Christine Kilgore

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies, both of which appear in the June issue of Pediatrics, show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media. “Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation. Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than what they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said. Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

Dr. McCormick and his colleagues assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores. However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said, adding that “practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to most accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies, both of which appear in the June issue of Pediatrics, show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media. “Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation. Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than what they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said. Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

Dr. McCormick and his colleagues assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores. However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said, adding that “practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to most accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

Watchful waiting for nonsevere acute otitis media can be as acceptable to parents as immediate antibiotic treatment—if parents are properly educated about the options, new study findings and survey results indicate.

Parents' satisfaction with their children's care was no different among parents whose children were randomized to receive either immediate antibiotic treatment or watchful waiting in an outcomes study of the two approaches. The parents all were educated at the study site—a pediatric clinic in Galveston, Texas—about the risks and benefits of treatment.

In a separate study, only a minority of parents who were randomly surveyed by mail about a hypothetical visit for an ear infection—without being given much information—said they would feel comfortable with a watchful waiting approach. Most said they would feel neutral or dissatisfied with such an approach.

The studies, both of which appear in the June issue of Pediatrics, show that “when it's properly explained, parents are equally satisfied with watchful waiting and antibiotic treatment [for nonsevere acute otitis media],” said Allan S. Lieberthal, M.D., who led development of the American Academy of Pediatrics' guidelines on the diagnosis and management of acute otitis media. “Now we need tools for educating parents within the confines of a busy pediatric office,” he said in an interview.

Investigators in the randomized study used a handheld flip chart for a 5- to 10-minute review with parents of the definition and causes of ear infections, characteristics of nonsevere and severe acute otitis media (AOM), antibiotic resistance and costs, rate of symptom response to antibiotics, and possible adverse outcomes associated with immediate treatment versus observation. Parent satisfaction was no different between a group of 111 children randomized to a watchful waiting group and 112 randomized to receive immediate antibiotics, either at day 12 or day 30 after the children were seen, reported David P. McCormick, M.D., of the University of Texas, Galveston, and his colleagues (Pediatrics 2005:115;1455–65).

In the survey, 5,129 parents in 16 Massachusetts communities were asked to rate their level of satisfaction “if your child's doctor diagnosed an ear infection and recommended waiting 1 or 2 days before starting antibiotics (to see if the symptoms get better on their own).”

Of 2,054 parents who returned the survey, 34% said they would be somewhat or extremely satisfied. Another 26% indicated they would be neutral, and the remaining 40% said they would be somewhat or extremely dissatisfied, reported Jonathan A. Finkelstein, M.D., of Harvard Medical School, Boston, and his associates (Pediatrics 2005:115;1466–73).

Both studies were conducted before the AAP guidelines were published last year.

In addition to offering new insight into issues of parent acceptance, findings from the randomized study affirm what the guidelines say: that some children with nonsevere AOM may be observed with watchful waiting as long as they maintain nonsevere status and are kept comfortable with appropriate symptom management, Dr. Lieberthal said.

Of the children randomized to the watchful waiting group, 66% completed the study without antibiotics.

Immediate antibiotic treatment was associated with 16% fewer treatment failures—a difference that the investigators said was larger than what they “expected from [their] review of the literature”—and improved symptom control.

Antibiotic treatment also was associated, however, with increased antibiotic-related adverse events. And although immediate treatment resulted in eradication of Streptococcus pneumoniae carriage in the majority of children, the S. pneumoniae strains cultured from children in the antibiotic group at day 12 were more likely to be multidrug-resistant than were strains from the watchful waiting group, the investigators reported.

“Watchful waiting seems to be an alternative that is acceptable to parents, reduces the number and cost of antibiotic prescriptions, and reduces the percent of multidrug-resistant bacteria colonizing the nasopharynx of children after an episode of AOM,” Dr. McCormick and his associates said. Regardless of the intervention, children who had received antibiotics within the previous 30 days were more than twice as likely to fail treatment as those who had not recently received antibiotics.

In addition to parent education, key factors for implementation of a watchful waiting strategy include access to follow-up care, management of AOM symptoms, and a method to classify AOM severity, the investigators said.

Dr. McCormick and his colleagues assessed AOM severity based on four factors: parental perception of severity, otoscopic examination, body temperature, and tympanogram scores. However, “in retrospect,” they reported, they “could have obtained the same results”—identifying 87% of the nonsevere cases identified with the four-factor scoring system—by using a two-factor scoring system that omitted body temperature and tympanogram.

“Most children with AOM are afebrile at the time of diagnosis as a result of antipyretic medication,” they said, adding that “practicing clinicians rarely use the tympanogram to make a diagnosis of AOM.”

Dr. Lieberthal, cochair of the AAP's subcommittee on management of AOM and professor of pediatrics at the University of Southern California, Los Angeles, said the issue of how to most accurately and uniformly assess AOM severity is still unresolved. “We still need a validated scoring system.”

WASHINGTON — Mobile-bearing knee implants are hyped in advertisements and demanded by patients, but the jury is still out on whether the devices deliver what's promised.

During a panel discussion on “controversial issues and hot topics” in primary total knee replacement at the annual meeting of the American Academy of Orthopaedic Surgeons, several panelists objected to the idea that rotating platform knee implants are superior in many ways to fixed-bearing designs.

“There's certainly some skepticism here about whether mobile-bearing designs are really more forgiving [of rotational misalignment of the femoral and tibial components] and whether there truly is less wear,” said William J. Maloney, M.D., professor of orthopedic surgery at Stanford (Calif.) University, who moderated the discussion.

Rotating platform, or mobile-bearing, knee replacements are designed for potentially longer performance with less wear to parts of the prosthesis. The devices have been marketed and are recommended by some physicians, particularly for younger, active, or overweight patients.

