagnosed as a benign femoral osteochondroma. Significant inflammation to the surrounding soft-tissue structures was observed. A questionable old fracture of the osteochondroma was noted. The remaining bony structures and joints appeared normal.

An ultrasound of the lesion was also ordered to investigate soft-tissue swelling. This revealed a hypoechoic collar around the distal end of the osteochondroma, which could represent a fluid collection, hematoma from trauma, or bursitis. The soft tissues were deemed normal.

Because of the extent of inflammation, the radiologist recommended MRI without contrast to rule out bursitis or trauma to the osteochondroma.

DISCUSSION
Osteochondromas, which may be present in up to 3% of the general population, are the most common benign bone tumors.^1-3 An osteochondroma is a cartilage-capped bony projection that arises on the external surface of the bone; it contains a marrow cavity that is continuous with the underlying bone.^2,4 The majority of osteochondromas are solitary, accounting for perhaps 85% to 90% of all such lesions, and they are typically nonhereditary; the remaining 10% to 15% of osteochondromas are hereditary multiple osteochondromas or exostoses^1,2 (see “Definition of Multiple Exostoses Syndrome”^2,5,6,7).

Most lesions are painless and slow growing, and they usually occur in children and adolescents.² They typically stop growing at skeletal maturity with the closure of the growth plates.^3,8,9 There is no predilection for males or females in single lesions.²

Solitary osteochondromas typically appear in the lower extremities and at long tubular bone metaphyses,^1-3,10 especially on the femur, humerus, tibia, spine, and hip. Any part of the skeleton can be affected, but 30% of lesions occur on the femur and 40% at either the proximal metaphysis of the tibia or the distal metaphysis of the femur.^2,11

Most osteochondromas are asymptomatic and are found incidentally.^1,3 However, some patients present with local pain as a result of irritation to adjacent structures, limitation of joint motion, growth disturbance, or fracture of the pedicle.^3,4,9,11,12 A very small proportion of patients (no more than 1%) with solitary osteochondromas experience malignant transformation.^2,3,6,7 No particular blood work is recommended for patients with solitary osteochondromas.²

Differential Diagnosis
In addition to osteochondromas, several other lesions should be considered in the patient with musculoskeletal lesions (see Table 1^5,6,13-19).

Cartilaginous tumors. Chondrosarcomas are malignant cartilaginous tumors.^20-22 They commonly affect long bones, including the humerus and femur, and some flat bones, such as the pelvic bones.^13,22 They are most commonly seen in adults, and have no predisposition by gender.¹³

Chondrosarcomas can be primary (ie, arising de novo) or secondary (developing on preexisting benign cartilaginous neoplasms, including osteochondromas). The majority of chondrosarcomas are slow growing, and they rarely metastasize. It is difficult to differentiate between a benign lesion (such as an osteochondroma) and a chondrosarcoma by either histology or radiology. However, reliable predictors for malignancy include size exceeding 5 cm and location in the axial skeleton.²⁰

Bone tumors.Osteosarcomas are the most common malignant bone tumors in children and adolescents, with 400 to 560 US patients in this age-group diagnosed each year.^14-16 Osteosarcomas are uncommon in children younger than 10; their incidence peaks during the early teenage years (median peak age, 16), then declines rapidly among older patients. They are more common in males than females.¹⁵

Osteosarcomas commonly develop during periods of rapid bone turnover, such as the adolescent growth spurt. Common sites include the distal femur, proximal humerus, and proximal tibia,^15,16 particularly near the knee.¹³ Usually, osteosarcomas present with nonspecific symptoms, including strain-related pain of several months’ duration, which may disrupt sleep.¹⁶ Laboratory findings in affected patients may include elevations in LDH, alkaline phosphatase, and/or ESR.^15,23

Physical exam reveals a visible or palpable mass in the affected area, along with decreased joint motion; localized warmth or erythema may also be present. Late signs of osteosarcoma include weight loss, general malaise, and fever. First-line imaging for the patient with a suspected osteosarcoma is x-ray, which will show ill-defined borders, osteoblastic and/or osteolytic features, and an associated soft tissue mass. Advanced imaging, such as MRI, is warranted.¹⁶

Ewing sarcoma, the second most common bone tumor in children and adolescents, is an aggressive form of childhood cancer.^14,18 Approximately 25% of all Ewing sarcomas arise in soft tissues rather than bones.¹⁸ They are more common in whites than in other ethnic groups and have a slight male predominance.^13,18 The median age at diagnosis is 15.¹³ The most common presenting symptoms are tumor related, such as pain or a noticeable mass. While x-rays are usually ordered first, MRI is preferred.¹⁸

Soft tissue tumors and masses.Rhabdomyosarcomas are malignancies that account for more than half of the soft tissue sarcomas in children and adolescents. Less than one-fifth of cases occur in the extremities, and most occur in children younger than 10. These lesions have a slight male predominance and are more common in whites than in other patients.^14,17,24

Approximately 6% of childhood soft tissue tumors are adipose tissue tumors, which may be benign (eg, lipomas) or malignant (eg, liposarcomas). Lipomas in children account for nearly 4% of all soft tissue tumors and can be classified as superficial (which are often diagnosed clinically) or deep (frequently requiring imaging).²⁵

Lymphomaaccounts for 7% of cancers in US children and adolescents and more than 25% of newly diagnosed cancers in patients between 15 and 19, making it the most common malignancy in adolescents and the third most common in children.^26,27 Non-Hodgkin lymphoma is the fourth leading type of malignancy in US adolescents.²⁷ Rarely, lymphomas present with primary event soft tissue involvement.²⁸

Myositis ossificans (MO) is a rare benign disorder involving formation of heterotrophic bone in skeletal muscles and soft tissues.²⁹ Though possible in patients of any age, MO is most commonly seen in adolescents and young adults. Often the result of soft tissue injury (in which case it is referred to as myositis ossificans circumscripta or traumatic), MO develops in areas that are exposed to trauma, such as the anterior thighs or arms. Lesions can be diagnosed via plain x-ray or CT, although MRI and ultrasound can also be useful evaluation tools.^17,29,30

Because MO circumscripta typically presents as a painful soft tissue mass, it can be mistaken for a soft tissue sarcoma or an osteosarcoma; radiologic evaluation is required to make the proper diagnosis. Less common forms of MO are myositis ossificans progressiva and myositis ossificans without a history of trauma.²⁹

Ollier diseaseis a rare, nonfamilial disorder characterized by multiple enchondromas (or enchondromatoses), which are distributed asymmetrically with areas of dysplastic cartilage. Enchondromas are benign cartilage tumors that frequently affect long tubular bones along the metaphyses in proximity to the growth plate. The enchondromas result in significant growth abnormalities. About one in 1 million people are diagnosed yearly.^5,19 (Similarly, Maffucci syndrome is represented by multiple enchondromas in association with hemangiomas.⁵)

Ollier disease typically manifests during childhood⁵ with bone swelling, local pain, and palpable bony masses, which are often associated with bone deformities.¹⁹ Patients generally present with an asymmetric shortening of one extremity and the appearance of palpable bony masses on their fingers or toes, which may or may not be associated with pathologic fractures.^5,19 In 20% to 50% of patients with Ollier disease, enchondromas are at risk for malignant transformation into chondrosarcomas.⁵

Vascular malformations. Certain abnormalities of vascular development cause birthmarks and abnormalities of varying degree in underlying tissues.³¹ They are usually present at birth and grow proportionally to the child’s growth.^25,31 However, they can also be seen in later childhood and adolescence.

Radiologic Investigation
Plain radiography of the affected area is the first-line radiologic study to be performed.¹³ While most osteochondromas can be diagnosed by plain x-ray, cross-sectional imaging via CT or MRI is recommended in lesions with certain characteristics, such as a broad stalk or location in the axial skeleton. Because MRI involves no radiation exposure, it is a particularly good diagnostic tool for children.³²

Ultrasound is a good imaging method for evaluating for complications of osteochondromas, including bursa formation or vascular compromise.³²

Treatment and Management
Although usually asymptomatic, osteochondroma can trigger some significant symptoms. Osteochondromas are at risk for fracture and can cause body deformities, mechanical joint problems, weakness of the affected limb, numbness, vascular compression, aneurysm, arterial thrombosis, venous thrombosis, pain, acute ischemia, and nerve compression. Clinical signs of malignant transformation include pain, swelling, and increased lesion size.²

Surgical excision is recommended but should be delayed until after the patient has reached skeletal maturity in order to decrease the risk for recurrence.³³

Patient Education and Follow-up
In addition to explaining appropriate pain management (eg, NSAIDs), it is especially important for the pediatric NP or PA to encourage the patient with a solitary osteochondroma to follow up with the pediatric orthopedic surgeon. Reasons include the need to monitor growth of the lesion (which is likely to continue in a patient who has not yet reached skeletal maturity) and assess for associated functional or joint problems. Patients should also be advised to seek the specialist’s attention if such problems develop or if pain increases.

Generally, the pediatric clinician should be sufficiently informed to answer questions about this condition from the patient or family. Any follow-up laboratory work recommended by the specialist can also be performed by the pediatric NP or PA.

OUTCOME FOR THE CASE PATIENT
MRI without contrast, as recommended by the radiologist to rule out a bursa or trauma to the osteochondroma, was considered an important part of the follow-up plan. As the patient had not yet reached skeletal maturity, she was referred to a pediatric orthopedic surgeon for possible excision of the lesion, due to its size and the pain associated with running or other exertion.

CONCLUSION
Solitary osteochondromas are the most common benign bone tumors. Although they are generally asymptomatic, pain and other symptoms can arise as a result of irritation to the adjacent structures. In this case, the patient’s chief complaint was an irritating “bump” that she had had on her right leg for at least six months.

Generally, follow-up monitoring of the osteochondroma and orthopedic follow-up care are warranted, at least until the patient reaches skeletal maturity. At that point, surgical excision of the lesion is recommended.            

REFERENCES
1. Florez B, Mönckeberg J, Castillo G, Beguiristain J. Solitary osteochondroma long-term follow-up. J Pediatr Orthop B. 2008;17:91-94.

2. Kitsoulis P, Galani V, Stefanaki K, et al. Osteochondromas: review of the clinical, radiological and pathological features. In Vivo. 2008;22:633-646.

3. Ramos-Pascua LR, Sánchez-Herráez S, Alonso-Barrio JA, Alonso-León A. Solitary proximal end of femur osteochondroma: an indication and result of the en bloc resection without hip luxation [in Spanish]. Rev Esp Cir Ortop Traumatol. 2012;56:24-31.

4. Payne WT, Merrell G. Benign bony and soft tissue tumors of the hand. J Hand Surg. 2010;35:1901-1910.

5. Pannier S, Legeai-Mallet L. Hereditary multiple exostoses and enchondromatosis. Best Pract Res Clin Rheumatol. 2008;22:45-54.

6. Bovée JV. Multiple osteochondromas. Orphanet J Rare Dis. 2008;3(3).

7. Staals EL, Bacchini P, Mercuri M, Bertoni F. Dedifferentiated chondrosarcomas arising in preexisting osteochondromas. J Bone Joint Surg Am. 2007;89:987-993.

8. Singh R, Jain M, Siwach R, et al. Large para-articular osteochondroma of the knee joint: a case report. Acta Orthop Traumatol Turc. 2012;46:139-143.

9. Lee JY, Lee S, Joo KB, et al. Intraarticular osteochondroma of shoulder: a case report. Clin Imaging. 2013;37:379-381.

10. Kim Y-C, Ahn JH, Lee JW. Osteochondroma of the distal tibia complicated by a tibialis posterior tendon tear. J Foot Ankle Surg. 2012;51: 660-663.

11. Allagui M, Amara K, Aloui I, et al. Historical giant near-circumferential osteochondroma of the proximal humerus. J Shoulder Elbow Surg. 2010;19:e12-e15.

12.
Li M, Luettringhaus T, Walker KR, Cole PA. Operative treatment of femoral neck osteochondroma through a digastric approach in a pediatric patient: a case report and review of the literature. J Pediatr Orthop B. 2012;21:230-234.

13. Hogendoorn PC, Athanasou N, Bielack S, et al; ESMO/EUROBONET Working Group. Bone sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21 suppl 5:v204-v213.

14. Arndt CAS, Rose PS, Folpe AL, Laack NN. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc. 2012;87:475-487.

15. Ta HT, Dass CR, Choong PF, Dunstan DE. Osteosarcoma treatment: state of the art. Cancer Metastasis Rev. 2009;28:247-263.

16. Messerschmitt PJ, Garcia RM, Abdul-Karim FW, et al. Osteosarcoma. J Am Acad Orthop Surg. 2009;17:515-527.

17. Laffan EE, Ngan B-Y, Navarro OM. Pediatric soft-tissue tumors and pseudotumors: MR imaging features with pathologic correlation: Part 2. Tumors of fibroblastic/myofibroblastic, so-called fibrohistiocytic, muscular, lymphomatous, neurogenic, hair matrix, and uncertain origin. Radiographics. 2009;29:e36.

