[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

[email protected]

The general pediatrician's role in managing an adolescent with an autism spectrum disorder depends largely on his or her comfort with doing counseling, testing, and medication management.

Most adolescents with an autism spectrum disorder already have a pretty thick chart from a history of pediatrician and pediatric subspecialist consultations, but the etiology question may remain. If a child's intelligence is within the normal range, a lot of elaborate medical testing generally is not necessary. If the child has cognitive dysfunction, such as an IQ below 70, there is a greater probability of finding an underlying cause for the disorder.

Consider separate counseling and procedural visits. Like many pediatric patients, one with an autism spectrum disorder can be anxious about vaccinations, needles, or any other unpleasant procedure. So if they know a particular visit is limited to a discussion of concerns, they are more likely to relax and be more communicative.

Counseling will depend on the cognitive and language abilities of the patient. Discussions will have to be tailored to the level of understanding of the teen with autism spectrum disorder.

Counseling can include addressing sexuality issues. Discuss physical and emotional changes associated with adolescence and the effects they can have on the patient and the family. Teenagers in general are often confused about these changes, and those with autism spectrum disorder are no exception.

Discussions of the sort of sexual interest the patient has or does not have will depend on the patient's expressive capacity. Ask open-ended questions about any situations that may have arisen or about any concerns the patient may have about the future.

Also, educate the teen about the prevention of unwanted pregnancy and sexually transmitted infections.

Medication management is important in this population. Many adolescents on the autism spectrum already take psychopharmacologic agents. There is a wide range of comfort levels among pediatricians regarding prescription of psychopharmacologic agents and management of behavioral challenges. Refer the patient to a specialist if you are not at ease in these situations.

Similarly, some pediatricians will be more comfortable than others in ordering and evaluating genetic testing.

Technology has advanced from general karyotype testing a decade ago to more accurate molecular fragile X assays and chromosome microarray analyses that are available today.

If you feel up to date based on your training and experience, go ahead and order initial testing or updated testing as indicated.

General pediatricians are well equipped to manage any underlying medical issues. For example, if a patient has spells that might suggest seizures, an EEG might be in order, especially in this higher-risk population.

Start a transition plan once the adolescent is in high school. Pediatricians are integral in creating this plan, along with family physicians, internists, and/or other adult care providers.

Also work with school personnel to ensure an optimal outcome. Specific goals can include preparing the patient for postsecondary education or having the patient get necessary vocational skills as he or she becomes more independent and joins the workforce.

Work with parents to clarify goals for future living arrangements. Also suggest that parents establish a special needs trust to protect assets designated for the adolescent while still maintaining eligibility for government benefit programs.

A new study on the efficacy of surgical masks compared with respirator masks in combating the spread of influenza shouldn’t lead directly to increased prophylactic mask usage, one hospitalist group leader says. In fact, with hospitals and patients fully aware of another potential H1N1 flu pandemic this winter, HM groups should focus more on traditional hygiene issues and staff management to stem the impact of flu season, says William Ford, MD, FHM, medical director at Cogent Healthcare and director of the hospitalist program at Temple University in Philadelphia.

The randomized controlled trial published online (JAMA. October 2009. doi:10.1001/jama.2009.1466) ) tracked 446 nurses in EDs, medical units, and pediatric units in eight tertiary-care hospitals in Ontario. Researchers found that influenza infection occurred in 23.6% of nurses in the surgical-mask group and in 22.9% of nurses in the N95 respirator group (absolute risk difference –0.73%; 95% CI, –8.8% to 7.3%; P=0.86).

Dr. Ford says masks "can't hurt" as helpful barriers against the spread of influenza among hospital workers, but HM directors would be better served planning for staffing issues and emphasizing prevention. That includes harping on "hand-washing, hand-washing, and hand-washing," as well as being prepared to implement emergency schedules to rotate physicians into floor shifts should rank-and-file hospitalists call out sick.

"As hospitalist directors, I'd be very cognizant of my backup contingency plan," Dr. Ford says. "We have to take certain steps this year in a worst-case scenario."