The mobile-bearing knees use three components—just like fixed-bearing replacements—but have a different bearing surface. The metallic femoral component and the metallic tibial tray both move across a mobile polyethylene insert. The insert creates a dual-surface articulation, absorbing force across a greater contact surface and ensuring congruent contact between the femoral and tibial components.

These implants, said panelist Douglas A. Dennis, M.D., “allow increased conformity in both planes without dramatically increasing fixation stresses and the risk of component loosening.”

This, he said, reduces polyethylene wear—which should be the focus of “any total knee design.” Polyethylene wear has been the major mode of total knee replacement failure, said Dr. Dennis, of the Rocky Mountain Musculoskeletal Research Laboratory in Denver.

“We have seen in our laboratory better kinematics in gait with mobile bearings. They're more tolerant of condylar lift-off, which should reduce the potential for polyethylene wear, and I think they're more forgiving of component rotational mal-alignment—the bearing has the potential to self-correct,” he said.

In a 10-year study of total knee replacements, Dr. Dennis and his colleagues found that mobile-bearing knees allow for a wider range of axial rotation without creating excessive polyethylene stresses. “A fairly large number [of mobile-bearing knees] rotated greater than 20 degrees, which is beyond the rotational boundaries of most fixed-bearing designs,” he said.

Arlen D. Hanssen, M.D., argued that several studies have shown no difference in motion and no difference in patello-femoral mechanics between fixed and mobile-bearing knees. Early dislocation and instability continue to be a problem with the rotating-platform knee, and recently there have been reports of late dislocation.

“Late dislocation occurs in this knee because of advanced wear,” said Dr. Hanssen, of the Mayo Clinic in Rochester, Minn.

“One of the reasons to use the rotating-platform knee has been to avoid osteolysis wear … but osteolysis seems to be significantly higher [in patients with the mobile-bearing knee],” he said.

The rigid tibial trays that are required in the rotating platform design also contribute to stress shielding of the proximal tibia, he said.

“Why would you take a knee that [has only been studied] in the elderly, has no better motion, no better patello-femoral mechanics, has the unique complication of dislocation and instability, and now appears to have some wear and osteolysis problems and stress shielding problems?” Dr. Hanssen asked. “My answer is no thanks.”

Other panelists agreed. “The advertisements say [the mobile-bearing knee] is the best thing, that it's going to give us 20 years,” said Merrill A. Ritter, M.D., of the Center for Hip and Knee Surgery in Mooresville, Ind. “There [are] no data to support this, and there are too many things that do work.”

Leo A. Whiteside, M.D., of the Missouri Bone and Joint Center in St. Louis, said that theoretically, the mobile-bearing design should perform better. “What worries me [are] the multiple reports of higher wear,” he said.

Bearing surface is just one of several choices surgeons make when performing total knee arthroplasty. The type of fixation, the modularity of implants, and surgical technique are also controversial, Dr. Maloney added.

WASHINGTON — Mobile-bearing knee implants are hyped in advertisements and demanded by patients, but the jury is still out on whether the devices deliver what's promised.

During a panel discussion on “controversial issues and hot topics” in primary total knee replacement at the annual meeting of the American Academy of Orthopaedic Surgeons, several panelists objected to the idea that rotating platform knee implants are superior in many ways to fixed-bearing designs.

“There's certainly some skepticism here about whether mobile-bearing designs are really more forgiving [of rotational misalignment of the femoral and tibial components] and whether there truly is less wear,” said William J. Maloney, M.D., professor of orthopedic surgery at Stanford (Calif.) University, who moderated the discussion.

Rotating platform, or mobile-bearing, knee replacements are designed for potentially longer performance with less wear to parts of the prosthesis. The devices have been marketed and are recommended by some physicians, particularly for younger, active, or overweight patients.

The mobile-bearing knees use three components—just like fixed-bearing replacements—but have a different bearing surface. The metallic femoral component and the metallic tibial tray both move across a mobile polyethylene insert. The insert creates a dual-surface articulation, absorbing force across a greater contact surface and ensuring congruent contact between the femoral and tibial components.

These implants, said panelist Douglas A. Dennis, M.D., “allow increased conformity in both planes without dramatically increasing fixation stresses and the risk of component loosening.”

This, he said, reduces polyethylene wear—which should be the focus of “any total knee design.” Polyethylene wear has been the major mode of total knee replacement failure, said Dr. Dennis, of the Rocky Mountain Musculoskeletal Research Laboratory in Denver.

“We have seen in our laboratory better kinematics in gait with mobile bearings. They're more tolerant of condylar lift-off, which should reduce the potential for polyethylene wear, and I think they're more forgiving of component rotational mal-alignment—the bearing has the potential to self-correct,” he said.

In a 10-year study of total knee replacements, Dr. Dennis and his colleagues found that mobile-bearing knees allow for a wider range of axial rotation without creating excessive polyethylene stresses. “A fairly large number [of mobile-bearing knees] rotated greater than 20 degrees, which is beyond the rotational boundaries of most fixed-bearing designs,” he said.

Arlen D. Hanssen, M.D., argued that several studies have shown no difference in motion and no difference in patello-femoral mechanics between fixed and mobile-bearing knees. Early dislocation and instability continue to be a problem with the rotating-platform knee, and recently there have been reports of late dislocation.

“Late dislocation occurs in this knee because of advanced wear,” said Dr. Hanssen, of the Mayo Clinic in Rochester, Minn.

“One of the reasons to use the rotating-platform knee has been to avoid osteolysis wear … but osteolysis seems to be significantly higher [in patients with the mobile-bearing knee],” he said.