18. Balamuth NJ, Womer RB. Ewing’s sarcoma. Lancet Oncol. 2010;11(2):184.

19. D’Angelo L, Massimi L, Narducci A, Di Rocco C. Ollier disease. Childs Nerv Syst. 2009;25:647-653.

20. Gelderblom H, Hogendoorn PC, Dijkstra SD, et al. The clinical approach towards chondrosarcoma. Oncologist. 2008;13:320-329.

21. Nosratzehi T, Pakfetrat A. Chondrosarcoma. Zahedan J Res Med Sci. 2013;15:64-64.

22. Prado FO, Nishimoto IN, Perez DE, et al. Head and neck chondrosarcoma: analysis of 16 cases. Br J Oral Maxillofacial Surg. 2009;47:555-557.

23. Kim HJ, Chalmers PN, Morris CD. Pediatric osteogenic sarcoma. Curr Opin Pediatr. 2010;22:61-66.

24. Sultan I, Qaddoumi I, Yaser S, et al. Comparing adult and pediatric rhabdomyosarcoma in the surveillance, epidemiology and end results program, 1973 to 2005: an analysis of 2,600 patients. J Clin Oncol. 2009;27:3391-3397.

25. Navarro OM, Laffan EE, Ngan B-Y. Pediatric soft-tissue tumors and pseudo-tumors: MR imaging features with pathologic correlation: Part 1. Imaging approach, pseudotumors, vascular lesions, and adipocytic tumors. Radiographics. 2009;29:887-906.

26. Gross TG, Termuhlen AM. Pediatric non-Hodgkin lymphoma. Curr Hematol Malig Rep. 2008;3:167-173.

27. Hochberg J, Waxman IM, Kelly KM, et al. Adolescent non-Hodgkin lymphoma and Hodgkin lymphoma: state of the science. Br J Haematol. 2009;144:24-40.

28. Derenzini E, Casadei B, Pellegrini C, et al. Non-Hodgkin lymphomas presenting as soft tissue masses: A single center experience and meta-analysis of the published series. Clin Lymphoma Myeloma Leuk. 2012 Dec 12. [Epub ahead of print]

29. Micheli A, Trapani S, Brizzi I, et al. Myositis ossificans circumscripta: a paediatric case and review of the literature. Eur J Pediatr. 2009;168:523-529.

30. McKenzie G, Raby N, Ritchie D. Non-neoplastic soft-tissue masses. Br J Radiol. 2009;82:775-785.

31. Buckmiller LM, Richter GT, Suen JY. Diagnosis and management of hemangiomas and vascular malformations of the head and neck. Oral Dis. 2010;16:405-418.

32. Khanna G, Bennett DL. Pediatric bone lesions: beyond the plain radiographic evaluation. Semin Roentgenol. 2012;47:90-99.

33.
Rijal L, Nepal P, Baral S, et al. Solitary diaphyseal exostosis of femur, how common is it? Eur J Orthop Surg Traumatol. 2011;21:363-365.

A girl, age 13 years, 4 months, presented to her primary care provider’s office for a well visit. Among her concerns, she mentioned a “bump” she had had on her right leg “for the past six months, maybe longer.” The area felt irritated when touched or when the patient “ran too much.” She had seen no change in the bump since she first noticed it. The patient knew of no trauma or other preceding factors. She denied any fever or warmth, redness, or ecchymosis to the area.

Medical history was unremarkable except for familial short stature and myopia. The patient was the fifth of eight children born to nonconsanguinous parents. She denied any surgical history or hospitalizations and was premenarcheal. She was up to date on all age-appropriate vaccines, with her meningococcal vaccine administered at that visit.

The patient’s blood pressure was 99/58 mm Hg with an apical pulse rate of 82 beats/min. Her growth parameters were following her curve. Her height was 55” (0.3 percentile); weight, 81 lb (7.5 percentile); and BMI, 18.8 (48.6 percentile).

The physical exam was normal with the exception of the musculoskeletal exam. Examination of the lower extremities revealed a palpable, 4 cm x 5 cm lesion at the right distal medial thigh just proximal to the knee. The lesion could not be visualized but on palpation was tender and firm. There was some question as to whether the lesion itself or inflamed soft tissue overlying the lesion was mobile. No overlying warmth, induration, erythema, or ecchymosis was noted.

Passive and active range of motion was intact at the hip and knee. No lesions to the upper extremities were evident, and no scoliosis was seen.

Blood work was done to rule out certain diagnoses. Results from a complete blood count with differential, lactate dehydrogenase (LDH), parathyroid hormone, lipid profiles, thyroid function, and a comprehensive metabolic profile were unremarkable. A low level of vitamin D 25-OH was detected: 21.7 ng/mL (normal range, 32 to 100 ng/mL).

Distal femur x-rays with posteroanterior, lateral, and oblique views were ordered. The imaging revealed a 3 cm x 3 cm lesion projecting from the “distal, somewhat medial” femur, which was diagnosed as a benign femoral osteochondroma. Significant inflammation to the surrounding soft-tissue structures was observed. A questionable old fracture of the osteochondroma was noted. The remaining bony structures and joints appeared normal.

An ultrasound of the lesion was also ordered to investigate soft-tissue swelling. This revealed a hypoechoic collar around the distal end of the osteochondroma, which could represent a fluid collection, hematoma from trauma, or bursitis. The soft tissues were deemed normal.

Because of the extent of inflammation, the radiologist recommended MRI without contrast to rule out bursitis or trauma to the osteochondroma.

DISCUSSION
Osteochondromas, which may be present in up to 3% of the general population, are the most common benign bone tumors.^1-3 An osteochondroma is a cartilage-capped bony projection that arises on the external surface of the bone; it contains a marrow cavity that is continuous with the underlying bone.^2,4 The majority of osteochondromas are solitary, accounting for perhaps 85% to 90% of all such lesions, and they are typically nonhereditary; the remaining 10% to 15% of osteochondromas are hereditary multiple osteochondromas or exostoses^1,2 (see “Definition of Multiple Exostoses Syndrome”^2,5,6,7).

Most lesions are painless and slow growing, and they usually occur in children and adolescents.² They typically stop growing at skeletal maturity with the closure of the growth plates.^3,8,9 There is no predilection for males or females in single lesions.²

Solitary osteochondromas typically appear in the lower extremities and at long tubular bone metaphyses,^1-3,10 especially on the femur, humerus, tibia, spine, and hip. Any part of the skeleton can be affected, but 30% of lesions occur on the femur and 40% at either the proximal metaphysis of the tibia or the distal metaphysis of the femur.^2,11

Most osteochondromas are asymptomatic and are found incidentally.^1,3 However, some patients present with local pain as a result of irritation to adjacent structures, limitation of joint motion, growth disturbance, or fracture of the pedicle.^3,4,9,11,12 A very small proportion of patients (no more than 1%) with solitary osteochondromas experience malignant transformation.^2,3,6,7 No particular blood work is recommended for patients with solitary osteochondromas.²

Differential Diagnosis
In addition to osteochondromas, several other lesions should be considered in the patient with musculoskeletal lesions (see Table 1^5,6,13-19).

Cartilaginous tumors. Chondrosarcomas are malignant cartilaginous tumors.^20-22 They commonly affect long bones, including the humerus and femur, and some flat bones, such as the pelvic bones.^13,22 They are most commonly seen in adults, and have no predisposition by gender.¹³

Chondrosarcomas can be primary (ie, arising de novo) or secondary (developing on preexisting benign cartilaginous neoplasms, including osteochondromas). The majority of chondrosarcomas are slow growing, and they rarely metastasize. It is difficult to differentiate between a benign lesion (such as an osteochondroma) and a chondrosarcoma by either histology or radiology. However, reliable predictors for malignancy include size exceeding 5 cm and location in the axial skeleton.²⁰

Bone tumors.Osteosarcomas are the most common malignant bone tumors in children and adolescents, with 400 to 560 US patients in this age-group diagnosed each year.^14-16 Osteosarcomas are uncommon in children younger than 10; their incidence peaks during the early teenage years (median peak age, 16), then declines rapidly among older patients. They are more common in males than females.¹⁵

Osteosarcomas commonly develop during periods of rapid bone turnover, such as the adolescent growth spurt. Common sites include the distal femur, proximal humerus, and proximal tibia,^15,16 particularly near the knee.¹³ Usually, osteosarcomas present with nonspecific symptoms, including strain-related pain of several months’ duration, which may disrupt sleep.¹⁶ Laboratory findings in affected patients may include elevations in LDH, alkaline phosphatase, and/or ESR.^15,23

Physical exam reveals a visible or palpable mass in the affected area, along with decreased joint motion; localized warmth or erythema may also be present. Late signs of osteosarcoma include weight loss, general malaise, and fever. First-line imaging for the patient with a suspected osteosarcoma is x-ray, which will show ill-defined borders, osteoblastic and/or osteolytic features, and an associated soft tissue mass. Advanced imaging, such as MRI, is warranted.¹⁶

Ewing sarcoma, the second most common bone tumor in children and adolescents, is an aggressive form of childhood cancer.^14,18 Approximately 25% of all Ewing sarcomas arise in soft tissues rather than bones.¹⁸ They are more common in whites than in other ethnic groups and have a slight male predominance.^13,18 The median age at diagnosis is 15.¹³ The most common presenting symptoms are tumor related, such as pain or a noticeable mass. While x-rays are usually ordered first, MRI is preferred.¹⁸

Soft tissue tumors and masses.Rhabdomyosarcomas are malignancies that account for more than half of the soft tissue sarcomas in children and adolescents. Less than one-fifth of cases occur in the extremities, and most occur in children younger than 10. These lesions have a slight male predominance and are more common in whites than in other patients.^14,17,24

Approximately 6% of childhood soft tissue tumors are adipose tissue tumors, which may be benign (eg, lipomas) or malignant (eg, liposarcomas). Lipomas in children account for nearly 4% of all soft tissue tumors and can be classified as superficial (which are often diagnosed clinically) or deep (frequently requiring imaging).²⁵

Lymphomaaccounts for 7% of cancers in US children and adolescents and more than 25% of newly diagnosed cancers in patients between 15 and 19, making it the most common malignancy in adolescents and the third most common in children.^26,27 Non-Hodgkin lymphoma is the fourth leading type of malignancy in US adolescents.²⁷ Rarely, lymphomas present with primary event soft tissue involvement.²⁸

Myositis ossificans (MO) is a rare benign disorder involving formation of heterotrophic bone in skeletal muscles and soft tissues.²⁹ Though possible in patients of any age, MO is most commonly seen in adolescents and young adults. Often the result of soft tissue injury (in which case it is referred to as myositis ossificans circumscripta or traumatic), MO develops in areas that are exposed to trauma, such as the anterior thighs or arms. Lesions can be diagnosed via plain x-ray or CT, although MRI and ultrasound can also be useful evaluation tools.^17,29,30

Because MO circumscripta typically presents as a painful soft tissue mass, it can be mistaken for a soft tissue sarcoma or an osteosarcoma; radiologic evaluation is required to make the proper diagnosis. Less common forms of MO are myositis ossificans progressiva and myositis ossificans without a history of trauma.²⁹

Ollier diseaseis a rare, nonfamilial disorder characterized by multiple enchondromas (or enchondromatoses), which are distributed asymmetrically with areas of dysplastic cartilage. Enchondromas are benign cartilage tumors that frequently affect long tubular bones along the metaphyses in proximity to the growth plate. The enchondromas result in significant growth abnormalities. About one in 1 million people are diagnosed yearly.^5,19 (Similarly, Maffucci syndrome is represented by multiple enchondromas in association with hemangiomas.⁵)

Ollier disease typically manifests during childhood⁵ with bone swelling, local pain, and palpable bony masses, which are often associated with bone deformities.¹⁹ Patients generally present with an asymmetric shortening of one extremity and the appearance of palpable bony masses on their fingers or toes, which may or may not be associated with pathologic fractures.^5,19 In 20% to 50% of patients with Ollier disease, enchondromas are at risk for malignant transformation into chondrosarcomas.⁵

Vascular malformations. Certain abnormalities of vascular development cause birthmarks and abnormalities of varying degree in underlying tissues.³¹ They are usually present at birth and grow proportionally to the child’s growth.^25,31 However, they can also be seen in later childhood and adolescence.

Radiologic Investigation
Plain radiography of the affected area is the first-line radiologic study to be performed.¹³ While most osteochondromas can be diagnosed by plain x-ray, cross-sectional imaging via CT or MRI is recommended in lesions with certain characteristics, such as a broad stalk or location in the axial skeleton. Because MRI involves no radiation exposure, it is a particularly good diagnostic tool for children.³²

Ultrasound is a good imaging method for evaluating for complications of osteochondromas, including bursa formation or vascular compromise.³²

Treatment and Management
Although usually asymptomatic, osteochondroma can trigger some significant symptoms. Osteochondromas are at risk for fracture and can cause body deformities, mechanical joint problems, weakness of the affected limb, numbness, vascular compression, aneurysm, arterial thrombosis, venous thrombosis, pain, acute ischemia, and nerve compression. Clinical signs of malignant transformation include pain, swelling, and increased lesion size.²

Surgical excision is recommended but should be delayed until after the patient has reached skeletal maturity in order to decrease the risk for recurrence.³³

Patient Education and Follow-up
In addition to explaining appropriate pain management (eg, NSAIDs), it is especially important for the pediatric NP or PA to encourage the patient with a solitary osteochondroma to follow up with the pediatric orthopedic surgeon. Reasons include the need to monitor growth of the lesion (which is likely to continue in a patient who has not yet reached skeletal maturity) and assess for associated functional or joint problems. Patients should also be advised to seek the specialist’s attention if such problems develop or if pain increases.