A new study on the efficacy of surgical masks compared with respirator masks in combating the spread of influenza shouldn’t lead directly to increased prophylactic mask usage, one hospitalist group leader says. In fact, with hospitals and patients fully aware of another potential H1N1 flu pandemic this winter, HM groups should focus more on traditional hygiene issues and staff management to stem the impact of flu season, says William Ford, MD, FHM, medical director at Cogent Healthcare and director of the hospitalist program at Temple University in Philadelphia.

The randomized controlled trial published online (JAMA. October 2009. doi:10.1001/jama.2009.1466) ) tracked 446 nurses in EDs, medical units, and pediatric units in eight tertiary-care hospitals in Ontario. Researchers found that influenza infection occurred in 23.6% of nurses in the surgical-mask group and in 22.9% of nurses in the N95 respirator group (absolute risk difference –0.73%; 95% CI, –8.8% to 7.3%; P=0.86).

Dr. Ford says masks "can't hurt" as helpful barriers against the spread of influenza among hospital workers, but HM directors would be better served planning for staffing issues and emphasizing prevention. That includes harping on "hand-washing, hand-washing, and hand-washing," as well as being prepared to implement emergency schedules to rotate physicians into floor shifts should rank-and-file hospitalists call out sick.

"As hospitalist directors, I'd be very cognizant of my backup contingency plan," Dr. Ford says. "We have to take certain steps this year in a worst-case scenario."

A new study on the efficacy of surgical masks compared with respirator masks in combating the spread of influenza shouldn’t lead directly to increased prophylactic mask usage, one hospitalist group leader says. In fact, with hospitals and patients fully aware of another potential H1N1 flu pandemic this winter, HM groups should focus more on traditional hygiene issues and staff management to stem the impact of flu season, says William Ford, MD, FHM, medical director at Cogent Healthcare and director of the hospitalist program at Temple University in Philadelphia.

The randomized controlled trial published online (JAMA. October 2009. doi:10.1001/jama.2009.1466) ) tracked 446 nurses in EDs, medical units, and pediatric units in eight tertiary-care hospitals in Ontario. Researchers found that influenza infection occurred in 23.6% of nurses in the surgical-mask group and in 22.9% of nurses in the N95 respirator group (absolute risk difference –0.73%; 95% CI, –8.8% to 7.3%; P=0.86).

Dr. Ford says masks "can't hurt" as helpful barriers against the spread of influenza among hospital workers, but HM directors would be better served planning for staffing issues and emphasizing prevention. That includes harping on "hand-washing, hand-washing, and hand-washing," as well as being prepared to implement emergency schedules to rotate physicians into floor shifts should rank-and-file hospitalists call out sick.

"As hospitalist directors, I'd be very cognizant of my backup contingency plan," Dr. Ford says. "We have to take certain steps this year in a worst-case scenario."

Obtaining intravenous access to treat dehydrated infants and youths can be a challenge for the everyday hospitalist. One alternative is subcutaneous rehydration. Interim results from the Increased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration I (INFUSE) study presented at the recent American College of Emergency Physicians meeting in Boston suggests subcutaneous rehydration as a viable alternative in children with mild to moderate dehydration.

Complete study results were published in the October issue of Pediatrics (doi:10.1542/peds.2008-3588).

"The study included 51 children admitted to emergency rooms throughout the country who were given Hylenex (hyaluronidase human injection-Baxter)," says Sharon Mace, MD, director of pediatric education and quality improvement at the Cleveland Clinic. Hylenex is a purified preparation of the hyaluronidase enzyme; after being administered subcutaneously, it facilitates the infusion of subcutaneous

fluids. "The majority of the patients were able to be given subcutaneous fluids and then sent home," Dr. Mace adds. "In 86% of patients, the catheter was successfully placed on the first attempt. This contrasts to other studies suggesting that the success rate for IV placement in young children is 50% at best."

Shawn L. Ralston, MD, a pediatric hospitalist at the University of Texas Health Sciences Center in San Antonio, notes that most of the time the question of access already has been addressed in the ED. However, there is a subset of medically complex patients in which subcutaneous rehydration is a useful technique to consider.

"The great thing for the hospitalist is that subcutaneous rehydration is almost always one-stick," Dr. Ralston says. "We also find that after rehydration the kids are able to soon begin taking nutrition and water by mouth again."

