Kate Johnson

Updated guidelines on the management of intracerebral hemorrhage reflect a wealth of new findings on diagnosing and treating the condition, according to Dr. Joseph Broderick, who chaired the guideline writing committee.

The guidelines, issued jointly by the American Heart Association (AHA) and the American Stroke Association (ASA) and published online, reflect “the recent dramatic increase in clinical trials of ICH/IVH [intracerebral hemorrhage/intraventricular hemorrhage]” whose initial findings “provide great hope for new and effective treatments,” wrote Dr. Broderick, professor and chair of neurology at the University of Cincinnati, and colleagues (DOI: 10.1161/STROKEAHA.107.183689). The last AHA/ASA guidelines were issued in 1999. Since then, 15 pilot and larger randomized medical and surgical trials for ICH/IVH have been completed or are ongoing.

“I feel much better about where we are with intracerebral hemorrhage,” Dr. Broderick said in an interview. “In general, the critical care of these patients is much improved … so I think we're making progress.”

Probably one of the biggest changes in the new guidelines is that the role of surgery for ICH now is more limited than it was previously, said Dr. Broderick.

In addressing the feasibility and timing of surgical options, the guidelines relied heavily on the International Surgical Trial in Intracerebral Hemorrhage (STICH) (Lancet 2005; 365:387–97) and other smaller trials that suggested that surgery is not helpful in treating most supratentorial ICH and is probably harmful in coma patients.

However, “surgery—particularly craniotomy—may be helpful in treating those lobar clots within 1 cm of the surface that present in patients with milder deficits,” wrote the authors. Additionally, surgical removal of cerebellar hemorrhages greater than 3 cm in size is recommended in patients “who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction.” This is a class I recommendation, meaning “there is evidence for and/or general agreement that the procedure or treatment is useful and effective.” Minimally invasive ways to remove clots are also under investigation.

In terms of medical management of ICH, the new guidelines suggest that recombinant activated factor VII (rFVIIa) is a potential new treatment. Administered within 4 hours of the ICH, rFVIIa may limit bleeding, reduce mortality, and improve patients' functional outcome at 90 days. However, the results of the rFVIIa in Acute Hemorrhagic Stroke Treatment (FAST) trial, presented last month at the American Academy of Neurology meeting in Boston, showed no reduction in the rates of mortality or severe disability with either of two doses of the drug, a lthough it did reduce hematoma growth by up to 50% more than placebo.

“We have to rethink where and on whom we want to use this. What's important for right now is that use of factor VII should only be done in the context of a clinical trial,” said Dr. Broderick.

He added that the trial investigators were disappointed not to have found the same clinical effect of rFVIIa that had been found in a previous phase II trial, “which was actually a very prominent effect, but now we know we have a medication that actually slows bleeding. … If you can stop the bleeding—and we know continued bleeding is related to [a] bad outcome—we have a chance to change the natural history of the disease. But we have to do that in the first several hours, likely.”

Blood pressure management, although addressed with some suggestions in the guidelines, remains an open question awaiting the results of some ongoing clinical trials. “The primary rationale for lowering blood pressure is to avoid hemorrhagic expansion from potential sites of bleeding,” wrote the authors. However, for primary ICH, “little prospective evidence exists to support a specific blood pressure threshold,” they noted. “Until ongoing trials of blood pressure intervention for ICH are completed, physicians must manage blood pressure on the basis of the present incomplete evidence.”

Recommendations for imaging have changed from the previous guidelines. “Before, a CT scan was the primary option for evaluating stroke patients in an emergency,” said Dr. Broderick. “Data now show that MR scans also do the job, and both are first-choice options,” each carrying a class I recommendation. Specifically, “CT may be superior at demonstrating associated ventricular extension, whereas magnetic resonance imaging … is superior at detecting underlying structural lesions and delineating the amount of perihematomal edema and herniation,” say the guidelines.

For the first time, the guidelines address end-of-life issues and withdrawal of care. “This is the first time the guidelines try to address how and when physicians should discuss 'do-not-resuscitate (DNR)' orders,” said Dr. Broderick. DNR orders are often inappropriately associated with a lack of aggressive care in the first 24 hours following ICH, a trend the guidelines aim to change, he said. The class II (conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment) recommendation urges “careful consideration of aggressive full care” in the first 24 hours, and that new DNR orders during that time be postponed.

“ICH is an extraordinarily deadly disease. Forty percent or more of people are going to be dead in a month, and half of those deaths occur in the first couple of days.” But one of the things we want to make certain doesn't happen is people saying 'it's a pretty big hemorrhage so we're just going to let the person go' without really seeing what they can do in the first 24-hour window.”

'What's important for right now is that use of factor VII should only be done in the context of a clinical trial.' DR. BRODERICK

Updated guidelines on the management of intracerebral hemorrhage reflect a wealth of new findings on diagnosing and treating the condition, according to Dr. Joseph Broderick, who chaired the guideline writing committee.

The guidelines, issued jointly by the American Heart Association (AHA) and the American Stroke Association (ASA) and published online, reflect “the recent dramatic increase in clinical trials of ICH/IVH [intracerebral hemorrhage/intraventricular hemorrhage]” whose initial findings “provide great hope for new and effective treatments,” wrote Dr. Broderick, professor and chair of neurology at the University of Cincinnati, and colleagues (DOI: 10.1161/STROKEAHA.107.183689). The last AHA/ASA guidelines were issued in 1999. Since then, 15 pilot and larger randomized medical and surgical trials for ICH/IVH have been completed or are ongoing.

“I feel much better about where we are with intracerebral hemorrhage,” Dr. Broderick said in an interview. “In general, the critical care of these patients is much improved … so I think we're making progress.”

Probably one of the biggest changes in the new guidelines is that the role of surgery for ICH now is more limited than it was previously, said Dr. Broderick.

In addressing the feasibility and timing of surgical options, the guidelines relied heavily on the International Surgical Trial in Intracerebral Hemorrhage (STICH) (Lancet 2005; 365:387–97) and other smaller trials that suggested that surgery is not helpful in treating most supratentorial ICH and is probably harmful in coma patients.

However, “surgery—particularly craniotomy—may be helpful in treating those lobar clots within 1 cm of the surface that present in patients with milder deficits,” wrote the authors. Additionally, surgical removal of cerebellar hemorrhages greater than 3 cm in size is recommended in patients “who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction.” This is a class I recommendation, meaning “there is evidence for and/or general agreement that the procedure or treatment is useful and effective.” Minimally invasive ways to remove clots are also under investigation.

In terms of medical management of ICH, the new guidelines suggest that recombinant activated factor VII (rFVIIa) is a potential new treatment. Administered within 4 hours of the ICH, rFVIIa may limit bleeding, reduce mortality, and improve patients' functional outcome at 90 days. However, the results of the rFVIIa in Acute Hemorrhagic Stroke Treatment (FAST) trial, presented last month at the American Academy of Neurology meeting in Boston, showed no reduction in the rates of mortality or severe disability with either of two doses of the drug, a lthough it did reduce hematoma growth by up to 50% more than placebo.

“We have to rethink where and on whom we want to use this. What's important for right now is that use of factor VII should only be done in the context of a clinical trial,” said Dr. Broderick.

He added that the trial investigators were disappointed not to have found the same clinical effect of rFVIIa that had been found in a previous phase II trial, “which was actually a very prominent effect, but now we know we have a medication that actually slows bleeding. … If you can stop the bleeding—and we know continued bleeding is related to [a] bad outcome—we have a chance to change the natural history of the disease. But we have to do that in the first several hours, likely.”