The rigid tibial trays that are required in the rotating platform design also contribute to stress shielding of the proximal tibia, he said.

“Why would you take a knee that [has only been studied] in the elderly, has no better motion, no better patello-femoral mechanics, has the unique complication of dislocation and instability, and now appears to have some wear and osteolysis problems and stress shielding problems?” Dr. Hanssen asked. “My answer is no thanks.”

Other panelists agreed. “The advertisements say [the mobile-bearing knee] is the best thing, that it's going to give us 20 years,” said Merrill A. Ritter, M.D., of the Center for Hip and Knee Surgery in Mooresville, Ind. “There [are] no data to support this, and there are too many things that do work.”

Leo A. Whiteside, M.D., of the Missouri Bone and Joint Center in St. Louis, said that theoretically, the mobile-bearing design should perform better. “What worries me [are] the multiple reports of higher wear,” he said.

Bearing surface is just one of several choices surgeons make when performing total knee arthroplasty. The type of fixation, the modularity of implants, and surgical technique are also controversial, Dr. Maloney added.

WASHINGTON — Mobile-bearing knee implants are hyped in advertisements and demanded by patients, but the jury is still out on whether the devices deliver what's promised.

During a panel discussion on “controversial issues and hot topics” in primary total knee replacement at the annual meeting of the American Academy of Orthopaedic Surgeons, several panelists objected to the idea that rotating platform knee implants are superior in many ways to fixed-bearing designs.

“There's certainly some skepticism here about whether mobile-bearing designs are really more forgiving [of rotational misalignment of the femoral and tibial components] and whether there truly is less wear,” said William J. Maloney, M.D., professor of orthopedic surgery at Stanford (Calif.) University, who moderated the discussion.

Rotating platform, or mobile-bearing, knee replacements are designed for potentially longer performance with less wear to parts of the prosthesis. The devices have been marketed and are recommended by some physicians, particularly for younger, active, or overweight patients.

The mobile-bearing knees use three components—just like fixed-bearing replacements—but have a different bearing surface. The metallic femoral component and the metallic tibial tray both move across a mobile polyethylene insert. The insert creates a dual-surface articulation, absorbing force across a greater contact surface and ensuring congruent contact between the femoral and tibial components.

These implants, said panelist Douglas A. Dennis, M.D., “allow increased conformity in both planes without dramatically increasing fixation stresses and the risk of component loosening.”

This, he said, reduces polyethylene wear—which should be the focus of “any total knee design.” Polyethylene wear has been the major mode of total knee replacement failure, said Dr. Dennis, of the Rocky Mountain Musculoskeletal Research Laboratory in Denver.

“We have seen in our laboratory better kinematics in gait with mobile bearings. They're more tolerant of condylar lift-off, which should reduce the potential for polyethylene wear, and I think they're more forgiving of component rotational mal-alignment—the bearing has the potential to self-correct,” he said.

In a 10-year study of total knee replacements, Dr. Dennis and his colleagues found that mobile-bearing knees allow for a wider range of axial rotation without creating excessive polyethylene stresses. “A fairly large number [of mobile-bearing knees] rotated greater than 20 degrees, which is beyond the rotational boundaries of most fixed-bearing designs,” he said.

Arlen D. Hanssen, M.D., argued that several studies have shown no difference in motion and no difference in patello-femoral mechanics between fixed and mobile-bearing knees. Early dislocation and instability continue to be a problem with the rotating-platform knee, and recently there have been reports of late dislocation.

“Late dislocation occurs in this knee because of advanced wear,” said Dr. Hanssen, of the Mayo Clinic in Rochester, Minn.

“One of the reasons to use the rotating-platform knee has been to avoid osteolysis wear … but osteolysis seems to be significantly higher [in patients with the mobile-bearing knee],” he said.

The rigid tibial trays that are required in the rotating platform design also contribute to stress shielding of the proximal tibia, he said.

“Why would you take a knee that [has only been studied] in the elderly, has no better motion, no better patello-femoral mechanics, has the unique complication of dislocation and instability, and now appears to have some wear and osteolysis problems and stress shielding problems?” Dr. Hanssen asked. “My answer is no thanks.”

Other panelists agreed. “The advertisements say [the mobile-bearing knee] is the best thing, that it's going to give us 20 years,” said Merrill A. Ritter, M.D., of the Center for Hip and Knee Surgery in Mooresville, Ind. “There [are] no data to support this, and there are too many things that do work.”

Leo A. Whiteside, M.D., of the Missouri Bone and Joint Center in St. Louis, said that theoretically, the mobile-bearing design should perform better. “What worries me [are] the multiple reports of higher wear,” he said.

Bearing surface is just one of several choices surgeons make when performing total knee arthroplasty. The type of fixation, the modularity of implants, and surgical technique are also controversial, Dr. Maloney added.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who have the disorder.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates reviewed the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA).

The investigators then analyzed functional outcomes data collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores from parent PODCI forms revealed significant relationships between lumbar spine BMD and upper extremity function, and an analysis of scores from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used for baseline measurements and monitoring of patients who have osteogenesis imperfecta, but in the future more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who have the disorder.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates reviewed the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA).

The investigators then analyzed functional outcomes data collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores from parent PODCI forms revealed significant relationships between lumbar spine BMD and upper extremity function, and an analysis of scores from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used for baseline measurements and monitoring of patients who have osteogenesis imperfecta, but in the future more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who have the disorder.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates reviewed the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA).