Generally, the pediatric clinician should be sufficiently informed to answer questions about this condition from the patient or family. Any follow-up laboratory work recommended by the specialist can also be performed by the pediatric NP or PA.

OUTCOME FOR THE CASE PATIENT
MRI without contrast, as recommended by the radiologist to rule out a bursa or trauma to the osteochondroma, was considered an important part of the follow-up plan. As the patient had not yet reached skeletal maturity, she was referred to a pediatric orthopedic surgeon for possible excision of the lesion, due to its size and the pain associated with running or other exertion.

CONCLUSION
Solitary osteochondromas are the most common benign bone tumors. Although they are generally asymptomatic, pain and other symptoms can arise as a result of irritation to the adjacent structures. In this case, the patient’s chief complaint was an irritating “bump” that she had had on her right leg for at least six months.

Generally, follow-up monitoring of the osteochondroma and orthopedic follow-up care are warranted, at least until the patient reaches skeletal maturity. At that point, surgical excision of the lesion is recommended.            

REFERENCES
1. Florez B, Mönckeberg J, Castillo G, Beguiristain J. Solitary osteochondroma long-term follow-up. J Pediatr Orthop B. 2008;17:91-94.

2. Kitsoulis P, Galani V, Stefanaki K, et al. Osteochondromas: review of the clinical, radiological and pathological features. In Vivo. 2008;22:633-646.

3. Ramos-Pascua LR, Sánchez-Herráez S, Alonso-Barrio JA, Alonso-León A. Solitary proximal end of femur osteochondroma: an indication and result of the en bloc resection without hip luxation [in Spanish]. Rev Esp Cir Ortop Traumatol. 2012;56:24-31.

4. Payne WT, Merrell G. Benign bony and soft tissue tumors of the hand. J Hand Surg. 2010;35:1901-1910.

5. Pannier S, Legeai-Mallet L. Hereditary multiple exostoses and enchondromatosis. Best Pract Res Clin Rheumatol. 2008;22:45-54.

6. Bovée JV. Multiple osteochondromas. Orphanet J Rare Dis. 2008;3(3).

7. Staals EL, Bacchini P, Mercuri M, Bertoni F. Dedifferentiated chondrosarcomas arising in preexisting osteochondromas. J Bone Joint Surg Am. 2007;89:987-993.

8. Singh R, Jain M, Siwach R, et al. Large para-articular osteochondroma of the knee joint: a case report. Acta Orthop Traumatol Turc. 2012;46:139-143.

9. Lee JY, Lee S, Joo KB, et al. Intraarticular osteochondroma of shoulder: a case report. Clin Imaging. 2013;37:379-381.

10. Kim Y-C, Ahn JH, Lee JW. Osteochondroma of the distal tibia complicated by a tibialis posterior tendon tear. J Foot Ankle Surg. 2012;51: 660-663.

11. Allagui M, Amara K, Aloui I, et al. Historical giant near-circumferential osteochondroma of the proximal humerus. J Shoulder Elbow Surg. 2010;19:e12-e15.

12.
Li M, Luettringhaus T, Walker KR, Cole PA. Operative treatment of femoral neck osteochondroma through a digastric approach in a pediatric patient: a case report and review of the literature. J Pediatr Orthop B. 2012;21:230-234.

13. Hogendoorn PC, Athanasou N, Bielack S, et al; ESMO/EUROBONET Working Group. Bone sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21 suppl 5:v204-v213.

14. Arndt CAS, Rose PS, Folpe AL, Laack NN. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc. 2012;87:475-487.

15. Ta HT, Dass CR, Choong PF, Dunstan DE. Osteosarcoma treatment: state of the art. Cancer Metastasis Rev. 2009;28:247-263.

16. Messerschmitt PJ, Garcia RM, Abdul-Karim FW, et al. Osteosarcoma. J Am Acad Orthop Surg. 2009;17:515-527.

17. Laffan EE, Ngan B-Y, Navarro OM. Pediatric soft-tissue tumors and pseudotumors: MR imaging features with pathologic correlation: Part 2. Tumors of fibroblastic/myofibroblastic, so-called fibrohistiocytic, muscular, lymphomatous, neurogenic, hair matrix, and uncertain origin. Radiographics. 2009;29:e36.

18. Balamuth NJ, Womer RB. Ewing’s sarcoma. Lancet Oncol. 2010;11(2):184.

19. D’Angelo L, Massimi L, Narducci A, Di Rocco C. Ollier disease. Childs Nerv Syst. 2009;25:647-653.

20. Gelderblom H, Hogendoorn PC, Dijkstra SD, et al. The clinical approach towards chondrosarcoma. Oncologist. 2008;13:320-329.

21. Nosratzehi T, Pakfetrat A. Chondrosarcoma. Zahedan J Res Med Sci. 2013;15:64-64.

22. Prado FO, Nishimoto IN, Perez DE, et al. Head and neck chondrosarcoma: analysis of 16 cases. Br J Oral Maxillofacial Surg. 2009;47:555-557.

23. Kim HJ, Chalmers PN, Morris CD. Pediatric osteogenic sarcoma. Curr Opin Pediatr. 2010;22:61-66.

24. Sultan I, Qaddoumi I, Yaser S, et al. Comparing adult and pediatric rhabdomyosarcoma in the surveillance, epidemiology and end results program, 1973 to 2005: an analysis of 2,600 patients. J Clin Oncol. 2009;27:3391-3397.

25. Navarro OM, Laffan EE, Ngan B-Y. Pediatric soft-tissue tumors and pseudo-tumors: MR imaging features with pathologic correlation: Part 1. Imaging approach, pseudotumors, vascular lesions, and adipocytic tumors. Radiographics. 2009;29:887-906.

26. Gross TG, Termuhlen AM. Pediatric non-Hodgkin lymphoma. Curr Hematol Malig Rep. 2008;3:167-173.

27. Hochberg J, Waxman IM, Kelly KM, et al. Adolescent non-Hodgkin lymphoma and Hodgkin lymphoma: state of the science. Br J Haematol. 2009;144:24-40.

28. Derenzini E, Casadei B, Pellegrini C, et al. Non-Hodgkin lymphomas presenting as soft tissue masses: A single center experience and meta-analysis of the published series. Clin Lymphoma Myeloma Leuk. 2012 Dec 12. [Epub ahead of print]

29. Micheli A, Trapani S, Brizzi I, et al. Myositis ossificans circumscripta: a paediatric case and review of the literature. Eur J Pediatr. 2009;168:523-529.

30. McKenzie G, Raby N, Ritchie D. Non-neoplastic soft-tissue masses. Br J Radiol. 2009;82:775-785.

31. Buckmiller LM, Richter GT, Suen JY. Diagnosis and management of hemangiomas and vascular malformations of the head and neck. Oral Dis. 2010;16:405-418.

32. Khanna G, Bennett DL. Pediatric bone lesions: beyond the plain radiographic evaluation. Semin Roentgenol. 2012;47:90-99.

33.
Rijal L, Nepal P, Baral S, et al. Solitary diaphyseal exostosis of femur, how common is it? Eur J Orthop Surg Traumatol. 2011;21:363-365.

A girl, age 13 years, 4 months, presented to her primary care provider’s office for a well visit. Among her concerns, she mentioned a “bump” she had had on her right leg “for the past six months, maybe longer.” The area felt irritated when touched or when the patient “ran too much.” She had seen no change in the bump since she first noticed it. The patient knew of no trauma or other preceding factors. She denied any fever or warmth, redness, or ecchymosis to the area.

Medical history was unremarkable except for familial short stature and myopia. The patient was the fifth of eight children born to nonconsanguinous parents. She denied any surgical history or hospitalizations and was premenarcheal. She was up to date on all age-appropriate vaccines, with her meningococcal vaccine administered at that visit.

The patient’s blood pressure was 99/58 mm Hg with an apical pulse rate of 82 beats/min. Her growth parameters were following her curve. Her height was 55” (0.3 percentile); weight, 81 lb (7.5 percentile); and BMI, 18.8 (48.6 percentile).

The physical exam was normal with the exception of the musculoskeletal exam. Examination of the lower extremities revealed a palpable, 4 cm x 5 cm lesion at the right distal medial thigh just proximal to the knee. The lesion could not be visualized but on palpation was tender and firm. There was some question as to whether the lesion itself or inflamed soft tissue overlying the lesion was mobile. No overlying warmth, induration, erythema, or ecchymosis was noted.

Passive and active range of motion was intact at the hip and knee. No lesions to the upper extremities were evident, and no scoliosis was seen.

Blood work was done to rule out certain diagnoses. Results from a complete blood count with differential, lactate dehydrogenase (LDH), parathyroid hormone, lipid profiles, thyroid function, and a comprehensive metabolic profile were unremarkable. A low level of vitamin D 25-OH was detected: 21.7 ng/mL (normal range, 32 to 100 ng/mL).

Distal femur x-rays with posteroanterior, lateral, and oblique views were ordered. The imaging revealed a 3 cm x 3 cm lesion projecting from the “distal, somewhat medial” femur, which was diagnosed as a benign femoral osteochondroma. Significant inflammation to the surrounding soft-tissue structures was observed. A questionable old fracture of the osteochondroma was noted. The remaining bony structures and joints appeared normal.

An ultrasound of the lesion was also ordered to investigate soft-tissue swelling. This revealed a hypoechoic collar around the distal end of the osteochondroma, which could represent a fluid collection, hematoma from trauma, or bursitis. The soft tissues were deemed normal.

Because of the extent of inflammation, the radiologist recommended MRI without contrast to rule out bursitis or trauma to the osteochondroma.

DISCUSSION
Osteochondromas, which may be present in up to 3% of the general population, are the most common benign bone tumors.^1-3 An osteochondroma is a cartilage-capped bony projection that arises on the external surface of the bone; it contains a marrow cavity that is continuous with the underlying bone.^2,4 The majority of osteochondromas are solitary, accounting for perhaps 85% to 90% of all such lesions, and they are typically nonhereditary; the remaining 10% to 15% of osteochondromas are hereditary multiple osteochondromas or exostoses^1,2 (see “Definition of Multiple Exostoses Syndrome”^2,5,6,7).

Most lesions are painless and slow growing, and they usually occur in children and adolescents.² They typically stop growing at skeletal maturity with the closure of the growth plates.^3,8,9 There is no predilection for males or females in single lesions.²

Solitary osteochondromas typically appear in the lower extremities and at long tubular bone metaphyses,^1-3,10 especially on the femur, humerus, tibia, spine, and hip. Any part of the skeleton can be affected, but 30% of lesions occur on the femur and 40% at either the proximal metaphysis of the tibia or the distal metaphysis of the femur.^2,11

Most osteochondromas are asymptomatic and are found incidentally.^1,3 However, some patients present with local pain as a result of irritation to adjacent structures, limitation of joint motion, growth disturbance, or fracture of the pedicle.^3,4,9,11,12 A very small proportion of patients (no more than 1%) with solitary osteochondromas experience malignant transformation.^2,3,6,7 No particular blood work is recommended for patients with solitary osteochondromas.²

Differential Diagnosis
In addition to osteochondromas, several other lesions should be considered in the patient with musculoskeletal lesions (see Table 1^5,6,13-19).