Blood pressure management, although addressed with some suggestions in the guidelines, remains an open question awaiting the results of some ongoing clinical trials. “The primary rationale for lowering blood pressure is to avoid hemorrhagic expansion from potential sites of bleeding,” wrote the authors. However, for primary ICH, “little prospective evidence exists to support a specific blood pressure threshold,” they noted. “Until ongoing trials of blood pressure intervention for ICH are completed, physicians must manage blood pressure on the basis of the present incomplete evidence.”

Recommendations for imaging have changed from the previous guidelines. “Before, a CT scan was the primary option for evaluating stroke patients in an emergency,” said Dr. Broderick. “Data now show that MR scans also do the job, and both are first-choice options,” each carrying a class I recommendation. Specifically, “CT may be superior at demonstrating associated ventricular extension, whereas magnetic resonance imaging … is superior at detecting underlying structural lesions and delineating the amount of perihematomal edema and herniation,” say the guidelines.

For the first time, the guidelines address end-of-life issues and withdrawal of care. “This is the first time the guidelines try to address how and when physicians should discuss 'do-not-resuscitate (DNR)' orders,” said Dr. Broderick. DNR orders are often inappropriately associated with a lack of aggressive care in the first 24 hours following ICH, a trend the guidelines aim to change, he said. The class II (conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment) recommendation urges “careful consideration of aggressive full care” in the first 24 hours, and that new DNR orders during that time be postponed.

“ICH is an extraordinarily deadly disease. Forty percent or more of people are going to be dead in a month, and half of those deaths occur in the first couple of days.” But one of the things we want to make certain doesn't happen is people saying 'it's a pretty big hemorrhage so we're just going to let the person go' without really seeing what they can do in the first 24-hour window.”

'What's important for right now is that use of factor VII should only be done in the context of a clinical trial.' DR. BRODERICK

Updated guidelines on the management of intracerebral hemorrhage reflect a wealth of new findings on diagnosing and treating the condition, according to Dr. Joseph Broderick, who chaired the guideline writing committee.

The guidelines, issued jointly by the American Heart Association (AHA) and the American Stroke Association (ASA) and published online, reflect “the recent dramatic increase in clinical trials of ICH/IVH [intracerebral hemorrhage/intraventricular hemorrhage]” whose initial findings “provide great hope for new and effective treatments,” wrote Dr. Broderick, professor and chair of neurology at the University of Cincinnati, and colleagues (DOI: 10.1161/STROKEAHA.107.183689). The last AHA/ASA guidelines were issued in 1999. Since then, 15 pilot and larger randomized medical and surgical trials for ICH/IVH have been completed or are ongoing.

“I feel much better about where we are with intracerebral hemorrhage,” Dr. Broderick said in an interview. “In general, the critical care of these patients is much improved … so I think we're making progress.”

Probably one of the biggest changes in the new guidelines is that the role of surgery for ICH now is more limited than it was previously, said Dr. Broderick.

In addressing the feasibility and timing of surgical options, the guidelines relied heavily on the International Surgical Trial in Intracerebral Hemorrhage (STICH) (Lancet 2005; 365:387–97) and other smaller trials that suggested that surgery is not helpful in treating most supratentorial ICH and is probably harmful in coma patients.

However, “surgery—particularly craniotomy—may be helpful in treating those lobar clots within 1 cm of the surface that present in patients with milder deficits,” wrote the authors. Additionally, surgical removal of cerebellar hemorrhages greater than 3 cm in size is recommended in patients “who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction.” This is a class I recommendation, meaning “there is evidence for and/or general agreement that the procedure or treatment is useful and effective.” Minimally invasive ways to remove clots are also under investigation.

In terms of medical management of ICH, the new guidelines suggest that recombinant activated factor VII (rFVIIa) is a potential new treatment. Administered within 4 hours of the ICH, rFVIIa may limit bleeding, reduce mortality, and improve patients' functional outcome at 90 days. However, the results of the rFVIIa in Acute Hemorrhagic Stroke Treatment (FAST) trial, presented last month at the American Academy of Neurology meeting in Boston, showed no reduction in the rates of mortality or severe disability with either of two doses of the drug, a lthough it did reduce hematoma growth by up to 50% more than placebo.

“We have to rethink where and on whom we want to use this. What's important for right now is that use of factor VII should only be done in the context of a clinical trial,” said Dr. Broderick.

He added that the trial investigators were disappointed not to have found the same clinical effect of rFVIIa that had been found in a previous phase II trial, “which was actually a very prominent effect, but now we know we have a medication that actually slows bleeding. … If you can stop the bleeding—and we know continued bleeding is related to [a] bad outcome—we have a chance to change the natural history of the disease. But we have to do that in the first several hours, likely.”

Blood pressure management, although addressed with some suggestions in the guidelines, remains an open question awaiting the results of some ongoing clinical trials. “The primary rationale for lowering blood pressure is to avoid hemorrhagic expansion from potential sites of bleeding,” wrote the authors. However, for primary ICH, “little prospective evidence exists to support a specific blood pressure threshold,” they noted. “Until ongoing trials of blood pressure intervention for ICH are completed, physicians must manage blood pressure on the basis of the present incomplete evidence.”

Recommendations for imaging have changed from the previous guidelines. “Before, a CT scan was the primary option for evaluating stroke patients in an emergency,” said Dr. Broderick. “Data now show that MR scans also do the job, and both are first-choice options,” each carrying a class I recommendation. Specifically, “CT may be superior at demonstrating associated ventricular extension, whereas magnetic resonance imaging … is superior at detecting underlying structural lesions and delineating the amount of perihematomal edema and herniation,” say the guidelines.

For the first time, the guidelines address end-of-life issues and withdrawal of care. “This is the first time the guidelines try to address how and when physicians should discuss 'do-not-resuscitate (DNR)' orders,” said Dr. Broderick. DNR orders are often inappropriately associated with a lack of aggressive care in the first 24 hours following ICH, a trend the guidelines aim to change, he said. The class II (conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment) recommendation urges “careful consideration of aggressive full care” in the first 24 hours, and that new DNR orders during that time be postponed.

“ICH is an extraordinarily deadly disease. Forty percent or more of people are going to be dead in a month, and half of those deaths occur in the first couple of days.” But one of the things we want to make certain doesn't happen is people saying 'it's a pretty big hemorrhage so we're just going to let the person go' without really seeing what they can do in the first 24-hour window.”

'What's important for right now is that use of factor VII should only be done in the context of a clinical trial.' DR. BRODERICK

TORONTO — The order in which consecutive injections of pentavalent and pneumococcal conjugate vaccines are given during the same office visit can significantly impact the amount of pain they cause, Dr. Moshe Ipp said at the annual meeting of the Pediatric Academic Societies.

In a double-blind trial conducted by Dr. Ipp and associates, which was supported by an unrestricted grant from Sanofi Pasteur, 60 infants (aged 2 to 6 months) were randomized to receive either the pentavalent vaccine (DTaP-Hib) followed by the pneumococcal conjugate vaccine (PCV), or the other way around.

Pain was measured using the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10.

“When you consider these two vaccines, one is more painful [PCV], and one is less painful [DTaP-Hib],” reported Dr. Ipp, a pediatrician at the Hospital for Sick Children, Toronto.

“It's not the needle itself, but it is the vaccine material. We think it's related to pH,” Dr. Ipp said in an interview.