The investigators then analyzed functional outcomes data collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores from parent PODCI forms revealed significant relationships between lumbar spine BMD and upper extremity function, and an analysis of scores from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used for baseline measurements and monitoring of patients who have osteogenesis imperfecta, but in the future more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who are afflicted with osteogenesis imperfecta.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates conducted a review of the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA). He and his coinvestigators then analyzed functional outcomes data that were collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores obtained from parent PODCI forms revealed that there were significant relationships between lumbar spine BMD and upper extremity function. In addition, an analysis of scores that were obtained from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed that there were significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used as a means of obtaining baseline measurements and for monitoring patients with osteogenesis imperfecta, but more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who are afflicted with osteogenesis imperfecta.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates conducted a review of the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA). He and his coinvestigators then analyzed functional outcomes data that were collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores obtained from parent PODCI forms revealed that there were significant relationships between lumbar spine BMD and upper extremity function. In addition, an analysis of scores that were obtained from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed that there were significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used as a means of obtaining baseline measurements and for monitoring patients with osteogenesis imperfecta, but more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Bone mineral density is directly tied to functional outcome and ability in children with osteogenesis imperfecta, Robert Huang, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

The findings lend credence to a current focus in treatment on improving bone mineral density (BMD) in children who are afflicted with osteogenesis imperfecta.

“Bisphosphonates have come to the forefront of treatment for osteogenesis imperfecta, but [we haven't known] the relationship of BMD ultimately to function,” said Dr. Huang of Houston Shriners Hospital.

Dr. Huang and his associates conducted a review of the records of 29 consecutive patients with osteogenesis imperfecta (ages 4–17) who underwent BMD assessment (mostly of the lumbar spine and wrist) using dual-energy x-ray absorptiometry (DXA). He and his coinvestigators then analyzed functional outcomes data that were collected using the Pediatric Outcomes Data Collection Instrument (PODCI).

Their analysis of scores obtained from parent PODCI forms revealed that there were significant relationships between lumbar spine BMD and upper extremity function. In addition, an analysis of scores that were obtained from the child PODCI scores (15 children were old enough to complete the child PODCI forms) revealed that there were significant relationships between wrist BMD and upper extremity function.

The investigators also found relationships between BMD and other functional domains within PODCI. “Certainly, BMD is an indicator of physical function,” Dr. Huang said.

DXA scanning is increasingly being used as a means of obtaining baseline measurements and for monitoring patients with osteogenesis imperfecta, but more “BMD data for children with osteogenesis imperfecta will be required to establish specific guidelines for the treatment of children with [the disorder],” he said.

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain originates from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%–70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients who have neck pain, Dr. Wang said.

Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms in evaluating neck pain.

“I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians who practice at UCLA order diskograms of the cervical spine as they do of the lumbar spine, but “I tend not to get diskograms,” Dr. Wang observed. “I'm not quite sure what to make of them.”

MRI helps identify severe narrowing of the spinal cord. The circles highlight swelling.

A lateral x-ray shows degenerative changes of the cervical spine. Photos courtesy Dr. Jeffrey C. Wang

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain originates from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%–70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients who have neck pain, Dr. Wang said.

Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms in evaluating neck pain.

“I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians who practice at UCLA order diskograms of the cervical spine as they do of the lumbar spine, but “I tend not to get diskograms,” Dr. Wang observed. “I'm not quite sure what to make of them.”

MRI helps identify severe narrowing of the spinal cord. The circles highlight swelling.

A lateral x-ray shows degenerative changes of the cervical spine. Photos courtesy Dr. Jeffrey C. Wang

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain originates from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%–70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients who have neck pain, Dr. Wang said.

Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms in evaluating neck pain.

“I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians who practice at UCLA order diskograms of the cervical spine as they do of the lumbar spine, but “I tend not to get diskograms,” Dr. Wang observed. “I'm not quite sure what to make of them.”

MRI helps identify severe narrowing of the spinal cord. The circles highlight swelling.

A lateral x-ray shows degenerative changes of the cervical spine. Photos courtesy Dr. Jeffrey C. Wang

Prenatal exposure to combustion-related air pollution may cause chromosomal abnormalities in fetal tissue, according to findings from a study of 60 New York City newborns.

In studies of other populations, such abnormalities have been linked to an increased risk of leukemia and other cancers, said Kirsti A. Bocskay of the department of environmental health sciences at Columbia University, New York, and her colleagues.

The investigators monitored exposure to polycyclic aromatic hydrocarbons (PAHs)—pollutants found in emissions from cars and other vehicles, residential heating, power generation, and tobacco smoking—among nonsmoking African American and Dominican mothers living in three low-income neighborhoods in the city.

The mothers filled out questionnaires and wore portable air monitors for 48 hours during the third trimester. Chromosomal abnormalities were measured in umbilical cord blood obtained at delivery.

The investigators found 4.7 chromosome abnormalities per 1,000 white blood cells in newborns from mothers with low exposure to PAHs and 7.2 abnormalities per 1,000 white blood cells in newborns from mothers with high exposure to PAHs.

(“Low” exposure meant air pollution levels below the average, while “high” exposure referred to above-average levels).

In particular, it was stable chromosomal aberrations—not unstable aberrations—that were increased. Stable aberrations are persistent, rather than transient, markers of cytogenetic damage.

“This study has demonstrated a significant association between prenatal environmental exposure to airborne carcinogenic PAHs and stable aberrations in cord blood at the relatively low environmental concentrations found in New York City,” the investigators said (Cancer Epidemiol. Biomarkers Prev. 2005;14:506–11).

Prenatal exposure to combustion-related air pollution may cause chromosomal abnormalities in fetal tissue, according to findings from a study of 60 New York City newborns.

In studies of other populations, such abnormalities have been linked to an increased risk of leukemia and other cancers, said Kirsti A. Bocskay of the department of environmental health sciences at Columbia University, New York, and her colleagues.