According to Dr. Mace, only such minor adverse events as swelling and redness at the injection site were observed. No allergic responses were noticed.

Obtaining intravenous access to treat dehydrated infants and youths can be a challenge for the everyday hospitalist. One alternative is subcutaneous rehydration. Interim results from the Increased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration I (INFUSE) study presented at the recent American College of Emergency Physicians meeting in Boston suggests subcutaneous rehydration as a viable alternative in children with mild to moderate dehydration.

Complete study results were published in the October issue of Pediatrics (doi:10.1542/peds.2008-3588).

"The study included 51 children admitted to emergency rooms throughout the country who were given Hylenex (hyaluronidase human injection-Baxter)," says Sharon Mace, MD, director of pediatric education and quality improvement at the Cleveland Clinic. Hylenex is a purified preparation of the hyaluronidase enzyme; after being administered subcutaneously, it facilitates the infusion of subcutaneous

fluids. "The majority of the patients were able to be given subcutaneous fluids and then sent home," Dr. Mace adds. "In 86% of patients, the catheter was successfully placed on the first attempt. This contrasts to other studies suggesting that the success rate for IV placement in young children is 50% at best."

Shawn L. Ralston, MD, a pediatric hospitalist at the University of Texas Health Sciences Center in San Antonio, notes that most of the time the question of access already has been addressed in the ED. However, there is a subset of medically complex patients in which subcutaneous rehydration is a useful technique to consider.

"The great thing for the hospitalist is that subcutaneous rehydration is almost always one-stick," Dr. Ralston says. "We also find that after rehydration the kids are able to soon begin taking nutrition and water by mouth again."

According to Dr. Mace, only such minor adverse events as swelling and redness at the injection site were observed. No allergic responses were noticed.

Obtaining intravenous access to treat dehydrated infants and youths can be a challenge for the everyday hospitalist. One alternative is subcutaneous rehydration. Interim results from the Increased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration I (INFUSE) study presented at the recent American College of Emergency Physicians meeting in Boston suggests subcutaneous rehydration as a viable alternative in children with mild to moderate dehydration.

Complete study results were published in the October issue of Pediatrics (doi:10.1542/peds.2008-3588).

"The study included 51 children admitted to emergency rooms throughout the country who were given Hylenex (hyaluronidase human injection-Baxter)," says Sharon Mace, MD, director of pediatric education and quality improvement at the Cleveland Clinic. Hylenex is a purified preparation of the hyaluronidase enzyme; after being administered subcutaneously, it facilitates the infusion of subcutaneous

fluids. "The majority of the patients were able to be given subcutaneous fluids and then sent home," Dr. Mace adds. "In 86% of patients, the catheter was successfully placed on the first attempt. This contrasts to other studies suggesting that the success rate for IV placement in young children is 50% at best."

Shawn L. Ralston, MD, a pediatric hospitalist at the University of Texas Health Sciences Center in San Antonio, notes that most of the time the question of access already has been addressed in the ED. However, there is a subset of medically complex patients in which subcutaneous rehydration is a useful technique to consider.

"The great thing for the hospitalist is that subcutaneous rehydration is almost always one-stick," Dr. Ralston says. "We also find that after rehydration the kids are able to soon begin taking nutrition and water by mouth again."

According to Dr. Mace, only such minor adverse events as swelling and redness at the injection site were observed. No allergic responses were noticed.

The US Food and Drug Administration (FDA) has approved ofatumumab (Arzerra) to treat chronic lymphocytic leukemia (CLL) that is refractory to fludarabine and alemtuzumab.

The drug was approved under the FDA’s accelerated approval process,

which allows drugs that meet unmet medical needs to be approved faster.

Accelerated approval is based on a surrogate endpoint; for example, a

reduction in tumor, spleen, or lymph node size.

These indicators provide reasonable evidence that the drug will allow patients to live longer with fewer disease-related side effects.

However, accelerated approval requires studies of the drug to continue.

Currently, the manufacturer, Genmab, is conducting a clinical trial to confirm that adding ofatumumab to standard chemotherapy delays the progression of CLL.