Video recordings of infants receiving the injections demonstrated that, regardless of the order of injections, PCV was more painful that DTaP-Hib, with a score of 8.1 when given first and 9 when given second.

In contrast, the pain score of DTaP-Hib was 6.5 when administered first, and 8.5 when administered second.

The fact that both vaccines were measured as more painful when given second suggests “there must be some priming from the first needle that the child registers,” said Dr. Ipp.

He recommended that since DTaP-Hib is less painful it should be routinely administered before PCV.

“The pain issue and compliance go together, and I think pain has been ignored in the vaccine scenario.

“Reduce the pain and compliance with vaccination will improve,” Dr. Ipp concluded.

TORONTO — The order in which consecutive injections of pentavalent and pneumococcal conjugate vaccines are given during the same office visit can significantly impact the amount of pain they cause, Dr. Moshe Ipp said at the annual meeting of the Pediatric Academic Societies.

In a double-blind trial conducted by Dr. Ipp and associates, which was supported by an unrestricted grant from Sanofi Pasteur, 60 infants (aged 2 to 6 months) were randomized to receive either the pentavalent vaccine (DTaP-Hib) followed by the pneumococcal conjugate vaccine (PCV), or the other way around.

Pain was measured using the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10.

“When you consider these two vaccines, one is more painful [PCV], and one is less painful [DTaP-Hib],” reported Dr. Ipp, a pediatrician at the Hospital for Sick Children, Toronto.

“It's not the needle itself, but it is the vaccine material. We think it's related to pH,” Dr. Ipp said in an interview.

Video recordings of infants receiving the injections demonstrated that, regardless of the order of injections, PCV was more painful that DTaP-Hib, with a score of 8.1 when given first and 9 when given second.

In contrast, the pain score of DTaP-Hib was 6.5 when administered first, and 8.5 when administered second.

The fact that both vaccines were measured as more painful when given second suggests “there must be some priming from the first needle that the child registers,” said Dr. Ipp.

He recommended that since DTaP-Hib is less painful it should be routinely administered before PCV.

“The pain issue and compliance go together, and I think pain has been ignored in the vaccine scenario.

“Reduce the pain and compliance with vaccination will improve,” Dr. Ipp concluded.

TORONTO — The order in which consecutive injections of pentavalent and pneumococcal conjugate vaccines are given during the same office visit can significantly impact the amount of pain they cause, Dr. Moshe Ipp said at the annual meeting of the Pediatric Academic Societies.

In a double-blind trial conducted by Dr. Ipp and associates, which was supported by an unrestricted grant from Sanofi Pasteur, 60 infants (aged 2 to 6 months) were randomized to receive either the pentavalent vaccine (DTaP-Hib) followed by the pneumococcal conjugate vaccine (PCV), or the other way around.

Pain was measured using the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10.

“When you consider these two vaccines, one is more painful [PCV], and one is less painful [DTaP-Hib],” reported Dr. Ipp, a pediatrician at the Hospital for Sick Children, Toronto.

“It's not the needle itself, but it is the vaccine material. We think it's related to pH,” Dr. Ipp said in an interview.

Video recordings of infants receiving the injections demonstrated that, regardless of the order of injections, PCV was more painful that DTaP-Hib, with a score of 8.1 when given first and 9 when given second.

In contrast, the pain score of DTaP-Hib was 6.5 when administered first, and 8.5 when administered second.

The fact that both vaccines were measured as more painful when given second suggests “there must be some priming from the first needle that the child registers,” said Dr. Ipp.

He recommended that since DTaP-Hib is less painful it should be routinely administered before PCV.

“The pain issue and compliance go together, and I think pain has been ignored in the vaccine scenario.

“Reduce the pain and compliance with vaccination will improve,” Dr. Ipp concluded.

TORONTO — In France, a 50/50 mixture of inhaled nitrous oxide and oxygen is widely used for painful procedures in emergency departments and pediatric wards, noted Dr. Ricardo Carbajal, of the Hôpital d'enfants Armand-Trousseau in Paris.

“This is used in millions of patients,” he said in an interview. “Every time there is a painful procedure people should consider nitrous oxide. It is very short-acting and has an excellent to very good effect for children aged 24 to 30 months old or older, with a little bit less of an effect in younger children.”

At the annual meeting of the Pediatric Academic Societies, Dr. Carbajal presented his randomized, double-blind study involving 55 children younger than 24 months who received intramuscular injections of palivizumab for the prevention of severe lower respiratory tract infections due to respiratory syncytial virus. Patients received three consecutive monthly injections using three different analgesic protocols: inhaled nitrous oxide and oxygen (N20/02) and a placebo cream; EMLA (Eutectic Mixture of Local Anesthetics) cream and inhaled air (placebo); and a combination of both treatments.

All injections were videotaped, and infant pain levels were assessed from the time of needle insertion until 30 seconds after needle withdrawal; the researchers used the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10. A secondary outcome was pain as assessed by parents on a 0 to 100 numeric scale.

The combination of inhaled N20/02 and EMLA cream was the most effective in alleviating injection pain, compared with either medication alone, Dr. Carbajal said. EMLA cream was the least effective, with a score of 9.25 during injection and 7.76 post injection, compared with 8.76 and 7.42, respectively, for inhaled N20/02. When both medications were combined, the pain score during the injection was 8.24, dropping to 6.95 after injection.

Parents scored the medications similarly: EMLA alone scored 36, inhaled N20/02 scored 35, and the combination scored 26.

Dr. Carbajal noted that, given the high level of pain caused by intramuscular palivizumab, “the development of new analgesic strategies is still needed.”

North American delegates at the meeting were intrigued by the common use in France of inhaled N20/02, which Dr. Carbajal said has a well-established safety profile “if you don't mix it with other [systemic] medications … probably we have had more than a million users now with no accidents.”

He said French nurses are trained to give the medication and physicians are not required to be present because in France the 50/50 ratio of N20/02 is not considered to be an anesthetic.

Dr. Shetal Shah, a neonatologist at the State University of New York at Stony Brook, commented in an interview, “I think there may be barriers in the United States toward implementing this… specifically, if it gets classified as a conscious sedation technique, then you may wind up having to create a whole new level of certification for outpatient nursing staff.”

TORONTO — In France, a 50/50 mixture of inhaled nitrous oxide and oxygen is widely used for painful procedures in emergency departments and pediatric wards, noted Dr. Ricardo Carbajal, of the Hôpital d'enfants Armand-Trousseau in Paris.

“This is used in millions of patients,” he said in an interview. “Every time there is a painful procedure people should consider nitrous oxide. It is very short-acting and has an excellent to very good effect for children aged 24 to 30 months old or older, with a little bit less of an effect in younger children.”

At the annual meeting of the Pediatric Academic Societies, Dr. Carbajal presented his randomized, double-blind study involving 55 children younger than 24 months who received intramuscular injections of palivizumab for the prevention of severe lower respiratory tract infections due to respiratory syncytial virus. Patients received three consecutive monthly injections using three different analgesic protocols: inhaled nitrous oxide and oxygen (N20/02) and a placebo cream; EMLA (Eutectic Mixture of Local Anesthetics) cream and inhaled air (placebo); and a combination of both treatments.

All injections were videotaped, and infant pain levels were assessed from the time of needle insertion until 30 seconds after needle withdrawal; the researchers used the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10. A secondary outcome was pain as assessed by parents on a 0 to 100 numeric scale.