The investigators monitored exposure to polycyclic aromatic hydrocarbons (PAHs)—pollutants found in emissions from cars and other vehicles, residential heating, power generation, and tobacco smoking—among nonsmoking African American and Dominican mothers living in three low-income neighborhoods in the city.

The mothers filled out questionnaires and wore portable air monitors for 48 hours during the third trimester. Chromosomal abnormalities were measured in umbilical cord blood obtained at delivery.

The investigators found 4.7 chromosome abnormalities per 1,000 white blood cells in newborns from mothers with low exposure to PAHs and 7.2 abnormalities per 1,000 white blood cells in newborns from mothers with high exposure to PAHs.

(“Low” exposure meant air pollution levels below the average, while “high” exposure referred to above-average levels).

In particular, it was stable chromosomal aberrations—not unstable aberrations—that were increased. Stable aberrations are persistent, rather than transient, markers of cytogenetic damage.

“This study has demonstrated a significant association between prenatal environmental exposure to airborne carcinogenic PAHs and stable aberrations in cord blood at the relatively low environmental concentrations found in New York City,” the investigators said (Cancer Epidemiol. Biomarkers Prev. 2005;14:506–11).

Prenatal exposure to combustion-related air pollution may cause chromosomal abnormalities in fetal tissue, according to findings from a study of 60 New York City newborns.

In studies of other populations, such abnormalities have been linked to an increased risk of leukemia and other cancers, said Kirsti A. Bocskay of the department of environmental health sciences at Columbia University, New York, and her colleagues.

The investigators monitored exposure to polycyclic aromatic hydrocarbons (PAHs)—pollutants found in emissions from cars and other vehicles, residential heating, power generation, and tobacco smoking—among nonsmoking African American and Dominican mothers living in three low-income neighborhoods in the city.

The mothers filled out questionnaires and wore portable air monitors for 48 hours during the third trimester. Chromosomal abnormalities were measured in umbilical cord blood obtained at delivery.

The investigators found 4.7 chromosome abnormalities per 1,000 white blood cells in newborns from mothers with low exposure to PAHs and 7.2 abnormalities per 1,000 white blood cells in newborns from mothers with high exposure to PAHs.

(“Low” exposure meant air pollution levels below the average, while “high” exposure referred to above-average levels).

In particular, it was stable chromosomal aberrations—not unstable aberrations—that were increased. Stable aberrations are persistent, rather than transient, markers of cytogenetic damage.

“This study has demonstrated a significant association between prenatal environmental exposure to airborne carcinogenic PAHs and stable aberrations in cord blood at the relatively low environmental concentrations found in New York City,” the investigators said (Cancer Epidemiol. Biomarkers Prev. 2005;14:506–11).

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

"We can delete [items from the record], as long as we note that something has been deleted and who did it," said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

"The real reason patients don't ask to make deletions [now] is because most people don't look at their records," he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), "now there's a federal right of access to medical records."

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces "the idea that patients should be in control," and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether "a patient [should] be able to delete accurate, factual information" from medical records. The bottom line, however, is that "we're in the process of radically changing the medical record … into the patient's record," Mr. Annas said.

There are "lots of mistakes in medical records," making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate "you could argue that patients should be able to change anything," he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that "patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added," Mr. Annas explained.

Those who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. "He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him," said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. "And if he wanted it out of a paper record, I'd still say yes," though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from "physician's record" to "patient's record" would hinder communication among providers.

"Part of the purpose [of the medical record] is it helps individuals plan care," said one physician. "So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers]," she said.

It's true, Mr. Annas said, that "defense attorneys still say today that your best defense is a complete medical record."

Still, physicians, overall, "take the record too seriously" and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the record before the visit ends, he said. "It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you're telling me? Is it right?'"

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

"We can delete [items from the record], as long as we note that something has been deleted and who did it," said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

"The real reason patients don't ask to make deletions [now] is because most people don't look at their records," he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), "now there's a federal right of access to medical records."

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces "the idea that patients should be in control," and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether "a patient [should] be able to delete accurate, factual information" from medical records. The bottom line, however, is that "we're in the process of radically changing the medical record … into the patient's record," Mr. Annas said.

There are "lots of mistakes in medical records," making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate "you could argue that patients should be able to change anything," he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that "patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added," Mr. Annas explained.

Those who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. "He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him," said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. "And if he wanted it out of a paper record, I'd still say yes," though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from "physician's record" to "patient's record" would hinder communication among providers.

"Part of the purpose [of the medical record] is it helps individuals plan care," said one physician. "So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers]," she said.

It's true, Mr. Annas said, that "defense attorneys still say today that your best defense is a complete medical record."

Still, physicians, overall, "take the record too seriously" and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the record before the visit ends, he said. "It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you're telling me? Is it right?'"

The long-held perception that medical records should never be altered at a patient's request is quickly becoming erroneous, according to health lawyer and ethicist George Annas.

"We can delete [items from the record], as long as we note that something has been deleted and who did it," said Mr. Annas, chairman of the department of health law, bioethics, and human rights at Boston University.

In a webcast sponsored by the National Institutes of Health, he braced physicians for a future in which patients will increasingly ask them to correct, delete, or change items in the medical record that are either errors or items that they are concerned may pose harm to them.

"The real reason patients don't ask to make deletions [now] is because most people don't look at their records," he said. But with the advent of the Health Insurance Portability and Accountability Act (HIPAA), "now there's a federal right of access to medical records."

Moreover, President Bush's current emphasis on electronic medical records (EMRs) embraces "the idea that patients should be in control," and patients are generally much more concerned about the content of electronic records than paper records, said Mr. Annas, who is also professor of sociomedical sciences and community medicine at Boston University.