Side effects from previous studies include pneumonia, fever, cough, diarrhea, fatigue, shortness of breath, rash, nausea, bronchitis, upper respiratory tract infection, lower red blood cell count, and a decrease in normal white blood cells.

Increased risk of infection is the most serious risk, including progressive multifocal leukoencephalopathy. Patients at high risk for hepatitis B should be tested before using ofatumumab.

Researchers have also investigated other uses for ofatumumab, including the treatment of rheumatoid arthritis, in which it appeared to be safe and effective.

The US Food and Drug Administration (FDA) has approved ofatumumab (Arzerra) to treat chronic lymphocytic leukemia (CLL) that is refractory to fludarabine and alemtuzumab.

The drug was approved under the FDA’s accelerated approval process,

which allows drugs that meet unmet medical needs to be approved faster.

Accelerated approval is based on a surrogate endpoint; for example, a

reduction in tumor, spleen, or lymph node size.

These indicators provide reasonable evidence that the drug will allow patients to live longer with fewer disease-related side effects.

However, accelerated approval requires studies of the drug to continue.

Currently, the manufacturer, Genmab, is conducting a clinical trial to confirm that adding ofatumumab to standard chemotherapy delays the progression of CLL.

Side effects from previous studies include pneumonia, fever, cough, diarrhea, fatigue, shortness of breath, rash, nausea, bronchitis, upper respiratory tract infection, lower red blood cell count, and a decrease in normal white blood cells.

Increased risk of infection is the most serious risk, including progressive multifocal leukoencephalopathy. Patients at high risk for hepatitis B should be tested before using ofatumumab.

Researchers have also investigated other uses for ofatumumab, including the treatment of rheumatoid arthritis, in which it appeared to be safe and effective.

The US Food and Drug Administration (FDA) has approved ofatumumab (Arzerra) to treat chronic lymphocytic leukemia (CLL) that is refractory to fludarabine and alemtuzumab.

The drug was approved under the FDA’s accelerated approval process,

which allows drugs that meet unmet medical needs to be approved faster.

Accelerated approval is based on a surrogate endpoint; for example, a

reduction in tumor, spleen, or lymph node size.

These indicators provide reasonable evidence that the drug will allow patients to live longer with fewer disease-related side effects.

However, accelerated approval requires studies of the drug to continue.

Currently, the manufacturer, Genmab, is conducting a clinical trial to confirm that adding ofatumumab to standard chemotherapy delays the progression of CLL.

Side effects from previous studies include pneumonia, fever, cough, diarrhea, fatigue, shortness of breath, rash, nausea, bronchitis, upper respiratory tract infection, lower red blood cell count, and a decrease in normal white blood cells.

Increased risk of infection is the most serious risk, including progressive multifocal leukoencephalopathy. Patients at high risk for hepatitis B should be tested before using ofatumumab.

Researchers have also investigated other uses for ofatumumab, including the treatment of rheumatoid arthritis, in which it appeared to be safe and effective.

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

Clinical question: Is the use of acid-suppressive medications associated with increased risk of hospital-acquired pneumonia (HAP) in nonventilated inpatients?

Background: Acid-suppressive medications are used frequently in the hospital setting, even though their use often is not evidence-based. Data suggests an association between acid-suppressive medication use and community-acquired pneumonia in the outpatient setting.

Study design: Prospective pharmacoepidemiologic cohort study.

Setting: Large urban academic medical center in Boston.

Synopsis: The cohort was 63,878 admissions of nonventilated patients hospitalized for at least three days. Acid-suppressive medications were prescribed in 52% of admissions; HAP occurred in 3.5% of admissions.

The unadjusted HAP incidence was higher in the group exposed to acid-suppressive medication, compared with the unexposed group (4.9% vs. 2.0%). After adjustment, the likelihood of HAP increased with the use of acid-suppressive medication (adjusted odds ratio, (95% C.I.), 1.3, (1.1 vs. 1.4)).

The matched propensity score analyses and sensitivity analyses yielded similar results. The relationship appeared slightly stronger for aspiration pneumonia compared with nonaspiration pneumonia.