The combination of inhaled N20/02 and EMLA cream was the most effective in alleviating injection pain, compared with either medication alone, Dr. Carbajal said. EMLA cream was the least effective, with a score of 9.25 during injection and 7.76 post injection, compared with 8.76 and 7.42, respectively, for inhaled N20/02. When both medications were combined, the pain score during the injection was 8.24, dropping to 6.95 after injection.

Parents scored the medications similarly: EMLA alone scored 36, inhaled N20/02 scored 35, and the combination scored 26.

Dr. Carbajal noted that, given the high level of pain caused by intramuscular palivizumab, “the development of new analgesic strategies is still needed.”

North American delegates at the meeting were intrigued by the common use in France of inhaled N20/02, which Dr. Carbajal said has a well-established safety profile “if you don't mix it with other [systemic] medications … probably we have had more than a million users now with no accidents.”

He said French nurses are trained to give the medication and physicians are not required to be present because in France the 50/50 ratio of N20/02 is not considered to be an anesthetic.

Dr. Shetal Shah, a neonatologist at the State University of New York at Stony Brook, commented in an interview, “I think there may be barriers in the United States toward implementing this… specifically, if it gets classified as a conscious sedation technique, then you may wind up having to create a whole new level of certification for outpatient nursing staff.”

TORONTO — In France, a 50/50 mixture of inhaled nitrous oxide and oxygen is widely used for painful procedures in emergency departments and pediatric wards, noted Dr. Ricardo Carbajal, of the Hôpital d'enfants Armand-Trousseau in Paris.

“This is used in millions of patients,” he said in an interview. “Every time there is a painful procedure people should consider nitrous oxide. It is very short-acting and has an excellent to very good effect for children aged 24 to 30 months old or older, with a little bit less of an effect in younger children.”

At the annual meeting of the Pediatric Academic Societies, Dr. Carbajal presented his randomized, double-blind study involving 55 children younger than 24 months who received intramuscular injections of palivizumab for the prevention of severe lower respiratory tract infections due to respiratory syncytial virus. Patients received three consecutive monthly injections using three different analgesic protocols: inhaled nitrous oxide and oxygen (N20/02) and a placebo cream; EMLA (Eutectic Mixture of Local Anesthetics) cream and inhaled air (placebo); and a combination of both treatments.

All injections were videotaped, and infant pain levels were assessed from the time of needle insertion until 30 seconds after needle withdrawal; the researchers used the Modified Behavioral Pain Scale (MBPS) running from 0 (no pain) to 10. A secondary outcome was pain as assessed by parents on a 0 to 100 numeric scale.

The combination of inhaled N20/02 and EMLA cream was the most effective in alleviating injection pain, compared with either medication alone, Dr. Carbajal said. EMLA cream was the least effective, with a score of 9.25 during injection and 7.76 post injection, compared with 8.76 and 7.42, respectively, for inhaled N20/02. When both medications were combined, the pain score during the injection was 8.24, dropping to 6.95 after injection.

Parents scored the medications similarly: EMLA alone scored 36, inhaled N20/02 scored 35, and the combination scored 26.

Dr. Carbajal noted that, given the high level of pain caused by intramuscular palivizumab, “the development of new analgesic strategies is still needed.”

North American delegates at the meeting were intrigued by the common use in France of inhaled N20/02, which Dr. Carbajal said has a well-established safety profile “if you don't mix it with other [systemic] medications … probably we have had more than a million users now with no accidents.”

He said French nurses are trained to give the medication and physicians are not required to be present because in France the 50/50 ratio of N20/02 is not considered to be an anesthetic.

Dr. Shetal Shah, a neonatologist at the State University of New York at Stony Brook, commented in an interview, “I think there may be barriers in the United States toward implementing this… specifically, if it gets classified as a conscious sedation technique, then you may wind up having to create a whole new level of certification for outpatient nursing staff.”

MONTREAL — Exacerbations of chronic obstructive pulmonary disease may need more aggressive therapy when they co-occur with pneumonia, said Dr. Charles Chan, professor of medicine at the University of Toronto and head of respirology at University Health Network and Mount Sinai Hospital in Toronto.

Chronic obstructive pulmonary disease (COPD) can predispose patients to pneumonia, but differentiating between the two conditions can be difficult, Dr. Chan said at an international conference on community-acquired pneumonia.

“COPD exacerbations alone are generally recognized, but with pneumonia, they may be underappreciated” and thus undertreated, Dr. Chan said in an interview at the meeting, sponsored by the International Society of Chemotherapy.

Guidelines for treating mild exacerbations of COPD (Can. Respir. J. 2004;11[suppl. B]:3B-59B) recommend antibiotic treatment with macrolides, but only in the presence of purulent sputum.

In contrast, the guidelines for community-acquired pneumonia (CAP) in older patients with comorbidities such as COPD suggest that fluoroquinolones be administered to the patient (Clin. Infect. Dis. 2007;44:S27-S72).

But recognizing CAP in a patient with COPD exacerbation can be tricky.

“You can see the differences on x-ray, but even this can be subtle, and if you don't do an x-ray, …it is hard to tell the difference,” he said in the interview.

COPD exacerbation involves hyperinflated lungs (left); concurrent pneumonia involves nodular infiltrates (right). Photos courtesy Dr. Charles Chan

MONTREAL — Exacerbations of chronic obstructive pulmonary disease may need more aggressive therapy when they co-occur with pneumonia, said Dr. Charles Chan, professor of medicine at the University of Toronto and head of respirology at University Health Network and Mount Sinai Hospital in Toronto.

Chronic obstructive pulmonary disease (COPD) can predispose patients to pneumonia, but differentiating between the two conditions can be difficult, Dr. Chan said at an international conference on community-acquired pneumonia.

“COPD exacerbations alone are generally recognized, but with pneumonia, they may be underappreciated” and thus undertreated, Dr. Chan said in an interview at the meeting, sponsored by the International Society of Chemotherapy.

Guidelines for treating mild exacerbations of COPD (Can. Respir. J. 2004;11[suppl. B]:3B-59B) recommend antibiotic treatment with macrolides, but only in the presence of purulent sputum.

In contrast, the guidelines for community-acquired pneumonia (CAP) in older patients with comorbidities such as COPD suggest that fluoroquinolones be administered to the patient (Clin. Infect. Dis. 2007;44:S27-S72).

But recognizing CAP in a patient with COPD exacerbation can be tricky.

“You can see the differences on x-ray, but even this can be subtle, and if you don't do an x-ray, …it is hard to tell the difference,” he said in the interview.

COPD exacerbation involves hyperinflated lungs (left); concurrent pneumonia involves nodular infiltrates (right). Photos courtesy Dr. Charles Chan

MONTREAL — Exacerbations of chronic obstructive pulmonary disease may need more aggressive therapy when they co-occur with pneumonia, said Dr. Charles Chan, professor of medicine at the University of Toronto and head of respirology at University Health Network and Mount Sinai Hospital in Toronto.

Chronic obstructive pulmonary disease (COPD) can predispose patients to pneumonia, but differentiating between the two conditions can be difficult, Dr. Chan said at an international conference on community-acquired pneumonia.

“COPD exacerbations alone are generally recognized, but with pneumonia, they may be underappreciated” and thus undertreated, Dr. Chan said in an interview at the meeting, sponsored by the International Society of Chemotherapy.