The Bush administration has not addressed, in the context of its EMR proposals, whether "a patient [should] be able to delete accurate, factual information" from medical records. The bottom line, however, is that "we're in the process of radically changing the medical record … into the patient's record," Mr. Annas said.

There are "lots of mistakes in medical records," making it likely that many changes made in the future will address actual errors. Debate about other types of alterations will ensue, but under this new climate "you could argue that patients should be able to change anything," he told the physicians.

HIPAA addresses the issue of corrections to medical records, saying that "patients have a right to request corrections in the record, and if there's no response, they can write their own letter and have it added," Mr. Annas explained.

Those who attended the NIH session reviewed a case in which a patient presented at the National Institute of Neurological Diseases and Stroke to enroll in a sleep study. He had a chief complaint of insomnia but, during a visit with an NIH social worker, he also reported symptoms of severe depression and a history of drug use.

The day after the social worker evaluated the 37-year-old unemployed man, he requested that the information entered in the computerized record be deleted. "He was vague in his request, but he was concerned that someone would illegally obtain access … and use [the information] against him," said Elaine Chase, of the social work department at the NIH Clinical Center, Bethesda, Md.

Mr. Annas said that if he were the provider faced with this request, he would agree to delete the information most disconcerting to the patient. "And if he wanted it out of a paper record, I'd still say yes," though, in the interest of research integrity, the patient should then be excluded from the NIH study, he said.

He offered his verdict on the case example after a free-ranging discussion in which some physicians voiced concern that a move from "physician's record" to "patient's record" would hinder communication among providers.

"Part of the purpose [of the medical record] is it helps individuals plan care," said one physician. "So from this standpoint, you can't just delete things. … Or if there's going to be a patient medical record, maybe there needs to be another record [for providers]," she said.

It's true, Mr. Annas said, that "defense attorneys still say today that your best defense is a complete medical record."

Still, physicians, overall, "take the record too seriously" and, although questions remain, they are going to have to be more willing to consider patient requests to alter the medical records, Mr. Annas told this newspaper.

Theoretically, at least, the doctor and patient should review the record before the visit ends, he said. "It makes sense that when you take a history, you should go over it with the patient and ask, 'Is this what you're telling me? Is it right?'"

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill (as opposed to moderate or poor fill), low body mass index (BMI), and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge. Lower BMI was associated with better functional outcomes. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with poor fill grade also had higher BMI and a longer duration of symptoms, he reported.

In another study of osteoarticular transplantation surgery for large full-thickness cartilage defects of the knee, investigators found that 80% of 58 patients who underwent the procedure demonstrated significant improvement at an average of 36 months, reported Albert W. Pearsall IV, M.D., of the University of South Alabama Knollwood Park Hospital in Mobile.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill (as opposed to moderate or poor fill), low body mass index (BMI), and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge. Lower BMI was associated with better functional outcomes. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with poor fill grade also had higher BMI and a longer duration of symptoms, he reported.

In another study of osteoarticular transplantation surgery for large full-thickness cartilage defects of the knee, investigators found that 80% of 58 patients who underwent the procedure demonstrated significant improvement at an average of 36 months, reported Albert W. Pearsall IV, M.D., of the University of South Alabama Knollwood Park Hospital in Mobile.

Microfracture significantly improved knee function in patients with isolated full-thickness cartilage defects of the femur, Kai Mithoefer, M.D., reported at the annual meeting of the American Academy of Orthopaedic Surgeons.

His prospective evaluation of the common technique, which involves clearing out defective cartilage and creating a series of holes in the subchondral bone to stimulate growth of fibrocartilaginous repair tissue, showed that best results were obtained in patients who had good repair tissue fill (as opposed to moderate or poor fill), low body mass index (BMI), and symptom duration less than 12 months.

In the study, 48 patients were evaluated, with a minimum 2-year follow-up, using a combination of validated outcomes scores—including the SF-36 and Activities of Daily Living scores—cartilage-sensitive MRI, and a subjective rating. Most patients were male; they averaged 21 years of age.

Patients with good fill grade “had significantly more improvement in all the scores than patients with moderate fill grade,” reported Dr. Mithoefer, of Massachusetts General Hospital, Cambridge. Lower BMI was associated with better functional outcomes. Poor fill grade was associated with limited improvement and decreasing functional scores after 24 months. Patients with poor fill grade also had higher BMI and a longer duration of symptoms, he reported.

In another study of osteoarticular transplantation surgery for large full-thickness cartilage defects of the knee, investigators found that 80% of 58 patients who underwent the procedure demonstrated significant improvement at an average of 36 months, reported Albert W. Pearsall IV, M.D., of the University of South Alabama Knollwood Park Hospital in Mobile.

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain stems from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%-70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients with neck pain, Dr. Wang said. Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms. “I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians at UCLA order diskograms of the cervical spine, but “I tend not to get diskograms,” Dr. Wang said. “I'm not quite sure what to make of them.”

MRI (left) helps identify severe narrowing of the spinal cord. An x-ray shows degenerative changes. PHOTOS COURTESY DR. JEFFREY C. WANG

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain stems from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%-70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients with neck pain, Dr. Wang said. Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms. “I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians at UCLA order diskograms of the cervical spine, but “I tend not to get diskograms,” Dr. Wang said. “I'm not quite sure what to make of them.”

MRI (left) helps identify severe narrowing of the spinal cord. An x-ray shows degenerative changes. PHOTOS COURTESY DR. JEFFREY C. WANG

Physicians who urged conservative treatment for neck pain—including a waiting period for imaging studies—were peppered with questions at the annual meeting of the American Academy of Orthopaedic Surgeons about how to determine whether and when neck pain stems from the disk.