Cartilaginous tumors. Chondrosarcomas are malignant cartilaginous tumors.^20-22 They commonly affect long bones, including the humerus and femur, and some flat bones, such as the pelvic bones.^13,22 They are most commonly seen in adults, and have no predisposition by gender.¹³

Chondrosarcomas can be primary (ie, arising de novo) or secondary (developing on preexisting benign cartilaginous neoplasms, including osteochondromas). The majority of chondrosarcomas are slow growing, and they rarely metastasize. It is difficult to differentiate between a benign lesion (such as an osteochondroma) and a chondrosarcoma by either histology or radiology. However, reliable predictors for malignancy include size exceeding 5 cm and location in the axial skeleton.²⁰

Bone tumors.Osteosarcomas are the most common malignant bone tumors in children and adolescents, with 400 to 560 US patients in this age-group diagnosed each year.^14-16 Osteosarcomas are uncommon in children younger than 10; their incidence peaks during the early teenage years (median peak age, 16), then declines rapidly among older patients. They are more common in males than females.¹⁵

Osteosarcomas commonly develop during periods of rapid bone turnover, such as the adolescent growth spurt. Common sites include the distal femur, proximal humerus, and proximal tibia,^15,16 particularly near the knee.¹³ Usually, osteosarcomas present with nonspecific symptoms, including strain-related pain of several months’ duration, which may disrupt sleep.¹⁶ Laboratory findings in affected patients may include elevations in LDH, alkaline phosphatase, and/or ESR.^15,23

Physical exam reveals a visible or palpable mass in the affected area, along with decreased joint motion; localized warmth or erythema may also be present. Late signs of osteosarcoma include weight loss, general malaise, and fever. First-line imaging for the patient with a suspected osteosarcoma is x-ray, which will show ill-defined borders, osteoblastic and/or osteolytic features, and an associated soft tissue mass. Advanced imaging, such as MRI, is warranted.¹⁶

Ewing sarcoma, the second most common bone tumor in children and adolescents, is an aggressive form of childhood cancer.^14,18 Approximately 25% of all Ewing sarcomas arise in soft tissues rather than bones.¹⁸ They are more common in whites than in other ethnic groups and have a slight male predominance.^13,18 The median age at diagnosis is 15.¹³ The most common presenting symptoms are tumor related, such as pain or a noticeable mass. While x-rays are usually ordered first, MRI is preferred.¹⁸

Soft tissue tumors and masses.Rhabdomyosarcomas are malignancies that account for more than half of the soft tissue sarcomas in children and adolescents. Less than one-fifth of cases occur in the extremities, and most occur in children younger than 10. These lesions have a slight male predominance and are more common in whites than in other patients.^14,17,24

Approximately 6% of childhood soft tissue tumors are adipose tissue tumors, which may be benign (eg, lipomas) or malignant (eg, liposarcomas). Lipomas in children account for nearly 4% of all soft tissue tumors and can be classified as superficial (which are often diagnosed clinically) or deep (frequently requiring imaging).²⁵

Lymphomaaccounts for 7% of cancers in US children and adolescents and more than 25% of newly diagnosed cancers in patients between 15 and 19, making it the most common malignancy in adolescents and the third most common in children.^26,27 Non-Hodgkin lymphoma is the fourth leading type of malignancy in US adolescents.²⁷ Rarely, lymphomas present with primary event soft tissue involvement.²⁸

Myositis ossificans (MO) is a rare benign disorder involving formation of heterotrophic bone in skeletal muscles and soft tissues.²⁹ Though possible in patients of any age, MO is most commonly seen in adolescents and young adults. Often the result of soft tissue injury (in which case it is referred to as myositis ossificans circumscripta or traumatic), MO develops in areas that are exposed to trauma, such as the anterior thighs or arms. Lesions can be diagnosed via plain x-ray or CT, although MRI and ultrasound can also be useful evaluation tools.^17,29,30

Because MO circumscripta typically presents as a painful soft tissue mass, it can be mistaken for a soft tissue sarcoma or an osteosarcoma; radiologic evaluation is required to make the proper diagnosis. Less common forms of MO are myositis ossificans progressiva and myositis ossificans without a history of trauma.²⁹

Ollier diseaseis a rare, nonfamilial disorder characterized by multiple enchondromas (or enchondromatoses), which are distributed asymmetrically with areas of dysplastic cartilage. Enchondromas are benign cartilage tumors that frequently affect long tubular bones along the metaphyses in proximity to the growth plate. The enchondromas result in significant growth abnormalities. About one in 1 million people are diagnosed yearly.^5,19 (Similarly, Maffucci syndrome is represented by multiple enchondromas in association with hemangiomas.⁵)

Ollier disease typically manifests during childhood⁵ with bone swelling, local pain, and palpable bony masses, which are often associated with bone deformities.¹⁹ Patients generally present with an asymmetric shortening of one extremity and the appearance of palpable bony masses on their fingers or toes, which may or may not be associated with pathologic fractures.^5,19 In 20% to 50% of patients with Ollier disease, enchondromas are at risk for malignant transformation into chondrosarcomas.⁵

Vascular malformations. Certain abnormalities of vascular development cause birthmarks and abnormalities of varying degree in underlying tissues.³¹ They are usually present at birth and grow proportionally to the child’s growth.^25,31 However, they can also be seen in later childhood and adolescence.

Radiologic Investigation
Plain radiography of the affected area is the first-line radiologic study to be performed.¹³ While most osteochondromas can be diagnosed by plain x-ray, cross-sectional imaging via CT or MRI is recommended in lesions with certain characteristics, such as a broad stalk or location in the axial skeleton. Because MRI involves no radiation exposure, it is a particularly good diagnostic tool for children.³²

Ultrasound is a good imaging method for evaluating for complications of osteochondromas, including bursa formation or vascular compromise.³²

Treatment and Management
Although usually asymptomatic, osteochondroma can trigger some significant symptoms. Osteochondromas are at risk for fracture and can cause body deformities, mechanical joint problems, weakness of the affected limb, numbness, vascular compression, aneurysm, arterial thrombosis, venous thrombosis, pain, acute ischemia, and nerve compression. Clinical signs of malignant transformation include pain, swelling, and increased lesion size.²

Surgical excision is recommended but should be delayed until after the patient has reached skeletal maturity in order to decrease the risk for recurrence.³³

Patient Education and Follow-up
In addition to explaining appropriate pain management (eg, NSAIDs), it is especially important for the pediatric NP or PA to encourage the patient with a solitary osteochondroma to follow up with the pediatric orthopedic surgeon. Reasons include the need to monitor growth of the lesion (which is likely to continue in a patient who has not yet reached skeletal maturity) and assess for associated functional or joint problems. Patients should also be advised to seek the specialist’s attention if such problems develop or if pain increases.

Generally, the pediatric clinician should be sufficiently informed to answer questions about this condition from the patient or family. Any follow-up laboratory work recommended by the specialist can also be performed by the pediatric NP or PA.

OUTCOME FOR THE CASE PATIENT
MRI without contrast, as recommended by the radiologist to rule out a bursa or trauma to the osteochondroma, was considered an important part of the follow-up plan. As the patient had not yet reached skeletal maturity, she was referred to a pediatric orthopedic surgeon for possible excision of the lesion, due to its size and the pain associated with running or other exertion.

CONCLUSION
Solitary osteochondromas are the most common benign bone tumors. Although they are generally asymptomatic, pain and other symptoms can arise as a result of irritation to the adjacent structures. In this case, the patient’s chief complaint was an irritating “bump” that she had had on her right leg for at least six months.

Generally, follow-up monitoring of the osteochondroma and orthopedic follow-up care are warranted, at least until the patient reaches skeletal maturity. At that point, surgical excision of the lesion is recommended.            

REFERENCES
1. Florez B, Mönckeberg J, Castillo G, Beguiristain J. Solitary osteochondroma long-term follow-up. J Pediatr Orthop B. 2008;17:91-94.

2. Kitsoulis P, Galani V, Stefanaki K, et al. Osteochondromas: review of the clinical, radiological and pathological features. In Vivo. 2008;22:633-646.

3. Ramos-Pascua LR, Sánchez-Herráez S, Alonso-Barrio JA, Alonso-León A. Solitary proximal end of femur osteochondroma: an indication and result of the en bloc resection without hip luxation [in Spanish]. Rev Esp Cir Ortop Traumatol. 2012;56:24-31.

4. Payne WT, Merrell G. Benign bony and soft tissue tumors of the hand. J Hand Surg. 2010;35:1901-1910.

5. Pannier S, Legeai-Mallet L. Hereditary multiple exostoses and enchondromatosis. Best Pract Res Clin Rheumatol. 2008;22:45-54.

6. Bovée JV. Multiple osteochondromas. Orphanet J Rare Dis. 2008;3(3).

7. Staals EL, Bacchini P, Mercuri M, Bertoni F. Dedifferentiated chondrosarcomas arising in preexisting osteochondromas. J Bone Joint Surg Am. 2007;89:987-993.

8. Singh R, Jain M, Siwach R, et al. Large para-articular osteochondroma of the knee joint: a case report. Acta Orthop Traumatol Turc. 2012;46:139-143.

9. Lee JY, Lee S, Joo KB, et al. Intraarticular osteochondroma of shoulder: a case report. Clin Imaging. 2013;37:379-381.

10. Kim Y-C, Ahn JH, Lee JW. Osteochondroma of the distal tibia complicated by a tibialis posterior tendon tear. J Foot Ankle Surg. 2012;51: 660-663.

11. Allagui M, Amara K, Aloui I, et al. Historical giant near-circumferential osteochondroma of the proximal humerus. J Shoulder Elbow Surg. 2010;19:e12-e15.

12.
Li M, Luettringhaus T, Walker KR, Cole PA. Operative treatment of femoral neck osteochondroma through a digastric approach in a pediatric patient: a case report and review of the literature. J Pediatr Orthop B. 2012;21:230-234.

13. Hogendoorn PC, Athanasou N, Bielack S, et al; ESMO/EUROBONET Working Group. Bone sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2010;21 suppl 5:v204-v213.

14. Arndt CAS, Rose PS, Folpe AL, Laack NN. Common musculoskeletal tumors of childhood and adolescence. Mayo Clin Proc. 2012;87:475-487.

15. Ta HT, Dass CR, Choong PF, Dunstan DE. Osteosarcoma treatment: state of the art. Cancer Metastasis Rev. 2009;28:247-263.

16. Messerschmitt PJ, Garcia RM, Abdul-Karim FW, et al. Osteosarcoma. J Am Acad Orthop Surg. 2009;17:515-527.

17. Laffan EE, Ngan B-Y, Navarro OM. Pediatric soft-tissue tumors and pseudotumors: MR imaging features with pathologic correlation: Part 2. Tumors of fibroblastic/myofibroblastic, so-called fibrohistiocytic, muscular, lymphomatous, neurogenic, hair matrix, and uncertain origin. Radiographics. 2009;29:e36.

18. Balamuth NJ, Womer RB. Ewing’s sarcoma. Lancet Oncol. 2010;11(2):184.

19. D’Angelo L, Massimi L, Narducci A, Di Rocco C. Ollier disease. Childs Nerv Syst. 2009;25:647-653.

20. Gelderblom H, Hogendoorn PC, Dijkstra SD, et al. The clinical approach towards chondrosarcoma. Oncologist. 2008;13:320-329.

21. Nosratzehi T, Pakfetrat A. Chondrosarcoma. Zahedan J Res Med Sci. 2013;15:64-64.

22. Prado FO, Nishimoto IN, Perez DE, et al. Head and neck chondrosarcoma: analysis of 16 cases. Br J Oral Maxillofacial Surg. 2009;47:555-557.

23. Kim HJ, Chalmers PN, Morris CD. Pediatric osteogenic sarcoma. Curr Opin Pediatr. 2010;22:61-66.

24. Sultan I, Qaddoumi I, Yaser S, et al. Comparing adult and pediatric rhabdomyosarcoma in the surveillance, epidemiology and end results program, 1973 to 2005: an analysis of 2,600 patients. J Clin Oncol. 2009;27:3391-3397.

25. Navarro OM, Laffan EE, Ngan B-Y. Pediatric soft-tissue tumors and pseudo-tumors: MR imaging features with pathologic correlation: Part 1. Imaging approach, pseudotumors, vascular lesions, and adipocytic tumors. Radiographics. 2009;29:887-906.

26. Gross TG, Termuhlen AM. Pediatric non-Hodgkin lymphoma. Curr Hematol Malig Rep. 2008;3:167-173.

27. Hochberg J, Waxman IM, Kelly KM, et al. Adolescent non-Hodgkin lymphoma and Hodgkin lymphoma: state of the science. Br J Haematol. 2009;144:24-40.

28. Derenzini E, Casadei B, Pellegrini C, et al. Non-Hodgkin lymphomas presenting as soft tissue masses: A single center experience and meta-analysis of the published series. Clin Lymphoma Myeloma Leuk. 2012 Dec 12. [Epub ahead of print]

29. Micheli A, Trapani S, Brizzi I, et al. Myositis ossificans circumscripta: a paediatric case and review of the literature. Eur J Pediatr. 2009;168:523-529.

30. McKenzie G, Raby N, Ritchie D. Non-neoplastic soft-tissue masses. Br J Radiol. 2009;82:775-785.

31. Buckmiller LM, Richter GT, Suen JY. Diagnosis and management of hemangiomas and vascular malformations of the head and neck. Oral Dis. 2010;16:405-418.

32. Khanna G, Bennett DL. Pediatric bone lesions: beyond the plain radiographic evaluation. Semin Roentgenol. 2012;47:90-99.

33.
Rijal L, Nepal P, Baral S, et al. Solitary diaphyseal exostosis of femur, how common is it? Eur J Orthop Surg Traumatol. 2011;21:363-365.

Tobacco use is the leading preventable cause of death and disease in the United States,¹ but how best to help patients quit? US Public Health Service guidelines recommend a 2-tiered approach consisting of counseling and pharmaceutical treatment.² Because primary care physicians are busy caring for other patients, however, and pharmacists in our state can prescribe medication under collaborative practice agreements with physicians, we piloted a single-visit smoking cessation group intervention conducted by a pharmacist (NP) and health coach (HW).