When stratified by type of acid-suppressive medication, proton-pump inhibitors were associated with increased odds of HAP (AOR, (95% C.I.), 1.3 (1.1-1.4)), but histamine receptor antagonists were not (AOR, (95% C.I.), 1.2 (0.98-1.4).

This study was not powered appropriately to detect significance for an OR less than 1.3.

Bottom line: The use of acid-suppressive medications is associated with increased odds of HAP in nonventilated hospitalized patients.

Reference: Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120-2128.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

Clinical question: Is the use of acid-suppressive medications associated with increased risk of hospital-acquired pneumonia (HAP) in nonventilated inpatients?

Background: Acid-suppressive medications are used frequently in the hospital setting, even though their use often is not evidence-based. Data suggests an association between acid-suppressive medication use and community-acquired pneumonia in the outpatient setting.

Study design: Prospective pharmacoepidemiologic cohort study.

Setting: Large urban academic medical center in Boston.

Synopsis: The cohort was 63,878 admissions of nonventilated patients hospitalized for at least three days. Acid-suppressive medications were prescribed in 52% of admissions; HAP occurred in 3.5% of admissions.

The unadjusted HAP incidence was higher in the group exposed to acid-suppressive medication, compared with the unexposed group (4.9% vs. 2.0%). After adjustment, the likelihood of HAP increased with the use of acid-suppressive medication (adjusted odds ratio, (95% C.I.), 1.3, (1.1 vs. 1.4)).

The matched propensity score analyses and sensitivity analyses yielded similar results. The relationship appeared slightly stronger for aspiration pneumonia compared with nonaspiration pneumonia.

When stratified by type of acid-suppressive medication, proton-pump inhibitors were associated with increased odds of HAP (AOR, (95% C.I.), 1.3 (1.1-1.4)), but histamine receptor antagonists were not (AOR, (95% C.I.), 1.2 (0.98-1.4).

This study was not powered appropriately to detect significance for an OR less than 1.3.

Bottom line: The use of acid-suppressive medications is associated with increased odds of HAP in nonventilated hospitalized patients.

Reference: Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120-2128.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

Clinical question: Is the use of acid-suppressive medications associated with increased risk of hospital-acquired pneumonia (HAP) in nonventilated inpatients?

Background: Acid-suppressive medications are used frequently in the hospital setting, even though their use often is not evidence-based. Data suggests an association between acid-suppressive medication use and community-acquired pneumonia in the outpatient setting.

Study design: Prospective pharmacoepidemiologic cohort study.

Setting: Large urban academic medical center in Boston.

Synopsis: The cohort was 63,878 admissions of nonventilated patients hospitalized for at least three days. Acid-suppressive medications were prescribed in 52% of admissions; HAP occurred in 3.5% of admissions.

The unadjusted HAP incidence was higher in the group exposed to acid-suppressive medication, compared with the unexposed group (4.9% vs. 2.0%). After adjustment, the likelihood of HAP increased with the use of acid-suppressive medication (adjusted odds ratio, (95% C.I.), 1.3, (1.1 vs. 1.4)).

The matched propensity score analyses and sensitivity analyses yielded similar results. The relationship appeared slightly stronger for aspiration pneumonia compared with nonaspiration pneumonia.

When stratified by type of acid-suppressive medication, proton-pump inhibitors were associated with increased odds of HAP (AOR, (95% C.I.), 1.3 (1.1-1.4)), but histamine receptor antagonists were not (AOR, (95% C.I.), 1.2 (0.98-1.4).

This study was not powered appropriately to detect significance for an OR less than 1.3.

Bottom line: The use of acid-suppressive medications is associated with increased odds of HAP in nonventilated hospitalized patients.

Reference: Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301(20):2120-2128.

Reviewed for TH eWire by Alexander R. Carbo, MD, FHM; Suzanne Bertisch, MD, MPH; Lauren Doctoroff, MD; John Fani Srour, MD; Caleb Hale, MD; Nancy Torres-Finnerty, MD, FHM, Hospital Medicine Program, Beth Israel Deaconess Medical Center, Boston

A new study linking adults who play video games to greater risk for depression and a higher body mass index (BMI) raises the question of whether a gaming question should be added to the screening process used by psychiatric hospitalists.