“Unfortunately, we have no clear guidelines on how to determine whether neck pain is coming from the disk,” said Raj Rao, M.D. “If it's worse with extension, I'm more inclined to believe that this may be [disk-related] pain. But number one is just my instinctive feel.”

Dr. Rao, director of spine surgery at the Medical College of Wisconsin, Milwaukee, and Jeffrey C. Wang, M.D., had both emphasized during a session on the cervical spine that neck pain—which 50%-70% of people experience at some point—most often resolves with conservative measures.

“If there are no urgent findings, no history of trauma, no suspicion of neoplasm or infection, and [the patient doesn't] have a worsening neurologic deficit, there is an appropriate period of time you can wait before obtaining any imaging studies whatsoever,” said Dr. Wang, chief of the spine service at the UCLA School of Medicine.

He recommended waiting at least 4 weeks before performing plain radiography of the cervical spine and evaluating radiographs as thoroughly as possible before considering MRI.

“The newer thinking is that [in addition to many other factors] we want to look at the amount of space available for the spinal cord and the neurologic elements,” Dr. Wang said. “And remember, the oblique views are important.”

Despite recent concerns about nonsteroidal anti-inflammatory drugs, the drugs are still a first line of treatment for patients with neck pain, Dr. Wang said. Corticosteroids “do not have a role in neck pain alone without any neurologic symptoms,” and narcotics and muscle relaxants are appropriate only for short-term use, he said.

“Physical therapy,” he emphasized, “is very, very valuable. We can now send patients in the acute phase—there are many more modalities to control pain.”

Dr. Wang and Dr. Rao responded to physicians who said they were frustrated with patients involved in legal actions who seek their opinion on whether motor vehicle accidents caused their neck pain—and specifically whether the accidents caused disk herniations.

The two physicians urged their colleagues to be cautious. “My party-line answer is that I can't make a determination of whether [their neck pain] is caused by the accident. … And I rarely see patients with an acute herniated disk from a car accident,” Dr. Wang said.

“We have to remember we're dealing with pain. There are so many inputs,” Dr. Rao said. “It's very difficult to quantify how much of the pain is coming from the patient's neck, the patient's disk, and elsewhere.”

Studies show that one-third of patients who suffer whiplash in motor vehicle accidents will have symptoms for 1 year, and 25% will have symptoms for up to 2 years, Dr. Wang said.

The physicians also responded cautiously to a question from the session moderator Jeffrey S. Fischgrund, M.D., about the role of diskograms. “I'm sure that within 2 years, cervical disk replacements will become available, and there's no question that people will be looking at this as a treatment for neck pain. And I'm sure we'll see a lot more diskograms. … Will this be an option for people with neck pain?” said Dr. Fischgrund, who practices in Southfield, Mich.

Some physicians at UCLA order diskograms of the cervical spine, but “I tend not to get diskograms,” Dr. Wang said. “I'm not quite sure what to make of them.”

MRI (left) helps identify severe narrowing of the spinal cord. An x-ray shows degenerative changes. PHOTOS COURTESY DR. JEFFREY C. WANG

WASHINGTON — Septic arthritis of the hip can be diagnosed in a child using four predictors, Peter D. Pizzutillo, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

The predictors are: sudden onset of symptoms, fever, an erythrocyte sedimentation rate greater than 40 mm/hour, and a serum white blood cell count greater than 12,000.

“If all four criteria [are present], the possibility of having septic arthritis is 99%. If three of these four criteria are present, the risk is reduced to 93%,” he said. “These are good indicators.

“I think our pediatric colleagues are very attuned to … the need for early diagnosis of infection,” said Dr. Pizzutillo, director of pediatric orthopedic surgery at St. Christopher's Hospital for Children in Philadelphia.

Diagnosis is still a challenge, he said, and a delay in treatment of more than 4 days significantly increases the risk of a poor result. “If you're seeing the hip with a large swollen, tender thigh … positioned in flexion, abduction, and external rotation, something's been going on for a long period of time.”

The diagnosis of septic arthritis was the focus of research that won the 2005 Orthopedic Research and Education Foundation clinical research award. Mininder S. Kocher, M.D., and his associates did a retrospective study of children with acutely irritable hip and concluded that four predictors—the white blood cell count and sedimentation rate cited by Dr. Pizzutillo, fever, and the inability to bear weight—could be used to differentiate septic arthritis from transient synovitis of the hip.

Using these predictors, Dr. Kocher and associates at Children's Hospital in Boston then developed guidelines for managing septic arthritis in children. They found that patients treated after its development received care that varied less and was more efficient and effective than the care received before the guidelines were implemented.

Hydration and antibiotics remain the major components of treatment for septic arthritis of the hip, along with surgical drainage and irrigation of the hip joint, said Dr. Pizzutillo. He usually removes the capsular window to ensure continued drainage and leaves the drain in place until the volume of drainage decreases.

A switch from IV to oral antibiotics can be made once constitutional signs improve and if no concurrent osteomyelitis is present, he said.

“The problem is the kids who don't show response—you do the drainage, give appropriate antibiotics, and they're just not improving,” he said. “That's when [imaging] studies are useful—a bone scan, for instance, will help you determine if there's something you're missing.”

The sequelae of septic arthritis of the hip include partial or complete destruction of the proximal femoral physis, avascular necrosis of the femoral head, complete dissolution of the femoral head and neck, unstable hip articulation, and hip dislocation.

In addition to being febrile, a child with septic arthritis of the hip is irritable and limps or is unable to bear weight. The child will have severe pain with attempted passive motion of the hip joint, Dr. Pizzutillo said.

Neonates may only display anorexia, irritability, and lethargy, he added.

Staphylococcus aureus seems to be one of the most common organisms implicated, although “Kingella kingae is increasing in frequency, especially in healthy children under 4,” Dr Pizzutillo said.