Guidelines for treating mild exacerbations of COPD (Can. Respir. J. 2004;11[suppl. B]:3B-59B) recommend antibiotic treatment with macrolides, but only in the presence of purulent sputum.

In contrast, the guidelines for community-acquired pneumonia (CAP) in older patients with comorbidities such as COPD suggest that fluoroquinolones be administered to the patient (Clin. Infect. Dis. 2007;44:S27-S72).

But recognizing CAP in a patient with COPD exacerbation can be tricky.

“You can see the differences on x-ray, but even this can be subtle, and if you don't do an x-ray, …it is hard to tell the difference,” he said in the interview.

COPD exacerbation involves hyperinflated lungs (left); concurrent pneumonia involves nodular infiltrates (right). Photos courtesy Dr. Charles Chan

QUEBEC CITY — Intracompartmental pressure testing is the only way to definitively diagnose chronic compartment syndrome, but the test is useless without first exercising the affected muscle, said Dr. Preston Wiley at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“You first have to reproduce the pain in your office and then measure the intracompartmental pressure.” There is no point to measuring pressure at rest before the patient exercises, he advised.

Rather than sending patients out for a half-hour run to reproduce their symptoms, he asks those with anterior and/or lateral compartment pain to perform repeat dorsiflexion/eversion and plantar-flexion exercises while seated. Posterior compartment pain can be reproduced by having the patient hop on the affected foot.

Although both anterior/lateral and superficial posterior intracompartmental pressures can be measured in the office, deep posterior compartment testing should be done under ultrasound guidance to avoid damaging the neurovascular bundle, said Dr. Wiley, a sports medicine physician at the University of Calgary (Alta.).

An immediate postexercise pressure of more than 30 mm Hg is the first positive reading; confirmation is a measurement of more than 15 mm Hg at 2–3 minutes post exercise. Ample local anesthetic is advised, he stressed, because the device's 16-gauge needle needs to be inserted into the richly innervated fascia.

Intracompartmental pressure testing should be undertaken with the understanding that surgery is the only treatment.

“If the test is positive, patients either have to live with it and possibly modify their activity, or have a fasciotomy. There has never been a reported case that resolved without surgery,” he said.

Suspicion of chronic compartment syndrome can be based on a history of lower leg pain, tightness, and burning after activity, with symptoms subsiding at rest.

“It does not ache in the middle of the night,” Dr. Wiley said in an interview. The muscle that normally swells with exercise is restricted by the tight fascia, resulting in pain, and the area of discomfort reported by the patient clearly outlines a compartment, he explained.

“By having the patient point to the affected area, the physician can have an excellent indication of the problem.”

A test of the anterior compartment should follow dorsiflexion exercises. Courtesy Dr. Preston Wiley

QUEBEC CITY — Intracompartmental pressure testing is the only way to definitively diagnose chronic compartment syndrome, but the test is useless without first exercising the affected muscle, said Dr. Preston Wiley at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“You first have to reproduce the pain in your office and then measure the intracompartmental pressure.” There is no point to measuring pressure at rest before the patient exercises, he advised.

Rather than sending patients out for a half-hour run to reproduce their symptoms, he asks those with anterior and/or lateral compartment pain to perform repeat dorsiflexion/eversion and plantar-flexion exercises while seated. Posterior compartment pain can be reproduced by having the patient hop on the affected foot.

Although both anterior/lateral and superficial posterior intracompartmental pressures can be measured in the office, deep posterior compartment testing should be done under ultrasound guidance to avoid damaging the neurovascular bundle, said Dr. Wiley, a sports medicine physician at the University of Calgary (Alta.).

An immediate postexercise pressure of more than 30 mm Hg is the first positive reading; confirmation is a measurement of more than 15 mm Hg at 2–3 minutes post exercise. Ample local anesthetic is advised, he stressed, because the device's 16-gauge needle needs to be inserted into the richly innervated fascia.

Intracompartmental pressure testing should be undertaken with the understanding that surgery is the only treatment.

“If the test is positive, patients either have to live with it and possibly modify their activity, or have a fasciotomy. There has never been a reported case that resolved without surgery,” he said.

Suspicion of chronic compartment syndrome can be based on a history of lower leg pain, tightness, and burning after activity, with symptoms subsiding at rest.

“It does not ache in the middle of the night,” Dr. Wiley said in an interview. The muscle that normally swells with exercise is restricted by the tight fascia, resulting in pain, and the area of discomfort reported by the patient clearly outlines a compartment, he explained.

“By having the patient point to the affected area, the physician can have an excellent indication of the problem.”

A test of the anterior compartment should follow dorsiflexion exercises. Courtesy Dr. Preston Wiley

QUEBEC CITY — Intracompartmental pressure testing is the only way to definitively diagnose chronic compartment syndrome, but the test is useless without first exercising the affected muscle, said Dr. Preston Wiley at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport.

“You first have to reproduce the pain in your office and then measure the intracompartmental pressure.” There is no point to measuring pressure at rest before the patient exercises, he advised.

Rather than sending patients out for a half-hour run to reproduce their symptoms, he asks those with anterior and/or lateral compartment pain to perform repeat dorsiflexion/eversion and plantar-flexion exercises while seated. Posterior compartment pain can be reproduced by having the patient hop on the affected foot.

Although both anterior/lateral and superficial posterior intracompartmental pressures can be measured in the office, deep posterior compartment testing should be done under ultrasound guidance to avoid damaging the neurovascular bundle, said Dr. Wiley, a sports medicine physician at the University of Calgary (Alta.).

An immediate postexercise pressure of more than 30 mm Hg is the first positive reading; confirmation is a measurement of more than 15 mm Hg at 2–3 minutes post exercise. Ample local anesthetic is advised, he stressed, because the device's 16-gauge needle needs to be inserted into the richly innervated fascia.

Intracompartmental pressure testing should be undertaken with the understanding that surgery is the only treatment.

“If the test is positive, patients either have to live with it and possibly modify their activity, or have a fasciotomy. There has never been a reported case that resolved without surgery,” he said.

Suspicion of chronic compartment syndrome can be based on a history of lower leg pain, tightness, and burning after activity, with symptoms subsiding at rest.

“It does not ache in the middle of the night,” Dr. Wiley said in an interview. The muscle that normally swells with exercise is restricted by the tight fascia, resulting in pain, and the area of discomfort reported by the patient clearly outlines a compartment, he explained.

“By having the patient point to the affected area, the physician can have an excellent indication of the problem.”

A test of the anterior compartment should follow dorsiflexion exercises. Courtesy Dr. Preston Wiley

MONTREAL — Topical imiquimod 5% cream can dramatically reduce or resolve some infantile hemangiomas and could be a treatment option as early as the newborn phase, Dr. Marc Bourcier said at Dermatology Update 2007.

This early, noninvasive treatment has minimal side effects and is a welcome option for parents whose other alternatives are surgery or no treatment, said Dr. Bourcier, who is a dermatologist in private practice in Moncton, N.B.

Spontaneous resolution is common in this condition, but it can take as long as 7 years.

The treatment of infantile hemangioma with topical imiquimod was first described in the literature in 2004 in 10 patients; 4 achieved complete resolution, and 3 achieved excellent results (J. Am. Acad. Dermatol. 2004;51:639–42).

In addition, there was also one treatment failure, one treatment discontinuation, and one patient lost to follow-up, said Dr. Bourcier.

Since then there have been just a few reports in the literature, but, inspired by this evidence, Dr. Bourcier has treated three patients successfully.