The study found female gamers reported greater depression (M=1.57) and poorer health status (M=3.9) than females who don't play video games (depression, M=1.13; health status, M=3.57). Researchers at the Centers for Disease Control and Prevention (CDC), Emory University in Atlanta, and Andrews University in Berrian Springs, Mich., also reported that male gamers reported higher BMIs than nongamers (M=5.31 vs. M5.19; Am J Prev Med.2009;37(4):299-305).

But an accompanying commentary and an interview with a longtime psychiatric hospitalist both say more research is needed before any processes are tweaked.

“It’s sort of like drinking,” says Robert Albanese, MD, chief of the medicine service at the Boise (Idaho) Veterans Affairs Medical Center and director of its Psychiatric Consultation Service. “If people are drinking six beers a day, then that could be a significant part of their depression. If they’re drinking one beer a day, then it probably isn’t.”

The report “is something to be aware of,” Dr. Albanese continues. “But defining its role in the assessment of the psychiatric process—that's going to take some time.”

Dr. Albanese believes the impact of video gaming on adults is an area ripe for further study. He compares it to the value of research on C-reactive protein (CRP). “Many studies in many individuals have demonstrated that it is elevated in people at risk for coronary artery disease,” he notes, “but it still has not become standard of care as a screening instrument.”

A new study linking adults who play video games to greater risk for depression and a higher body mass index (BMI) raises the question of whether a gaming question should be added to the screening process used by psychiatric hospitalists.

The study found female gamers reported greater depression (M=1.57) and poorer health status (M=3.9) than females who don't play video games (depression, M=1.13; health status, M=3.57). Researchers at the Centers for Disease Control and Prevention (CDC), Emory University in Atlanta, and Andrews University in Berrian Springs, Mich., also reported that male gamers reported higher BMIs than nongamers (M=5.31 vs. M5.19; Am J Prev Med.2009;37(4):299-305).

But an accompanying commentary and an interview with a longtime psychiatric hospitalist both say more research is needed before any processes are tweaked.

“It’s sort of like drinking,” says Robert Albanese, MD, chief of the medicine service at the Boise (Idaho) Veterans Affairs Medical Center and director of its Psychiatric Consultation Service. “If people are drinking six beers a day, then that could be a significant part of their depression. If they’re drinking one beer a day, then it probably isn’t.”

The report “is something to be aware of,” Dr. Albanese continues. “But defining its role in the assessment of the psychiatric process—that's going to take some time.”

Dr. Albanese believes the impact of video gaming on adults is an area ripe for further study. He compares it to the value of research on C-reactive protein (CRP). “Many studies in many individuals have demonstrated that it is elevated in people at risk for coronary artery disease,” he notes, “but it still has not become standard of care as a screening instrument.”

A new study linking adults who play video games to greater risk for depression and a higher body mass index (BMI) raises the question of whether a gaming question should be added to the screening process used by psychiatric hospitalists.

The study found female gamers reported greater depression (M=1.57) and poorer health status (M=3.9) than females who don't play video games (depression, M=1.13; health status, M=3.57). Researchers at the Centers for Disease Control and Prevention (CDC), Emory University in Atlanta, and Andrews University in Berrian Springs, Mich., also reported that male gamers reported higher BMIs than nongamers (M=5.31 vs. M5.19; Am J Prev Med.2009;37(4):299-305).

But an accompanying commentary and an interview with a longtime psychiatric hospitalist both say more research is needed before any processes are tweaked.

“It’s sort of like drinking,” says Robert Albanese, MD, chief of the medicine service at the Boise (Idaho) Veterans Affairs Medical Center and director of its Psychiatric Consultation Service. “If people are drinking six beers a day, then that could be a significant part of their depression. If they’re drinking one beer a day, then it probably isn’t.”

The report “is something to be aware of,” Dr. Albanese continues. “But defining its role in the assessment of the psychiatric process—that's going to take some time.”

Dr. Albanese believes the impact of video gaming on adults is an area ripe for further study. He compares it to the value of research on C-reactive protein (CRP). “Many studies in many individuals have demonstrated that it is elevated in people at risk for coronary artery disease,” he notes, “but it still has not become standard of care as a screening instrument.”