Patients were recruited from 2 primary care practices to participate in a 2-hour group visit that included both behavioral and pharmacologic interventions. Follow-up phone calls and in-person visits with the health coach were made available, but were not part of the structured curriculum.

We used motivational interviewing to assist patients in developing individualized quit plans and offered small rewards for stopping, such as a note pad and 6-month certificate. Patients did not pay for the group visit, but were required to pay for pharmacotherapy (health insurance or out of pocket).

Between September 2011 and May 2012, a total of 35 patients attended one of 7 smoking cessation group visits. Twenty-seven (77%) participants opted for medication or nicotine replacement therapy and 23 (65.7%) used the health coach services.

As of June 2012—with participants ranging from one month to 9 months’ follow-up—23% remained tobacco free. This compares with documented one-year quit rates of 3% to 5% (unassisted), 7% to 16% (with behavioral intervention), and up to 24% with pharmacologic treatment and ongoing behavioral support.³ Similar smoking cessation rates have been described with multiple-session pharmacist-led group visits.⁴ This pilot program demonstrated that a single group intervention can be performed in a primary care setting with a pharmacist and health coach, freeing physicians to care for other patients.

Challenges include variable reimbursement from insurers for pharmacist-led tobacco cessation group visits and disparate pharmacy policies—pharmacists are not allowed to prescribe medication in every state. Nonetheless, this pilot, funded by Fairview Physician Associates and the University of Minnesota Academic Health Center, represents a promising means of delivering effective preventive services by leveraging team members in a busy primary care clinic.

Nicole Paterson, PharmD, BCPS
Holly Wiest, MA
Lynne Fiscus, MD, MPH 
Minneapolis, Minn

Tobacco use is the leading preventable cause of death and disease in the United States,¹ but how best to help patients quit? US Public Health Service guidelines recommend a 2-tiered approach consisting of counseling and pharmaceutical treatment.² Because primary care physicians are busy caring for other patients, however, and pharmacists in our state can prescribe medication under collaborative practice agreements with physicians, we piloted a single-visit smoking cessation group intervention conducted by a pharmacist (NP) and health coach (HW).

Patients were recruited from 2 primary care practices to participate in a 2-hour group visit that included both behavioral and pharmacologic interventions. Follow-up phone calls and in-person visits with the health coach were made available, but were not part of the structured curriculum.

We used motivational interviewing to assist patients in developing individualized quit plans and offered small rewards for stopping, such as a note pad and 6-month certificate. Patients did not pay for the group visit, but were required to pay for pharmacotherapy (health insurance or out of pocket).

Between September 2011 and May 2012, a total of 35 patients attended one of 7 smoking cessation group visits. Twenty-seven (77%) participants opted for medication or nicotine replacement therapy and 23 (65.7%) used the health coach services.

As of June 2012—with participants ranging from one month to 9 months’ follow-up—23% remained tobacco free. This compares with documented one-year quit rates of 3% to 5% (unassisted), 7% to 16% (with behavioral intervention), and up to 24% with pharmacologic treatment and ongoing behavioral support.³ Similar smoking cessation rates have been described with multiple-session pharmacist-led group visits.⁴ This pilot program demonstrated that a single group intervention can be performed in a primary care setting with a pharmacist and health coach, freeing physicians to care for other patients.

Challenges include variable reimbursement from insurers for pharmacist-led tobacco cessation group visits and disparate pharmacy policies—pharmacists are not allowed to prescribe medication in every state. Nonetheless, this pilot, funded by Fairview Physician Associates and the University of Minnesota Academic Health Center, represents a promising means of delivering effective preventive services by leveraging team members in a busy primary care clinic.

Nicole Paterson, PharmD, BCPS
Holly Wiest, MA
Lynne Fiscus, MD, MPH 
Minneapolis, Minn

Tobacco use is the leading preventable cause of death and disease in the United States,¹ but how best to help patients quit? US Public Health Service guidelines recommend a 2-tiered approach consisting of counseling and pharmaceutical treatment.² Because primary care physicians are busy caring for other patients, however, and pharmacists in our state can prescribe medication under collaborative practice agreements with physicians, we piloted a single-visit smoking cessation group intervention conducted by a pharmacist (NP) and health coach (HW).

Patients were recruited from 2 primary care practices to participate in a 2-hour group visit that included both behavioral and pharmacologic interventions. Follow-up phone calls and in-person visits with the health coach were made available, but were not part of the structured curriculum.

We used motivational interviewing to assist patients in developing individualized quit plans and offered small rewards for stopping, such as a note pad and 6-month certificate. Patients did not pay for the group visit, but were required to pay for pharmacotherapy (health insurance or out of pocket).

Between September 2011 and May 2012, a total of 35 patients attended one of 7 smoking cessation group visits. Twenty-seven (77%) participants opted for medication or nicotine replacement therapy and 23 (65.7%) used the health coach services.

As of June 2012—with participants ranging from one month to 9 months’ follow-up—23% remained tobacco free. This compares with documented one-year quit rates of 3% to 5% (unassisted), 7% to 16% (with behavioral intervention), and up to 24% with pharmacologic treatment and ongoing behavioral support.³ Similar smoking cessation rates have been described with multiple-session pharmacist-led group visits.⁴ This pilot program demonstrated that a single group intervention can be performed in a primary care setting with a pharmacist and health coach, freeing physicians to care for other patients.

Challenges include variable reimbursement from insurers for pharmacist-led tobacco cessation group visits and disparate pharmacy policies—pharmacists are not allowed to prescribe medication in every state. Nonetheless, this pilot, funded by Fairview Physician Associates and the University of Minnesota Academic Health Center, represents a promising means of delivering effective preventive services by leveraging team members in a busy primary care clinic.

Nicole Paterson, PharmD, BCPS
Holly Wiest, MA
Lynne Fiscus, MD, MPH 
Minneapolis, Minn

gb

AN OBGYN ENCOUNTERED SHOULDER DYSTOCIA. He used fundal pressure and downward lateral traction to free the baby’s shoulder. The child has a brachial plexus injury of the right shoulder, including nerve avulsion, a fractured clavicle, and permanent disfigurement. She underwent surgery; physical and occupational therapy will continue.

PARENTS' CLAIM The standard sequence of maneuvers should have been attempted before fundal pressure and lateral traction were used—the baby was sufficiently oxygenated to allow time for these maneuvers. Excessive lateral traction caused the injury.

DEFENDANTS' DEFENSE The injuries occurred in utero before or while the fetus progressed down the birth canal, and were due to the maternal forces of labor.

VERDICT A $3,070,000 Michigan verdict was returned against the hospital, ObGyn, and ObGyn group.

WHAT IS THE STANDARD SEQUENCE OF MANEUVERS FOR SHOULDER DYSTOCIA?
Read Dr. Robert L. Barbieri’s May Editorial, You are the second responder to a shoulder dystocia emergency. What do you do first? and Dr. Ronald T. Burkman’s March Stop/Start article, Stop all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia Meconium aspiration leads to brain injury

LATE IN HER PREGNANCY, a woman went to the emergency department (ED) with hypertension; she was discharged the same day. She saw her ObGyns, Dr. A and Dr. B, three times in the next 2 weeks. A day after her last visit, she returned to the ED in active labor. Dr. B assumed her care. Fetal monitoring indicated a nonreassuring heart rate with decelerations. Dr. B administered oxytocin and labor continued.

The baby was born by cesarean delivery after 25 minutes of fetal bradycardia. She was covered in meconium, with a low heart rate and irregular, labored respirations. The baby was transferred to another hospital, where she was treated for pulmonary hypertension, meconium aspiration, and seizures. The child is totally disabled, and will require constant care for life.

PARENTS' CLAIM The mother’s hypertension was not properly treated. Dr. B and the nurse waited too long to perform a cesarean delivery.

DEFENDANTS' DEFENSE Proper prenatal care was provided. There was no reason for additional testing; fetal heart tones at the mother’s last office visit were reactive. There were no clinical signs of a hematoma or cord varix during office visits. An unpredictable, unpreventable umbilical cord hematoma caused ischemia and hypoxia, and the subsequent brain injury. Meconium had been in the amniotic fluid for at least 10 hours due to the ischemic/hypoxic episode. The hematoma formed between her last office visit and when the mother came to the hospital the next day.

VERDICT Settlements were reached with Dr. A and the hospital. An Arkansas defense verdict was returned for Dr. B and the nurse.

14 months' recovery after mass removed

A GYNECOLOGIC ONCOLOGIST operated on a woman in her 50s to remove a large, noncancerous pelvic mass. The patient, discharged on postoperative day 2, was readmitted the next day with a fever (temperature, 103ºF), nausea, vomiting, and abdominal pain. Four days later, the oncologist repaired a perforated bowel and created an ileostomy. Other procedures were needed to drain abscesses and repair fistulas, and resect a large portion of colon due to continuing infection. Treatment lasted 14 months.

PATIENT'S CLAIM The gynecologic oncologist was negligent in failing to timely diagnose and treat the bowel perforation. Earlier repair would have curtailed development of the abscesses and fistulae.

PHYSICIAN'S DEFENSE Any complications the patient experienced were unrelated to any delay in treatment. 

VERDICT A $612,237 Michigan verdict was returned.

Colon perforated during abdominal access

WHEN A MORBIDLY OBESE 37-YEAR-OLD WOMAN reported chronic pelvic pain, her gynecologist suspected endometriosis. Conservative treatment failed and the gynecologist offered laparoscopic hysterectomy.

After abdominal insufflation was unsuccessfully attempted twice using a Veress needle, the gynecologist entered the abdomen with a Visiport optical trocar, and continued the procedure. The gynecologist inspected the abdomen before closing but found no injuries.

The patient did not do well after surgery. CT scan detected a bowel perforation on postoperative day 6. During exploratory laparotomy, a through-and-through “bayonet” colon perforation was repaired. Because of the extensive infection, the patient’s surgical wound was left open and several “washouts” were performed; the wound was closed several weeks later. The patient also underwent two adhesiolysis procedures.

PATIENT'S CLAIM Access to the abdomen was not properly performed and caused colon perforation. The injury should have been found and treated earlier.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT A $750,000 Virginia settlement was reached.

READ How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy, by Michael Baggish, MD (Surgical Techniques, October 2012) What caused this C. diff infection after hysterectomy?

AFTER A HYSTERECTOMY, a 42-year-old woman developed a persistent fever and increased white blood cell count. The gynecologist prescribed ciprofloxacin for a urinary tract infection, and discharged the patient from the hospital on postoperative day 4. She returned to the gynecologist’s office with severe abdominal pain and vomiting 4 days after discharge. The gynecologist prescribed an antacid and told her to continue taking ciprofloxacin.

The patient was taken to the ED by ambulance 3 days later. Testing revealed a Clostridium dificule (C. diff) infection. During emergency surgery, a large portion of her colon was resected, and a colostomy was performed. The colostomy was reversed 6 months later. The patient developed an incisional hernia and has abdominal scarring.

PATIENT'S CLAIM Prophylactic antibiotics should have been prescribed before surgery.

Two possible scenarios were presented: 1) A bowel injury occurred during surgery, and ciprofloxacin likely worsened the infection caused by the bowel injury; or 2) ciprofloxacin triggered the C. diff infection that caused leaking colon perforations and subsequent peritonitis.

The colon perforations could have been avoided if the gynecologist had diagnosed and treated the C. diff infection in a timely manner.

PHYSICIAN'S DEFENSE The patient’s symptoms did not suggest a C. diff infection; testing was not necessary. Ciprofloxacin might have allowed the proliferation of the C. diff infection, but the use of the drug was not negligent. The infection was not preventable and could not have been diagnosed earlier.

VERDICT A $776,000 New York verdict was returned.

Brain injury and cerebral palsy: When did this occur?

DURING LABOR AND DELIVERY, there were periods when the fetal heart-rate tracings were nonreassuring with variable decelerations and fetal tachycardia; some variables were severe. The child suffered anoxic encephalopathy that caused neurologic injury and cerebral palsy.

PARENTS' CLAIM The infant suffered numerous hypoxic incidents before cesarean delivery was performed. An earlier cesarean delivery could have prevented the injury.

PHYSICIAN'S DEFENSE The newborn had a normal blood cord gas level of 7.2 pH and Apgar scores of 9 and 10, at 1 and 5 minutes, respectively. Fetal heart-rate tracings did not show evidence of fetal hypoxia. The brain injury likely occurred prior to the onset of labor and was possibly related to a viral encephalopathy. 

VERDICT A Virginia defense verdict was returned. These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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AN OBGYN ENCOUNTERED SHOULDER DYSTOCIA. He used fundal pressure and downward lateral traction to free the baby’s shoulder. The child has a brachial plexus injury of the right shoulder, including nerve avulsion, a fractured clavicle, and permanent disfigurement. She underwent surgery; physical and occupational therapy will continue.