“It's a limited number … but so far they have had quite a dramatic response,” he said. “Compared with the natural evolution of this condition, what I've seen is significantly better than what we normally would expect.”

A clinical study involving 10 pediatric patients treated at Ste-Justine's Hospital in Montreal is expected to be published soon and will provide further data, he added.

Dr. Bourcier said he believes that, even without effecting a complete resolution, topical imiquimod can slow progression of hemangiomas enough to obviate extensive surgery later, if surgery is needed.

He added, however, that superficial lesions are more likely to respond, compared with deeper ones.

“There are some case reports in the literature of improvement in the deeper lesions, but it is felt that the superficial ones are best suited to topical therapy—and these are the ones that show the most because they are such a bright, fiery red,” he said.

“Hidden lesions are not such a concern, but for facial ones I strongly believe you have to do something before the children get to school, when they start to really socialize and become more self-conscious,” he said in an interview.

Dr. Bourcier speaks from personal experience: His daughter, now aged 12 years, was born with a facial hemangioma. He chose surgical therapy for her when she was 4 years old, with excellent results.

“Imiquimod therapy had not been prescribed for this back then, but if it had, I would surely have chosen it,” he commented.

MONTREAL — Topical imiquimod 5% cream can dramatically reduce or resolve some infantile hemangiomas and could be a treatment option as early as the newborn phase, Dr. Marc Bourcier said at Dermatology Update 2007.

This early, noninvasive treatment has minimal side effects and is a welcome option for parents whose other alternatives are surgery or no treatment, said Dr. Bourcier, who is a dermatologist in private practice in Moncton, N.B.

Spontaneous resolution is common in this condition, but it can take as long as 7 years.

The treatment of infantile hemangioma with topical imiquimod was first described in the literature in 2004 in 10 patients; 4 achieved complete resolution, and 3 achieved excellent results (J. Am. Acad. Dermatol. 2004;51:639–42).

In addition, there was also one treatment failure, one treatment discontinuation, and one patient lost to follow-up, said Dr. Bourcier.

Since then there have been just a few reports in the literature, but, inspired by this evidence, Dr. Bourcier has treated three patients successfully.

“It's a limited number … but so far they have had quite a dramatic response,” he said. “Compared with the natural evolution of this condition, what I've seen is significantly better than what we normally would expect.”

A clinical study involving 10 pediatric patients treated at Ste-Justine's Hospital in Montreal is expected to be published soon and will provide further data, he added.

Dr. Bourcier said he believes that, even without effecting a complete resolution, topical imiquimod can slow progression of hemangiomas enough to obviate extensive surgery later, if surgery is needed.

He added, however, that superficial lesions are more likely to respond, compared with deeper ones.

“There are some case reports in the literature of improvement in the deeper lesions, but it is felt that the superficial ones are best suited to topical therapy—and these are the ones that show the most because they are such a bright, fiery red,” he said.

“Hidden lesions are not such a concern, but for facial ones I strongly believe you have to do something before the children get to school, when they start to really socialize and become more self-conscious,” he said in an interview.

Dr. Bourcier speaks from personal experience: His daughter, now aged 12 years, was born with a facial hemangioma. He chose surgical therapy for her when she was 4 years old, with excellent results.

“Imiquimod therapy had not been prescribed for this back then, but if it had, I would surely have chosen it,” he commented.

MONTREAL — Topical imiquimod 5% cream can dramatically reduce or resolve some infantile hemangiomas and could be a treatment option as early as the newborn phase, Dr. Marc Bourcier said at Dermatology Update 2007.

This early, noninvasive treatment has minimal side effects and is a welcome option for parents whose other alternatives are surgery or no treatment, said Dr. Bourcier, who is a dermatologist in private practice in Moncton, N.B.

Spontaneous resolution is common in this condition, but it can take as long as 7 years.

The treatment of infantile hemangioma with topical imiquimod was first described in the literature in 2004 in 10 patients; 4 achieved complete resolution, and 3 achieved excellent results (J. Am. Acad. Dermatol. 2004;51:639–42).

In addition, there was also one treatment failure, one treatment discontinuation, and one patient lost to follow-up, said Dr. Bourcier.

Since then there have been just a few reports in the literature, but, inspired by this evidence, Dr. Bourcier has treated three patients successfully.

“It's a limited number … but so far they have had quite a dramatic response,” he said. “Compared with the natural evolution of this condition, what I've seen is significantly better than what we normally would expect.”

A clinical study involving 10 pediatric patients treated at Ste-Justine's Hospital in Montreal is expected to be published soon and will provide further data, he added.

Dr. Bourcier said he believes that, even without effecting a complete resolution, topical imiquimod can slow progression of hemangiomas enough to obviate extensive surgery later, if surgery is needed.

He added, however, that superficial lesions are more likely to respond, compared with deeper ones.

“There are some case reports in the literature of improvement in the deeper lesions, but it is felt that the superficial ones are best suited to topical therapy—and these are the ones that show the most because they are such a bright, fiery red,” he said.

“Hidden lesions are not such a concern, but for facial ones I strongly believe you have to do something before the children get to school, when they start to really socialize and become more self-conscious,” he said in an interview.

Dr. Bourcier speaks from personal experience: His daughter, now aged 12 years, was born with a facial hemangioma. He chose surgical therapy for her when she was 4 years old, with excellent results.

“Imiquimod therapy had not been prescribed for this back then, but if it had, I would surely have chosen it,” he commented.

QUEBEC CITY — Promoting flu shots among sports team members is worth the effort, but it may be more difficult to convince the team's support staff, coaches, and trainers to follow suit, according to Dr. Robert McCormack, chief medical officer for the Canadian Olympic Team.

Dr. McCormack, who is also an orthopedic surgeon at the University of British Columbia, Vancouver, spoke at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport about his successful efforts to promote flu vaccination among members of the Canadian 2006 Winter Olympic team.

“To my knowledge, there was not one case of influenza,” he said, noting that during the 1988 Winter Olympics in Calgary, influenza devastated teams from all over the world.

But whether it's an Olympic team or not, immunization is one of the final stepping stones to a team's and athlete's success, especially if one considers the years of training that precede these events, Dr. McCormack said.

After the campaign before the 2006 Winter Olympics, Dr. McCormack and his colleagues immunized 76% of the Canadian team's athletes. But, those rates dipped to 66% for the support staff and 40% for coaches, resulting in an immunization rate of only 65% for the team overall.

Reasons given for not getting immunized centered on a lack of confidence in the benefits and concerns about the risks, said Dr. McCormack, who emphasized that the way in which the suggestion of immunization is presented is important.

“It really boils down to framing. You can report the percentage of people who will still get the flu and who will have side effects, or you can focus on the percentage of people who will be disease free and with no side effects,” he said. And it may be even more difficult to promote immunization in individualized sports: The Canadian short-track skating, hockey, and curling teams, for example, had immunizations rates of 100%, whereas in decentralized, individual sports, such as snowboarding and figure skating, the rates were only 30%.

The Canadian Women's Hockey team won gold at the 2006 Winter Olympics. All the players were immunized. Courtesy Dr. Robert McCormack

QUEBEC CITY — Promoting flu shots among sports team members is worth the effort, but it may be more difficult to convince the team's support staff, coaches, and trainers to follow suit, according to Dr. Robert McCormack, chief medical officer for the Canadian Olympic Team.

Dr. McCormack, who is also an orthopedic surgeon at the University of British Columbia, Vancouver, spoke at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport about his successful efforts to promote flu vaccination among members of the Canadian 2006 Winter Olympic team.