The recent decision by a New York hospital system to offer a generous subsidy to affiliated physicians for adoption of electronic health records (EHR) has one hospitalist almost giddy at the thought of accessing community physician information through a seamless digital transition.

North Shore-Long Island Jewish Health System is thought to be the first nationwide to match the federal government's subsidy—$44,000 over five years—to push physicians toward EHR adoption. Mark Fitterman, MD, FACP, FHM, chief of staff and director of hospitalist services at Huntington Hospital of the North Shore-LIJ Health System, says hospitalists will benefit directly by having more access to patients' health records. That access can save valuable—and costly—time compared with the current situation, where Dr. Fitterman and others in his hospital still use paper records.

"It will help improve transitions of care both coming in and going out," Dr. Fitterman says. "We'll be able to improve patient care and record bi-directionally."

The health system, however, says in a statement that it won't judge success solely on a fiscal basis, focusing instead on "our ability to improve patient outcomes." North Shore's initiative is a $400 million project to link some 7,000 affiliated doctors to the health system's main record system.

The commitment speaks to the growing attention EHR has gathered in the healthcare reform debate. To wit, Dr. Fitterman points out that instead of launching the initiative at a few pilot sites, the system is committing to the project at an institutional level.

"It's not even an option," Dr. Fitterman says. "It's part of the evolution of better care, and those who don't jump on board will go extinct."

The recent decision by a New York hospital system to offer a generous subsidy to affiliated physicians for adoption of electronic health records (EHR) has one hospitalist almost giddy at the thought of accessing community physician information through a seamless digital transition.

North Shore-Long Island Jewish Health System is thought to be the first nationwide to match the federal government's subsidy—$44,000 over five years—to push physicians toward EHR adoption. Mark Fitterman, MD, FACP, FHM, chief of staff and director of hospitalist services at Huntington Hospital of the North Shore-LIJ Health System, says hospitalists will benefit directly by having more access to patients' health records. That access can save valuable—and costly—time compared with the current situation, where Dr. Fitterman and others in his hospital still use paper records.

"It will help improve transitions of care both coming in and going out," Dr. Fitterman says. "We'll be able to improve patient care and record bi-directionally."

The health system, however, says in a statement that it won't judge success solely on a fiscal basis, focusing instead on "our ability to improve patient outcomes." North Shore's initiative is a $400 million project to link some 7,000 affiliated doctors to the health system's main record system.

The commitment speaks to the growing attention EHR has gathered in the healthcare reform debate. To wit, Dr. Fitterman points out that instead of launching the initiative at a few pilot sites, the system is committing to the project at an institutional level.

"It's not even an option," Dr. Fitterman says. "It's part of the evolution of better care, and those who don't jump on board will go extinct."

The recent decision by a New York hospital system to offer a generous subsidy to affiliated physicians for adoption of electronic health records (EHR) has one hospitalist almost giddy at the thought of accessing community physician information through a seamless digital transition.

North Shore-Long Island Jewish Health System is thought to be the first nationwide to match the federal government's subsidy—$44,000 over five years—to push physicians toward EHR adoption. Mark Fitterman, MD, FACP, FHM, chief of staff and director of hospitalist services at Huntington Hospital of the North Shore-LIJ Health System, says hospitalists will benefit directly by having more access to patients' health records. That access can save valuable—and costly—time compared with the current situation, where Dr. Fitterman and others in his hospital still use paper records.

"It will help improve transitions of care both coming in and going out," Dr. Fitterman says. "We'll be able to improve patient care and record bi-directionally."

The health system, however, says in a statement that it won't judge success solely on a fiscal basis, focusing instead on "our ability to improve patient outcomes." North Shore's initiative is a $400 million project to link some 7,000 affiliated doctors to the health system's main record system.

The commitment speaks to the growing attention EHR has gathered in the healthcare reform debate. To wit, Dr. Fitterman points out that instead of launching the initiative at a few pilot sites, the system is committing to the project at an institutional level.

"It's not even an option," Dr. Fitterman says. "It's part of the evolution of better care, and those who don't jump on board will go extinct."