PARENTS' CLAIM The standard sequence of maneuvers should have been attempted before fundal pressure and lateral traction were used—the baby was sufficiently oxygenated to allow time for these maneuvers. Excessive lateral traction caused the injury.

DEFENDANTS' DEFENSE The injuries occurred in utero before or while the fetus progressed down the birth canal, and were due to the maternal forces of labor.

VERDICT A $3,070,000 Michigan verdict was returned against the hospital, ObGyn, and ObGyn group.

WHAT IS THE STANDARD SEQUENCE OF MANEUVERS FOR SHOULDER DYSTOCIA?
Read Dr. Robert L. Barbieri’s May Editorial, You are the second responder to a shoulder dystocia emergency. What do you do first? and Dr. Ronald T. Burkman’s March Stop/Start article, Stop all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia Meconium aspiration leads to brain injury

LATE IN HER PREGNANCY, a woman went to the emergency department (ED) with hypertension; she was discharged the same day. She saw her ObGyns, Dr. A and Dr. B, three times in the next 2 weeks. A day after her last visit, she returned to the ED in active labor. Dr. B assumed her care. Fetal monitoring indicated a nonreassuring heart rate with decelerations. Dr. B administered oxytocin and labor continued.

The baby was born by cesarean delivery after 25 minutes of fetal bradycardia. She was covered in meconium, with a low heart rate and irregular, labored respirations. The baby was transferred to another hospital, where she was treated for pulmonary hypertension, meconium aspiration, and seizures. The child is totally disabled, and will require constant care for life.

PARENTS' CLAIM The mother’s hypertension was not properly treated. Dr. B and the nurse waited too long to perform a cesarean delivery.

DEFENDANTS' DEFENSE Proper prenatal care was provided. There was no reason for additional testing; fetal heart tones at the mother’s last office visit were reactive. There were no clinical signs of a hematoma or cord varix during office visits. An unpredictable, unpreventable umbilical cord hematoma caused ischemia and hypoxia, and the subsequent brain injury. Meconium had been in the amniotic fluid for at least 10 hours due to the ischemic/hypoxic episode. The hematoma formed between her last office visit and when the mother came to the hospital the next day.

VERDICT Settlements were reached with Dr. A and the hospital. An Arkansas defense verdict was returned for Dr. B and the nurse.

14 months' recovery after mass removed

A GYNECOLOGIC ONCOLOGIST operated on a woman in her 50s to remove a large, noncancerous pelvic mass. The patient, discharged on postoperative day 2, was readmitted the next day with a fever (temperature, 103ºF), nausea, vomiting, and abdominal pain. Four days later, the oncologist repaired a perforated bowel and created an ileostomy. Other procedures were needed to drain abscesses and repair fistulas, and resect a large portion of colon due to continuing infection. Treatment lasted 14 months.

PATIENT'S CLAIM The gynecologic oncologist was negligent in failing to timely diagnose and treat the bowel perforation. Earlier repair would have curtailed development of the abscesses and fistulae.

PHYSICIAN'S DEFENSE Any complications the patient experienced were unrelated to any delay in treatment. 

VERDICT A $612,237 Michigan verdict was returned.

Colon perforated during abdominal access

WHEN A MORBIDLY OBESE 37-YEAR-OLD WOMAN reported chronic pelvic pain, her gynecologist suspected endometriosis. Conservative treatment failed and the gynecologist offered laparoscopic hysterectomy.

After abdominal insufflation was unsuccessfully attempted twice using a Veress needle, the gynecologist entered the abdomen with a Visiport optical trocar, and continued the procedure. The gynecologist inspected the abdomen before closing but found no injuries.

The patient did not do well after surgery. CT scan detected a bowel perforation on postoperative day 6. During exploratory laparotomy, a through-and-through “bayonet” colon perforation was repaired. Because of the extensive infection, the patient’s surgical wound was left open and several “washouts” were performed; the wound was closed several weeks later. The patient also underwent two adhesiolysis procedures.

PATIENT'S CLAIM Access to the abdomen was not properly performed and caused colon perforation. The injury should have been found and treated earlier.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT A $750,000 Virginia settlement was reached.

READ How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy, by Michael Baggish, MD (Surgical Techniques, October 2012) What caused this C. diff infection after hysterectomy?

AFTER A HYSTERECTOMY, a 42-year-old woman developed a persistent fever and increased white blood cell count. The gynecologist prescribed ciprofloxacin for a urinary tract infection, and discharged the patient from the hospital on postoperative day 4. She returned to the gynecologist’s office with severe abdominal pain and vomiting 4 days after discharge. The gynecologist prescribed an antacid and told her to continue taking ciprofloxacin.

The patient was taken to the ED by ambulance 3 days later. Testing revealed a Clostridium dificule (C. diff) infection. During emergency surgery, a large portion of her colon was resected, and a colostomy was performed. The colostomy was reversed 6 months later. The patient developed an incisional hernia and has abdominal scarring.

PATIENT'S CLAIM Prophylactic antibiotics should have been prescribed before surgery.

Two possible scenarios were presented: 1) A bowel injury occurred during surgery, and ciprofloxacin likely worsened the infection caused by the bowel injury; or 2) ciprofloxacin triggered the C. diff infection that caused leaking colon perforations and subsequent peritonitis.

The colon perforations could have been avoided if the gynecologist had diagnosed and treated the C. diff infection in a timely manner.

PHYSICIAN'S DEFENSE The patient’s symptoms did not suggest a C. diff infection; testing was not necessary. Ciprofloxacin might have allowed the proliferation of the C. diff infection, but the use of the drug was not negligent. The infection was not preventable and could not have been diagnosed earlier.

VERDICT A $776,000 New York verdict was returned.

Brain injury and cerebral palsy: When did this occur?

DURING LABOR AND DELIVERY, there were periods when the fetal heart-rate tracings were nonreassuring with variable decelerations and fetal tachycardia; some variables were severe. The child suffered anoxic encephalopathy that caused neurologic injury and cerebral palsy.

PARENTS' CLAIM The infant suffered numerous hypoxic incidents before cesarean delivery was performed. An earlier cesarean delivery could have prevented the injury.

PHYSICIAN'S DEFENSE The newborn had a normal blood cord gas level of 7.2 pH and Apgar scores of 9 and 10, at 1 and 5 minutes, respectively. Fetal heart-rate tracings did not show evidence of fetal hypoxia. The brain injury likely occurred prior to the onset of labor and was possibly related to a viral encephalopathy. 

VERDICT A Virginia defense verdict was returned. These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

gb

AN OBGYN ENCOUNTERED SHOULDER DYSTOCIA. He used fundal pressure and downward lateral traction to free the baby’s shoulder. The child has a brachial plexus injury of the right shoulder, including nerve avulsion, a fractured clavicle, and permanent disfigurement. She underwent surgery; physical and occupational therapy will continue.

PARENTS' CLAIM The standard sequence of maneuvers should have been attempted before fundal pressure and lateral traction were used—the baby was sufficiently oxygenated to allow time for these maneuvers. Excessive lateral traction caused the injury.

DEFENDANTS' DEFENSE The injuries occurred in utero before or while the fetus progressed down the birth canal, and were due to the maternal forces of labor.

VERDICT A $3,070,000 Michigan verdict was returned against the hospital, ObGyn, and ObGyn group.

WHAT IS THE STANDARD SEQUENCE OF MANEUVERS FOR SHOULDER DYSTOCIA?
Read Dr. Robert L. Barbieri’s May Editorial, You are the second responder to a shoulder dystocia emergency. What do you do first? and Dr. Ronald T. Burkman’s March Stop/Start article, Stop all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia Meconium aspiration leads to brain injury

LATE IN HER PREGNANCY, a woman went to the emergency department (ED) with hypertension; she was discharged the same day. She saw her ObGyns, Dr. A and Dr. B, three times in the next 2 weeks. A day after her last visit, she returned to the ED in active labor. Dr. B assumed her care. Fetal monitoring indicated a nonreassuring heart rate with decelerations. Dr. B administered oxytocin and labor continued.

The baby was born by cesarean delivery after 25 minutes of fetal bradycardia. She was covered in meconium, with a low heart rate and irregular, labored respirations. The baby was transferred to another hospital, where she was treated for pulmonary hypertension, meconium aspiration, and seizures. The child is totally disabled, and will require constant care for life.

PARENTS' CLAIM The mother’s hypertension was not properly treated. Dr. B and the nurse waited too long to perform a cesarean delivery.

DEFENDANTS' DEFENSE Proper prenatal care was provided. There was no reason for additional testing; fetal heart tones at the mother’s last office visit were reactive. There were no clinical signs of a hematoma or cord varix during office visits. An unpredictable, unpreventable umbilical cord hematoma caused ischemia and hypoxia, and the subsequent brain injury. Meconium had been in the amniotic fluid for at least 10 hours due to the ischemic/hypoxic episode. The hematoma formed between her last office visit and when the mother came to the hospital the next day.

VERDICT Settlements were reached with Dr. A and the hospital. An Arkansas defense verdict was returned for Dr. B and the nurse.

14 months' recovery after mass removed

A GYNECOLOGIC ONCOLOGIST operated on a woman in her 50s to remove a large, noncancerous pelvic mass. The patient, discharged on postoperative day 2, was readmitted the next day with a fever (temperature, 103ºF), nausea, vomiting, and abdominal pain. Four days later, the oncologist repaired a perforated bowel and created an ileostomy. Other procedures were needed to drain abscesses and repair fistulas, and resect a large portion of colon due to continuing infection. Treatment lasted 14 months.

PATIENT'S CLAIM The gynecologic oncologist was negligent in failing to timely diagnose and treat the bowel perforation. Earlier repair would have curtailed development of the abscesses and fistulae.

PHYSICIAN'S DEFENSE Any complications the patient experienced were unrelated to any delay in treatment. 

VERDICT A $612,237 Michigan verdict was returned.

Colon perforated during abdominal access

WHEN A MORBIDLY OBESE 37-YEAR-OLD WOMAN reported chronic pelvic pain, her gynecologist suspected endometriosis. Conservative treatment failed and the gynecologist offered laparoscopic hysterectomy.

After abdominal insufflation was unsuccessfully attempted twice using a Veress needle, the gynecologist entered the abdomen with a Visiport optical trocar, and continued the procedure. The gynecologist inspected the abdomen before closing but found no injuries.

The patient did not do well after surgery. CT scan detected a bowel perforation on postoperative day 6. During exploratory laparotomy, a through-and-through “bayonet” colon perforation was repaired. Because of the extensive infection, the patient’s surgical wound was left open and several “washouts” were performed; the wound was closed several weeks later. The patient also underwent two adhesiolysis procedures.

PATIENT'S CLAIM Access to the abdomen was not properly performed and caused colon perforation. The injury should have been found and treated earlier.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT A $750,000 Virginia settlement was reached.

READ How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy, by Michael Baggish, MD (Surgical Techniques, October 2012) What caused this C. diff infection after hysterectomy?

AFTER A HYSTERECTOMY, a 42-year-old woman developed a persistent fever and increased white blood cell count. The gynecologist prescribed ciprofloxacin for a urinary tract infection, and discharged the patient from the hospital on postoperative day 4. She returned to the gynecologist’s office with severe abdominal pain and vomiting 4 days after discharge. The gynecologist prescribed an antacid and told her to continue taking ciprofloxacin.

The patient was taken to the ED by ambulance 3 days later. Testing revealed a Clostridium dificule (C. diff) infection. During emergency surgery, a large portion of her colon was resected, and a colostomy was performed. The colostomy was reversed 6 months later. The patient developed an incisional hernia and has abdominal scarring.

PATIENT'S CLAIM Prophylactic antibiotics should have been prescribed before surgery.

Two possible scenarios were presented: 1) A bowel injury occurred during surgery, and ciprofloxacin likely worsened the infection caused by the bowel injury; or 2) ciprofloxacin triggered the C. diff infection that caused leaking colon perforations and subsequent peritonitis.

The colon perforations could have been avoided if the gynecologist had diagnosed and treated the C. diff infection in a timely manner.

PHYSICIAN'S DEFENSE The patient’s symptoms did not suggest a C. diff infection; testing was not necessary. Ciprofloxacin might have allowed the proliferation of the C. diff infection, but the use of the drug was not negligent. The infection was not preventable and could not have been diagnosed earlier.

VERDICT A $776,000 New York verdict was returned.

Brain injury and cerebral palsy: When did this occur?

DURING LABOR AND DELIVERY, there were periods when the fetal heart-rate tracings were nonreassuring with variable decelerations and fetal tachycardia; some variables were severe. The child suffered anoxic encephalopathy that caused neurologic injury and cerebral palsy.

PARENTS' CLAIM The infant suffered numerous hypoxic incidents before cesarean delivery was performed. An earlier cesarean delivery could have prevented the injury.

PHYSICIAN'S DEFENSE The newborn had a normal blood cord gas level of 7.2 pH and Apgar scores of 9 and 10, at 1 and 5 minutes, respectively. Fetal heart-rate tracings did not show evidence of fetal hypoxia. The brain injury likely occurred prior to the onset of labor and was possibly related to a viral encephalopathy. 