“To my knowledge, there was not one case of influenza,” he said, noting that during the 1988 Winter Olympics in Calgary, influenza devastated teams from all over the world.

But whether it's an Olympic team or not, immunization is one of the final stepping stones to a team's and athlete's success, especially if one considers the years of training that precede these events, Dr. McCormack said.

After the campaign before the 2006 Winter Olympics, Dr. McCormack and his colleagues immunized 76% of the Canadian team's athletes. But, those rates dipped to 66% for the support staff and 40% for coaches, resulting in an immunization rate of only 65% for the team overall.

Reasons given for not getting immunized centered on a lack of confidence in the benefits and concerns about the risks, said Dr. McCormack, who emphasized that the way in which the suggestion of immunization is presented is important.

“It really boils down to framing. You can report the percentage of people who will still get the flu and who will have side effects, or you can focus on the percentage of people who will be disease free and with no side effects,” he said. And it may be even more difficult to promote immunization in individualized sports: The Canadian short-track skating, hockey, and curling teams, for example, had immunizations rates of 100%, whereas in decentralized, individual sports, such as snowboarding and figure skating, the rates were only 30%.

The Canadian Women's Hockey team won gold at the 2006 Winter Olympics. All the players were immunized. Courtesy Dr. Robert McCormack

QUEBEC CITY — Promoting flu shots among sports team members is worth the effort, but it may be more difficult to convince the team's support staff, coaches, and trainers to follow suit, according to Dr. Robert McCormack, chief medical officer for the Canadian Olympic Team.

Dr. McCormack, who is also an orthopedic surgeon at the University of British Columbia, Vancouver, spoke at the joint annual meeting of the Canadian Academy of Sport Medicine and the Association Québécoise des Médecins du Sport about his successful efforts to promote flu vaccination among members of the Canadian 2006 Winter Olympic team.

“To my knowledge, there was not one case of influenza,” he said, noting that during the 1988 Winter Olympics in Calgary, influenza devastated teams from all over the world.

But whether it's an Olympic team or not, immunization is one of the final stepping stones to a team's and athlete's success, especially if one considers the years of training that precede these events, Dr. McCormack said.

After the campaign before the 2006 Winter Olympics, Dr. McCormack and his colleagues immunized 76% of the Canadian team's athletes. But, those rates dipped to 66% for the support staff and 40% for coaches, resulting in an immunization rate of only 65% for the team overall.

Reasons given for not getting immunized centered on a lack of confidence in the benefits and concerns about the risks, said Dr. McCormack, who emphasized that the way in which the suggestion of immunization is presented is important.

“It really boils down to framing. You can report the percentage of people who will still get the flu and who will have side effects, or you can focus on the percentage of people who will be disease free and with no side effects,” he said. And it may be even more difficult to promote immunization in individualized sports: The Canadian short-track skating, hockey, and curling teams, for example, had immunizations rates of 100%, whereas in decentralized, individual sports, such as snowboarding and figure skating, the rates were only 30%.

The Canadian Women's Hockey team won gold at the 2006 Winter Olympics. All the players were immunized. Courtesy Dr. Robert McCormack

MONTREAL — In community-acquired pneumonia, overuse of broad-spectrum antibiotics can be curbed with the help of biologic markers such as procalcitonin, according to Dr. Jean Chastre of the Hôpital de la Pitié-Salpêtrière, Paris.

Blood levels of procalcitonin (PCT) rise in patients with bacterial infections but remain fairly low in those with viral infections, and PCT levels decrease as the bacterial infection subsides. Measuring PCT levels thus aids decisions about whether to prescribe antibiotics, what type to prescribe, and for how long, said Dr. Chastre at an international conference on community-acquired pneumonia (CAP) that was sponsored by the International Society of Chemotherapy. “We use antibiotics for too long for too many patients, and in doing so are favoring the emergence of resistant strains,” he said in an interview.

“The more antibiotics we use, the more resistance we are going to see,” Dr. Jean-Claude Pechère agreed in an interview. In his presentation, he outlined a 2004 study in which PCT-guided therapy for lower respiratory tract infections significantly reduced antibiotic use, compared with standard care (Lancet 2004;363:600–7). “With these biomarkers, we suddenly realized we could cut antibiotic consumption almost in half. In Europe, we are speaking of millions of patients,” said Dr. Pechère, a professor of medicine at the University of Geneva.

Although a PCT assay is approved in Europe, it is still not widely available, and it is even less so in North America, according Dr. Thomas File, a professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown. “There are a few places where they have it available in the [emergency department], but in most places it takes several hours to get the result back—maybe even a day,” Dr. File said in an interview. Because initiation of antibiotic therapy is recommended within hours of a diagnosis of bacterial CAP, a PCT assay may not be practical for guiding initial treatment decisions, he said. “It's probably going to be more helpful in making decisions about duration of therapy, or changing therapy.”

For example, antibiotics can be stopped if the PCT results suggest that bacterial infection is unlikely, explained Dr. Chastre, who has received research funding and is a speaker for Brahms Diagnostics LLC, which makes a PCT assay. Or, therapy could be shortened if serial PCT measurements suggest a rapid response. “It's probably possible, even in severe pulmonary infection, to shorten the duration of antibiotics to 5 or 7 days if the PCT is decreasing very rapidly,” Dr. Chastre said.

European guidelines recommend that empiric therapy for bacterial CAP should provide coverage against the most common pathogen (Streptococcus pneumoniae) but not atypical pathogens, whereas North American experts favor a wider spectrum of coverage that includes the atypicals. PCT-guided therapy could allow European physicians to continue with less complete initial coverage by identifying the nonresponders who need expanded therapy, Dr. Pechère said.

In the future, it may even be possible to use PCT levels to distinguish typical from atypical CAP pathogens, he added, citing one study that noted lower levels in hospitalized CAP patients infected with typical, compared with atypical, bacteria (Infection 2000;28:68–73). But a more recent study concluded PCT levels were not predictive of type of pathogen (Clin. Microbiol. Infect. 2007;13:153–61).

Dr. Chastre said that in evaluating the severity and progression of pneumonia, PCT levels should always be considered in conjunction with other clinical parameters. “This marker is not 100% sensitive in some patients because, even with very severe disease, some people can have low levels,” he said, citing his own study showing low PCT levels in some patients with ventilator-associated pneumonia (Am. J. Respir. Crit. Care Med. 2005;171:48–53).

The reverse can also be true, with high levels of PCT seen in nonseptic conditions such as trauma, cardiogenic shock, and heat stroke, among others, he said.

MONTREAL — In community-acquired pneumonia, overuse of broad-spectrum antibiotics can be curbed with the help of biologic markers such as procalcitonin, according to Dr. Jean Chastre of the Hôpital de la Pitié-Salpêtrière, Paris.

Blood levels of procalcitonin (PCT) rise in patients with bacterial infections but remain fairly low in those with viral infections, and PCT levels decrease as the bacterial infection subsides. Measuring PCT levels thus aids decisions about whether to prescribe antibiotics, what type to prescribe, and for how long, said Dr. Chastre at an international conference on community-acquired pneumonia (CAP) that was sponsored by the International Society of Chemotherapy. “We use antibiotics for too long for too many patients, and in doing so are favoring the emergence of resistant strains,” he said in an interview.