WASHINGTON — Septic arthritis of the hip can be diagnosed in a child using four predictors, Peter D. Pizzutillo, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

The predictors are: sudden onset of symptoms, fever, an erythrocyte sedimentation rate greater than 40 mm/hour, and a serum white blood cell count greater than 12,000.

“If all four criteria [are present], the possibility of having septic arthritis is 99%. If three of these four criteria are present, the risk is reduced to 93%,” he said. “These are good indicators.

“I think our pediatric colleagues are very attuned to … the need for early diagnosis of infection,” said Dr. Pizzutillo, director of pediatric orthopedic surgery at St. Christopher's Hospital for Children in Philadelphia.

Diagnosis is still a challenge, he said, and a delay in treatment of more than 4 days significantly increases the risk of a poor result. “If you're seeing the hip with a large swollen, tender thigh … positioned in flexion, abduction, and external rotation, something's been going on for a long period of time.”

The diagnosis of septic arthritis was the focus of research that won the 2005 Orthopedic Research and Education Foundation clinical research award. Mininder S. Kocher, M.D., and his associates did a retrospective study of children with acutely irritable hip and concluded that four predictors—the white blood cell count and sedimentation rate cited by Dr. Pizzutillo, fever, and the inability to bear weight—could be used to differentiate septic arthritis from transient synovitis of the hip.

Using these predictors, Dr. Kocher and associates at Children's Hospital in Boston then developed guidelines for managing septic arthritis in children. They found that patients treated after its development received care that varied less and was more efficient and effective than the care received before the guidelines were implemented.

Hydration and antibiotics remain the major components of treatment for septic arthritis of the hip, along with surgical drainage and irrigation of the hip joint, said Dr. Pizzutillo. He usually removes the capsular window to ensure continued drainage and leaves the drain in place until the volume of drainage decreases.

A switch from IV to oral antibiotics can be made once constitutional signs improve and if no concurrent osteomyelitis is present, he said.

“The problem is the kids who don't show response—you do the drainage, give appropriate antibiotics, and they're just not improving,” he said. “That's when [imaging] studies are useful—a bone scan, for instance, will help you determine if there's something you're missing.”

The sequelae of septic arthritis of the hip include partial or complete destruction of the proximal femoral physis, avascular necrosis of the femoral head, complete dissolution of the femoral head and neck, unstable hip articulation, and hip dislocation.

In addition to being febrile, a child with septic arthritis of the hip is irritable and limps or is unable to bear weight. The child will have severe pain with attempted passive motion of the hip joint, Dr. Pizzutillo said.

Neonates may only display anorexia, irritability, and lethargy, he added.

Staphylococcus aureus seems to be one of the most common organisms implicated, although “Kingella kingae is increasing in frequency, especially in healthy children under 4,” Dr Pizzutillo said.

WASHINGTON — Septic arthritis of the hip can be diagnosed in a child using four predictors, Peter D. Pizzutillo, M.D., said at the annual meeting of the American Academy of Orthopedic Surgeons.

The predictors are: sudden onset of symptoms, fever, an erythrocyte sedimentation rate greater than 40 mm/hour, and a serum white blood cell count greater than 12,000.

“If all four criteria [are present], the possibility of having septic arthritis is 99%. If three of these four criteria are present, the risk is reduced to 93%,” he said. “These are good indicators.

“I think our pediatric colleagues are very attuned to … the need for early diagnosis of infection,” said Dr. Pizzutillo, director of pediatric orthopedic surgery at St. Christopher's Hospital for Children in Philadelphia.

Diagnosis is still a challenge, he said, and a delay in treatment of more than 4 days significantly increases the risk of a poor result. “If you're seeing the hip with a large swollen, tender thigh … positioned in flexion, abduction, and external rotation, something's been going on for a long period of time.”

The diagnosis of septic arthritis was the focus of research that won the 2005 Orthopedic Research and Education Foundation clinical research award. Mininder S. Kocher, M.D., and his associates did a retrospective study of children with acutely irritable hip and concluded that four predictors—the white blood cell count and sedimentation rate cited by Dr. Pizzutillo, fever, and the inability to bear weight—could be used to differentiate septic arthritis from transient synovitis of the hip.

Using these predictors, Dr. Kocher and associates at Children's Hospital in Boston then developed guidelines for managing septic arthritis in children. They found that patients treated after its development received care that varied less and was more efficient and effective than the care received before the guidelines were implemented.

Hydration and antibiotics remain the major components of treatment for septic arthritis of the hip, along with surgical drainage and irrigation of the hip joint, said Dr. Pizzutillo. He usually removes the capsular window to ensure continued drainage and leaves the drain in place until the volume of drainage decreases.

A switch from IV to oral antibiotics can be made once constitutional signs improve and if no concurrent osteomyelitis is present, he said.

“The problem is the kids who don't show response—you do the drainage, give appropriate antibiotics, and they're just not improving,” he said. “That's when [imaging] studies are useful—a bone scan, for instance, will help you determine if there's something you're missing.”

The sequelae of septic arthritis of the hip include partial or complete destruction of the proximal femoral physis, avascular necrosis of the femoral head, complete dissolution of the femoral head and neck, unstable hip articulation, and hip dislocation.

In addition to being febrile, a child with septic arthritis of the hip is irritable and limps or is unable to bear weight. The child will have severe pain with attempted passive motion of the hip joint, Dr. Pizzutillo said.

Neonates may only display anorexia, irritability, and lethargy, he added.

Staphylococcus aureus seems to be one of the most common organisms implicated, although “Kingella kingae is increasing in frequency, especially in healthy children under 4,” Dr Pizzutillo said.