VERDICT A Virginia defense verdict was returned. These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

Vaginal hysterectomy has a superior profile in terms of morbidity, safety, and cost, compared with other approaches to hysterectomy for benign disease. Despite this standing, vaginal hysterectomy is performed in a minority of cases. As the rates of other minimally invasive approaches—laparoscopic and robotic—have increased in the United States, the vaginal route has declined from 28% in 1998 to 20% in 2010.^1,2 In fact, a large majority (85%) of gynecologists in the United States perform fewer than five vaginal hysterectomies a year.³

The concept of same-day discharge after hysterectomy is not new. Previously published studies, including one from an author of this study,⁴ have shown that discharging patients 12 to 24 hours after laparoscopic or vaginal hysterectomy is feasible. However, outpatient hysterectomy generally has not been adopted to the same extent as outpatient cholecystectomy in the field of general surgery.

At a time of cost-containment and declining medical reimbursements, outpatient hysterectomy has the potential to affect the health-care economic landscape in a significant manner.

Details of the series
Zakaria and Levy describe a consecutive series of 1,071 women who underwent vaginal hysterectomy (performed by a single surgeon) according to a well-outlined outpatient protocol. Participants underwent preoperative counseling and evidence-based ­interventions (medications, hydration) before, during, and after surgery to preempt postoperative pain and nausea.

Median operative time was 34 minutes (range, 17–210 minutes), and median estimated blood loss was 45 mL (range,5–800 mL). Median uterine weight was 160 g (range, 25–1,380 g).

Following the protocol, same-day discharge (ie, within 12 hours) was accomplished in 96% of patients. A small number (41 women, or approximately 4%) required overnight hospitalization for pain, nausea, or the need to travel a significant distance to return to their home. Five patients required readmission or emergency room evaluation within the first postoperative month due to nausea and vomiting, abdominal pain, fever, pulmonary embolus, or vesicovaginal fistula.

Stengths and limitations
Besides demonstrating that patients can be discharged early, Zakaria and Levy also point out that even traditionally “difficult” vaginal cases—for example, nulliparous women (18% of cases), women with a history of cesarean delivery or pelvic surgery (20% of cases), and patients with uteri larger than 250 g (30% of cases)—can be accomplished vaginally. These cases all were performed using a vessel-sealing device over the 10 years of the series.

Single-surgeon and selection bias may limit the generalizability and conclusions of this study. Future investigations using a comparative cohort (with an inpatient arm) and employing validated measures to evaluate outcomes such as postoperative pain, total narcotic use, return to normal activity, and patient satisfaction, also would be helpful. In addition, it would be beneficial to determine whether the same protocol would be applicable to patients undergoing other hysterectomy approaches. 

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Most gynecologic practitioners continue to admit patients overnight following hysterectomy. This study demonstrates that same-day discharge is feasible and safe. It also highlights other routinely employed practices, such as the use of an indwelling catheter and liberal administration of intravenous narcotics postoperatively, that may adversely affect a patient’s recovery.
I strongly recommend that readers refer to this study and consider many of the techniques it describes to minimize postoperative pain and nausea in patients undergoing hysterectomy. Even when a patient is admitted overnight, techniques to minimize postoperative discomfort should be considered.

MADRID – Optimizing anti-inflammatory treatment may help to reduce the risk of heart-related problems in men with crystal-proven gout, judging from 7-year follow up data from a prospective study.

Five factors were found to increase substantially the risk for cardiovascular (CV) events in the 251-patient study: including: high levels of C-reactive protein (CRP); renal insufficiency; daily intake of more than 20 g of alcohol; current coronary heart disease (CHD); and a family history of premature CV events.

The odds ratio (OR) for any CV event was 5.71 for CRP levels greater than 5 mg/L on multivariate analysis. This increased to 10.31 and 14.26 when nonfatal and fatal CV events were considered separately.

Odds ratios for renal insufficiency, defined as a creatinine clearance of less than 60 mL/min per 1.73 m², were 4.76 for any CV event and 8.42 for fatal CV events. Respective values for a family history of CV events before the age of 55 years was 3.09 considering any CV event, but 7.53 if consideration was limited to fatal events only. Current CHD also increased the risk for any CV event (OR, 3.67) and for nonfatal events (OR, 10.41).

Alcohol intake of more than 20g/day carried an OR of 4.23 for any CV event.

"We have a cardiologist in our team to ensure the reliability of the cardiovascular outcomes," said Dr. Victoria Barskova of the Research Institute of Rheumatology in Moscow, who presented the findings at the annual European Congress of Rheumatology (Ann. Rheum. Dis. 2013;72[suppl. 3]:95). She explained that the study was designed to prospectively determine baseline factors that might influence the development of CV events in male patients with crystal-proven gout.

Between 2003 and 2006, a total of 407 men were screened and 301 deemed eligible for the study. Of these, 251 had follow-up data to 2010-2012. Data collected at baseline and at follow-up included patient demographics, including family history of gout and early CV disease, smoking history, and alcohol consumption. Comorbidities and gout characteristics were also assessed and all patients had an ECG and echocardiogram.

Comparing baseline clinical features with follow-up visit data, Dr. Barskova noted that the number of allopurinol users increased from 16% to 57% (P = .00001), although regular allopurinol use was not found to decrease the risk for CV events.

There was an increase in the percentage of patients with diabetes from 18% to 43% (P = .00001), chronic heart disease from 35% to 53% (P = .00001), and heart failure from 10% to 28% (P = .0001). Alcohol use significantly decreased (92% vs. 63%; P less than .0001).

The frequency of subcutaneous tophi and chronic arthritis comparing the first and last visits was the same.

Just under a quarter (23.1%, n = 58) of patients experienced a CV event. There were 32 (13%) deaths reported of which 22 were from cardiovascular causes. There were 36 nonfatal CV events.

"In our cohort of patients with crystal proven gout, the following independent risk factors for all CV events have been highlighted: CRP, renal insufficiency, alcohol intake, coronary heart disease, and a family history of CV events," Dr. Barskova said in conclusion.

The key message for rheumatologists, she added, is that "tight control of inflammation, which is measured not only by the obvious arthritis, but also by the serum CRP level, may have a positive effect on cardiovascular events in patients with gout."

MADRID – Optimizing anti-inflammatory treatment may help to reduce the risk of heart-related problems in men with crystal-proven gout, judging from 7-year follow up data from a prospective study.

Five factors were found to increase substantially the risk for cardiovascular (CV) events in the 251-patient study: including: high levels of C-reactive protein (CRP); renal insufficiency; daily intake of more than 20 g of alcohol; current coronary heart disease (CHD); and a family history of premature CV events.

The odds ratio (OR) for any CV event was 5.71 for CRP levels greater than 5 mg/L on multivariate analysis. This increased to 10.31 and 14.26 when nonfatal and fatal CV events were considered separately.

Odds ratios for renal insufficiency, defined as a creatinine clearance of less than 60 mL/min per 1.73 m², were 4.76 for any CV event and 8.42 for fatal CV events. Respective values for a family history of CV events before the age of 55 years was 3.09 considering any CV event, but 7.53 if consideration was limited to fatal events only. Current CHD also increased the risk for any CV event (OR, 3.67) and for nonfatal events (OR, 10.41).

Alcohol intake of more than 20g/day carried an OR of 4.23 for any CV event.

"We have a cardiologist in our team to ensure the reliability of the cardiovascular outcomes," said Dr. Victoria Barskova of the Research Institute of Rheumatology in Moscow, who presented the findings at the annual European Congress of Rheumatology (Ann. Rheum. Dis. 2013;72[suppl. 3]:95). She explained that the study was designed to prospectively determine baseline factors that might influence the development of CV events in male patients with crystal-proven gout.

Between 2003 and 2006, a total of 407 men were screened and 301 deemed eligible for the study. Of these, 251 had follow-up data to 2010-2012. Data collected at baseline and at follow-up included patient demographics, including family history of gout and early CV disease, smoking history, and alcohol consumption. Comorbidities and gout characteristics were also assessed and all patients had an ECG and echocardiogram.

Comparing baseline clinical features with follow-up visit data, Dr. Barskova noted that the number of allopurinol users increased from 16% to 57% (P = .00001), although regular allopurinol use was not found to decrease the risk for CV events.

There was an increase in the percentage of patients with diabetes from 18% to 43% (P = .00001), chronic heart disease from 35% to 53% (P = .00001), and heart failure from 10% to 28% (P = .0001). Alcohol use significantly decreased (92% vs. 63%; P less than .0001).

The frequency of subcutaneous tophi and chronic arthritis comparing the first and last visits was the same.

Just under a quarter (23.1%, n = 58) of patients experienced a CV event. There were 32 (13%) deaths reported of which 22 were from cardiovascular causes. There were 36 nonfatal CV events.

"In our cohort of patients with crystal proven gout, the following independent risk factors for all CV events have been highlighted: CRP, renal insufficiency, alcohol intake, coronary heart disease, and a family history of CV events," Dr. Barskova said in conclusion.

The key message for rheumatologists, she added, is that "tight control of inflammation, which is measured not only by the obvious arthritis, but also by the serum CRP level, may have a positive effect on cardiovascular events in patients with gout."

MADRID – Optimizing anti-inflammatory treatment may help to reduce the risk of heart-related problems in men with crystal-proven gout, judging from 7-year follow up data from a prospective study.

Five factors were found to increase substantially the risk for cardiovascular (CV) events in the 251-patient study: including: high levels of C-reactive protein (CRP); renal insufficiency; daily intake of more than 20 g of alcohol; current coronary heart disease (CHD); and a family history of premature CV events.

The odds ratio (OR) for any CV event was 5.71 for CRP levels greater than 5 mg/L on multivariate analysis. This increased to 10.31 and 14.26 when nonfatal and fatal CV events were considered separately.

Odds ratios for renal insufficiency, defined as a creatinine clearance of less than 60 mL/min per 1.73 m², were 4.76 for any CV event and 8.42 for fatal CV events. Respective values for a family history of CV events before the age of 55 years was 3.09 considering any CV event, but 7.53 if consideration was limited to fatal events only. Current CHD also increased the risk for any CV event (OR, 3.67) and for nonfatal events (OR, 10.41).

Alcohol intake of more than 20g/day carried an OR of 4.23 for any CV event.

"We have a cardiologist in our team to ensure the reliability of the cardiovascular outcomes," said Dr. Victoria Barskova of the Research Institute of Rheumatology in Moscow, who presented the findings at the annual European Congress of Rheumatology (Ann. Rheum. Dis. 2013;72[suppl. 3]:95). She explained that the study was designed to prospectively determine baseline factors that might influence the development of CV events in male patients with crystal-proven gout.

Between 2003 and 2006, a total of 407 men were screened and 301 deemed eligible for the study. Of these, 251 had follow-up data to 2010-2012. Data collected at baseline and at follow-up included patient demographics, including family history of gout and early CV disease, smoking history, and alcohol consumption. Comorbidities and gout characteristics were also assessed and all patients had an ECG and echocardiogram.

Comparing baseline clinical features with follow-up visit data, Dr. Barskova noted that the number of allopurinol users increased from 16% to 57% (P = .00001), although regular allopurinol use was not found to decrease the risk for CV events.

There was an increase in the percentage of patients with diabetes from 18% to 43% (P = .00001), chronic heart disease from 35% to 53% (P = .00001), and heart failure from 10% to 28% (P = .0001). Alcohol use significantly decreased (92% vs. 63%; P less than .0001).

The frequency of subcutaneous tophi and chronic arthritis comparing the first and last visits was the same.

Just under a quarter (23.1%, n = 58) of patients experienced a CV event. There were 32 (13%) deaths reported of which 22 were from cardiovascular causes. There were 36 nonfatal CV events.

"In our cohort of patients with crystal proven gout, the following independent risk factors for all CV events have been highlighted: CRP, renal insufficiency, alcohol intake, coronary heart disease, and a family history of CV events," Dr. Barskova said in conclusion.

The key message for rheumatologists, she added, is that "tight control of inflammation, which is measured not only by the obvious arthritis, but also by the serum CRP level, may have a positive effect on cardiovascular events in patients with gout."

When country singer Ed Bruce released "Mammas, Don’t Let Your Babies Grow Up to be Cowboys" in 1975, he suggested that they should consider becoming doctors instead, but if a new national survey of doctors is to be believed, that’s not such a good career move either.

The survey, conducted by the Georgia-based staffing company Jackson Healthcare, found that 59% of physicians would be unlikely to encourage a young person to become a doctor. The findings are based on the responses of 3,456 physicians who completed e-mailed surveys between March 7 and April 1, 2013.

Mary Ellen Schneider/IMNG Medical Media

Their dissatisfaction with medical practice is reflected in the career satisfaction numbers in the survey. Only 20% of physicians said that they were very satisfied in their work, while 39% were somewhat satisfied and 42% were somewhat or very dissatisfied.

The satisfied ones tended to be those employed by a hospital or working at a physician-owned practice where they had no ownership stake, according to the survey.

Satisfied doctors reported that they worked 11 hours a day or less and were supported by nurse practitioners or physician assistants.

In contrast, dissatisfied doctors tended to own their practices, work as locum tenens physicians, or work for a hospital-owned practice. They also worked longer hours and had few physician extenders.

Maybe the next generation will take Ed Bruce’s other suggested career path and become lawyers.

[email protected]

When country singer Ed Bruce released "Mammas, Don’t Let Your Babies Grow Up to be Cowboys" in 1975, he suggested that they should consider becoming doctors instead, but if a new national survey of doctors is to be believed, that’s not such a good career move either.

The survey, conducted by the Georgia-based staffing company Jackson Healthcare, found that 59% of physicians would be unlikely to encourage a young person to become a doctor. The findings are based on the responses of 3,456 physicians who completed e-mailed surveys between March 7 and April 1, 2013.

Mary Ellen Schneider/IMNG Medical Media

Their dissatisfaction with medical practice is reflected in the career satisfaction numbers in the survey. Only 20% of physicians said that they were very satisfied in their work, while 39% were somewhat satisfied and 42% were somewhat or very dissatisfied.

The satisfied ones tended to be those employed by a hospital or working at a physician-owned practice where they had no ownership stake, according to the survey.

Satisfied doctors reported that they worked 11 hours a day or less and were supported by nurse practitioners or physician assistants.

In contrast, dissatisfied doctors tended to own their practices, work as locum tenens physicians, or work for a hospital-owned practice. They also worked longer hours and had few physician extenders.

Maybe the next generation will take Ed Bruce’s other suggested career path and become lawyers.

[email protected]

When country singer Ed Bruce released "Mammas, Don’t Let Your Babies Grow Up to be Cowboys" in 1975, he suggested that they should consider becoming doctors instead, but if a new national survey of doctors is to be believed, that’s not such a good career move either.

The survey, conducted by the Georgia-based staffing company Jackson Healthcare, found that 59% of physicians would be unlikely to encourage a young person to become a doctor. The findings are based on the responses of 3,456 physicians who completed e-mailed surveys between March 7 and April 1, 2013.

Mary Ellen Schneider/IMNG Medical Media

Their dissatisfaction with medical practice is reflected in the career satisfaction numbers in the survey. Only 20% of physicians said that they were very satisfied in their work, while 39% were somewhat satisfied and 42% were somewhat or very dissatisfied.

The satisfied ones tended to be those employed by a hospital or working at a physician-owned practice where they had no ownership stake, according to the survey.

Satisfied doctors reported that they worked 11 hours a day or less and were supported by nurse practitioners or physician assistants.

In contrast, dissatisfied doctors tended to own their practices, work as locum tenens physicians, or work for a hospital-owned practice. They also worked longer hours and had few physician extenders.

Maybe the next generation will take Ed Bruce’s other suggested career path and become lawyers.

[email protected]

Preparing pills for a clinical trial
Credit: Esther Dyson

Medication mistakes, reporting errors, and record changes are what led the US Food and Drug Administration (FDA) to delay approval of the anticoagulant apixaban (Eliquis), according to a report in Pharmaceutical Approvals Monthly.

The report reveals that a number of patients enrolled on the ARISTOTLE trial received the wrong medication or the wrong dose, some serious adverse events went unreported, and employees who worked at trial sites in China altered records to cover up noncompliance with “good clinical practice.”

Apixaban won FDA approval last December as prophylaxis for stroke and systemic embolism in patients with nonvalvular atrial fibrillation. And that approval was based on results of the ARISTOTLE trial.

Prior to the approval, the FDA twice rejected a new drug application filed by apixaban’s developers, Pfizer and Bristol-Myers Squibb. But the agency’s reasons were not immediately made public.

Now, the Pharmaceutical Approvals Monthly report and FDA documents show that “data irregularities” were behind the decision. 

In January 2012, Bristol-Myers Squibb notified the FDA of the cover-up attempt that occurred at (at least) 1 trial site in China. The company had learned that its senior manager at a site in Shanghai and an employee from a contract research organization had altered source records to conceal good clinical practice violations. (The employees were subsequently fired.)

According to FDA documents, the cover-up included failure to report 4 potential adverse events, late reports on 3 other events, and the omission of 3 patient outcomes. In addition, there were errors in patient names and dates, some Chinese and English records didn’t match up, and some patient records disappeared before a site visit by FDA inspectors.

Only 35 patients enrolled in the ARISTOTLE trial were treated at the Shanghai site, but the employees who perpetrated the fraud had also worked at 24 of the 36 trial sites in China.

So the FDA performed analyses excluding data from the Shanghai site alone, from the 24 sites where the employees worked, and from all 36 sites in China. And they found that apixaban’s efficacy still held up.

However, there was still the issue of ARISTOTLE participants receiving the wrong medication or the wrong dose. According to Bristol-Myers Squibb, the trial’s double-blind design allowed for dispensing errors.

Initially, the company said this meant that 7.3% of patients who were set to receive apixaban and 1.2% of patients who were set to receive warfarin may have received the wrong drug or dose at some point during the study. However, after additional review, the company said those percentages were likely much lower.

Regardless of the actual percentages, the FDA said this information suggests a pattern of inadequate oversight. And an independent review by FDA medical team leader Thomas Marciniak appears to support that statement. In addition to the aforementioned errors, his review revealed records of doctor visits taking place after patients’ deaths.

In spite of the errors and the fraud, the FDA said it remained convinced of apixaban’s efficacy. So the agency decided to approve the drug and leave out any mention of the data irregularities on the drug’s label.

Preparing pills for a clinical trial
Credit: Esther Dyson

Medication mistakes, reporting errors, and record changes are what led the US Food and Drug Administration (FDA) to delay approval of the anticoagulant apixaban (Eliquis), according to a report in Pharmaceutical Approvals Monthly.

The report reveals that a number of patients enrolled on the ARISTOTLE trial received the wrong medication or the wrong dose, some serious adverse events went unreported, and employees who worked at trial sites in China altered records to cover up noncompliance with “good clinical practice.”

Apixaban won FDA approval last December as prophylaxis for stroke and systemic embolism in patients with nonvalvular atrial fibrillation. And that approval was based on results of the ARISTOTLE trial.

Prior to the approval, the FDA twice rejected a new drug application filed by apixaban’s developers, Pfizer and Bristol-Myers Squibb. But the agency’s reasons were not immediately made public.

Now, the Pharmaceutical Approvals Monthly report and FDA documents show that “data irregularities” were behind the decision. 

In January 2012, Bristol-Myers Squibb notified the FDA of the cover-up attempt that occurred at (at least) 1 trial site in China. The company had learned that its senior manager at a site in Shanghai and an employee from a contract research organization had altered source records to conceal good clinical practice violations. (The employees were subsequently fired.)

According to FDA documents, the cover-up included failure to report 4 potential adverse events, late reports on 3 other events, and the omission of 3 patient outcomes. In addition, there were errors in patient names and dates, some Chinese and English records didn’t match up, and some patient records disappeared before a site visit by FDA inspectors.

Only 35 patients enrolled in the ARISTOTLE trial were treated at the Shanghai site, but the employees who perpetrated the fraud had also worked at 24 of the 36 trial sites in China.

So the FDA performed analyses excluding data from the Shanghai site alone, from the 24 sites where the employees worked, and from all 36 sites in China. And they found that apixaban’s efficacy still held up.

However, there was still the issue of ARISTOTLE participants receiving the wrong medication or the wrong dose. According to Bristol-Myers Squibb, the trial’s double-blind design allowed for dispensing errors.

Initially, the company said this meant that 7.3% of patients who were set to receive apixaban and 1.2% of patients who were set to receive warfarin may have received the wrong drug or dose at some point during the study. However, after additional review, the company said those percentages were likely much lower.

Regardless of the actual percentages, the FDA said this information suggests a pattern of inadequate oversight. And an independent review by FDA medical team leader Thomas Marciniak appears to support that statement. In addition to the aforementioned errors, his review revealed records of doctor visits taking place after patients’ deaths.

In spite of the errors and the fraud, the FDA said it remained convinced of apixaban’s efficacy. So the agency decided to approve the drug and leave out any mention of the data irregularities on the drug’s label.

Preparing pills for a clinical trial
Credit: Esther Dyson

Medication mistakes, reporting errors, and record changes are what led the US Food and Drug Administration (FDA) to delay approval of the anticoagulant apixaban (Eliquis), according to a report in Pharmaceutical Approvals Monthly.

The report reveals that a number of patients enrolled on the ARISTOTLE trial received the wrong medication or the wrong dose, some serious adverse events went unreported, and employees who worked at trial sites in China altered records to cover up noncompliance with “good clinical practice.”

Apixaban won FDA approval last December as prophylaxis for stroke and systemic embolism in patients with nonvalvular atrial fibrillation. And that approval was based on results of the ARISTOTLE trial.

Prior to the approval, the FDA twice rejected a new drug application filed by apixaban’s developers, Pfizer and Bristol-Myers Squibb. But the agency’s reasons were not immediately made public.

Now, the Pharmaceutical Approvals Monthly report and FDA documents show that “data irregularities” were behind the decision. 

In January 2012, Bristol-Myers Squibb notified the FDA of the cover-up attempt that occurred at (at least) 1 trial site in China. The company had learned that its senior manager at a site in Shanghai and an employee from a contract research organization had altered source records to conceal good clinical practice violations. (The employees were subsequently fired.)

According to FDA documents, the cover-up included failure to report 4 potential adverse events, late reports on 3 other events, and the omission of 3 patient outcomes. In addition, there were errors in patient names and dates, some Chinese and English records didn’t match up, and some patient records disappeared before a site visit by FDA inspectors.

Only 35 patients enrolled in the ARISTOTLE trial were treated at the Shanghai site, but the employees who perpetrated the fraud had also worked at 24 of the 36 trial sites in China.

So the FDA performed analyses excluding data from the Shanghai site alone, from the 24 sites where the employees worked, and from all 36 sites in China. And they found that apixaban’s efficacy still held up.

However, there was still the issue of ARISTOTLE participants receiving the wrong medication or the wrong dose. According to Bristol-Myers Squibb, the trial’s double-blind design allowed for dispensing errors.

Initially, the company said this meant that 7.3% of patients who were set to receive apixaban and 1.2% of patients who were set to receive warfarin may have received the wrong drug or dose at some point during the study. However, after additional review, the company said those percentages were likely much lower.

Regardless of the actual percentages, the FDA said this information suggests a pattern of inadequate oversight. And an independent review by FDA medical team leader Thomas Marciniak appears to support that statement. In addition to the aforementioned errors, his review revealed records of doctor visits taking place after patients’ deaths.

In spite of the errors and the fraud, the FDA said it remained convinced of apixaban’s efficacy. So the agency decided to approve the drug and leave out any mention of the data irregularities on the drug’s label.

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

On one of my recent Internet excursions I spent some time on a highly useful website, Hospital Compare. This site is sponsored by Medicare.gov and provides a plethora of useful information for health care consumers who want to know quality metrics on health care facilities in their area. There is quality data on over 4,000 Medicare-certified hospitals across the country.

Hospital Compare is a very user-friendly site. Even those among us who are not so Web savvy can navigate this site in a snap. Just type in your zip code and up pops a list of hospitals in your specified area. You can even narrow your search by requesting what type of hospital you are interested in – acute care Veterans Affairs, acute care, children’s, or critical care access hospitals.

Next, putting a check in the boxes next to hospitals you want to compare produces a grid describing the different facilities. Users can find out which hospitals provide emergency services and whether lab results can be tracked between visits.

Of more interest to hospitalists is the next tab: Patient Survey Results. Here you can find out how well physicians and nurses on your staff communicated with patients during their hospitalization versus how well other health care providers in your region performed.

Courtesy of Medicare.gov

Scrolling through the tabs, you will then find tabs for Timely & Effective Care, which compares inpatient core measures, such as the percentage of patients with MI given aspirin at discharge and the percentage of heart failure patients receiving an ACE inhibitor or an angiotensin receptor blocker. Users can even find out the average wait time in the ED prior to being admitted to a particular hospital.

There is information on how to save money on prescription drugs, advanced directives and long term care, Medicare rights and forms, readmissions, hospital complications, 30-day death rates, health care–associated infections, and much more. While perusing that site, I also came upon yet another great site, Nursing Home Compare. Medicare.gov’s Nursing Home Compareis also chock-full of information for patients and family members who want to find the best care possible. Not only does it rate nursing homes, it gives ratings for rehabilitation facilities as well.

I was shocked to find out that one nursing home near my home had a terrible health inspection rating, while another one close by received flying colors for this metric. This type of information is invaluable for patients who are already sick and vulnerable. This site even provides information about fire safety ratings and details of health inspection reports and complaints.

Patients often ask me what I think about various facilities in the area, and I have had very little valuable information to offer them. It seemed like I always deferred that question to the social worker. Now, I can refer them to this website to help them make very important choices for their health care as well as care for their loved ones.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.