“The more antibiotics we use, the more resistance we are going to see,” Dr. Jean-Claude Pechère agreed in an interview. In his presentation, he outlined a 2004 study in which PCT-guided therapy for lower respiratory tract infections significantly reduced antibiotic use, compared with standard care (Lancet 2004;363:600–7). “With these biomarkers, we suddenly realized we could cut antibiotic consumption almost in half. In Europe, we are speaking of millions of patients,” said Dr. Pechère, a professor of medicine at the University of Geneva.

Although a PCT assay is approved in Europe, it is still not widely available, and it is even less so in North America, according Dr. Thomas File, a professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown. “There are a few places where they have it available in the [emergency department], but in most places it takes several hours to get the result back—maybe even a day,” Dr. File said in an interview. Because initiation of antibiotic therapy is recommended within hours of a diagnosis of bacterial CAP, a PCT assay may not be practical for guiding initial treatment decisions, he said. “It's probably going to be more helpful in making decisions about duration of therapy, or changing therapy.”

For example, antibiotics can be stopped if the PCT results suggest that bacterial infection is unlikely, explained Dr. Chastre, who has received research funding and is a speaker for Brahms Diagnostics LLC, which makes a PCT assay. Or, therapy could be shortened if serial PCT measurements suggest a rapid response. “It's probably possible, even in severe pulmonary infection, to shorten the duration of antibiotics to 5 or 7 days if the PCT is decreasing very rapidly,” Dr. Chastre said.

European guidelines recommend that empiric therapy for bacterial CAP should provide coverage against the most common pathogen (Streptococcus pneumoniae) but not atypical pathogens, whereas North American experts favor a wider spectrum of coverage that includes the atypicals. PCT-guided therapy could allow European physicians to continue with less complete initial coverage by identifying the nonresponders who need expanded therapy, Dr. Pechère said.

In the future, it may even be possible to use PCT levels to distinguish typical from atypical CAP pathogens, he added, citing one study that noted lower levels in hospitalized CAP patients infected with typical, compared with atypical, bacteria (Infection 2000;28:68–73). But a more recent study concluded PCT levels were not predictive of type of pathogen (Clin. Microbiol. Infect. 2007;13:153–61).

Dr. Chastre said that in evaluating the severity and progression of pneumonia, PCT levels should always be considered in conjunction with other clinical parameters. “This marker is not 100% sensitive in some patients because, even with very severe disease, some people can have low levels,” he said, citing his own study showing low PCT levels in some patients with ventilator-associated pneumonia (Am. J. Respir. Crit. Care Med. 2005;171:48–53).

The reverse can also be true, with high levels of PCT seen in nonseptic conditions such as trauma, cardiogenic shock, and heat stroke, among others, he said.

MONTREAL — In community-acquired pneumonia, overuse of broad-spectrum antibiotics can be curbed with the help of biologic markers such as procalcitonin, according to Dr. Jean Chastre of the Hôpital de la Pitié-Salpêtrière, Paris.

Blood levels of procalcitonin (PCT) rise in patients with bacterial infections but remain fairly low in those with viral infections, and PCT levels decrease as the bacterial infection subsides. Measuring PCT levels thus aids decisions about whether to prescribe antibiotics, what type to prescribe, and for how long, said Dr. Chastre at an international conference on community-acquired pneumonia (CAP) that was sponsored by the International Society of Chemotherapy. “We use antibiotics for too long for too many patients, and in doing so are favoring the emergence of resistant strains,” he said in an interview.

“The more antibiotics we use, the more resistance we are going to see,” Dr. Jean-Claude Pechère agreed in an interview. In his presentation, he outlined a 2004 study in which PCT-guided therapy for lower respiratory tract infections significantly reduced antibiotic use, compared with standard care (Lancet 2004;363:600–7). “With these biomarkers, we suddenly realized we could cut antibiotic consumption almost in half. In Europe, we are speaking of millions of patients,” said Dr. Pechère, a professor of medicine at the University of Geneva.

Although a PCT assay is approved in Europe, it is still not widely available, and it is even less so in North America, according Dr. Thomas File, a professor of internal medicine and head of infectious diseases at Northeastern Ohio Universities, Rootstown. “There are a few places where they have it available in the [emergency department], but in most places it takes several hours to get the result back—maybe even a day,” Dr. File said in an interview. Because initiation of antibiotic therapy is recommended within hours of a diagnosis of bacterial CAP, a PCT assay may not be practical for guiding initial treatment decisions, he said. “It's probably going to be more helpful in making decisions about duration of therapy, or changing therapy.”

For example, antibiotics can be stopped if the PCT results suggest that bacterial infection is unlikely, explained Dr. Chastre, who has received research funding and is a speaker for Brahms Diagnostics LLC, which makes a PCT assay. Or, therapy could be shortened if serial PCT measurements suggest a rapid response. “It's probably possible, even in severe pulmonary infection, to shorten the duration of antibiotics to 5 or 7 days if the PCT is decreasing very rapidly,” Dr. Chastre said.

European guidelines recommend that empiric therapy for bacterial CAP should provide coverage against the most common pathogen (Streptococcus pneumoniae) but not atypical pathogens, whereas North American experts favor a wider spectrum of coverage that includes the atypicals. PCT-guided therapy could allow European physicians to continue with less complete initial coverage by identifying the nonresponders who need expanded therapy, Dr. Pechère said.

In the future, it may even be possible to use PCT levels to distinguish typical from atypical CAP pathogens, he added, citing one study that noted lower levels in hospitalized CAP patients infected with typical, compared with atypical, bacteria (Infection 2000;28:68–73). But a more recent study concluded PCT levels were not predictive of type of pathogen (Clin. Microbiol. Infect. 2007;13:153–61).

Dr. Chastre said that in evaluating the severity and progression of pneumonia, PCT levels should always be considered in conjunction with other clinical parameters. “This marker is not 100% sensitive in some patients because, even with very severe disease, some people can have low levels,” he said, citing his own study showing low PCT levels in some patients with ventilator-associated pneumonia (Am. J. Respir. Crit. Care Med. 2005;171:48–53).

The reverse can also be true, with high levels of PCT seen in nonseptic conditions such as trauma, cardiogenic shock, and heat stroke, among others, he said.

MONTREAL — New guidelines for the management of community-acquired pneumonia provide an excellent framework for site-of-care decisions, but they must be augmented with a good dose of clinical judgment, according to Glenn Tillotson, Ph.D.

The consensus guidelines from the Infectious Diseases Society of America and the American Thoracic Society hinge on two severity scoring systems to aid in the decision about whether to hospitalize patients with community-acquired pneumonia (CAP) or treat them as outpatients (CID 2007;44[suppl. 2]:S29).

However, although the well-established Pneumonia Severity Index (PSI) and the CURB-65 (confusion, uremia, respiratory rate, blood pressure, age 65 years or older) scoring systems are excellent tools, “clinical judgment based on more subjective criteria should override the rules,” Dr. Tillotson said at an international conference on community-acquired pneumonia.

Disease severity scoring systems adequately classify most patients with CAP into either hospital or outpatient treatment, but such systems may be less reliable for young adults (aged 17–40 years) and the frail elderly, said Dr. Tillotson, who is executive director of scientific affairs at Replidyne Inc.

He outlined one study of young CAP patients (median age 20 years) in which previous pulmonary disease, initial vital signs, and lab values were not predictive of mortality or length of stay (Chest 2006;130[suppl.]:105S). Another study found that in frail elderly patients with CAP, chronic comorbidities were not predictive of disease severity (Chest 2006;130[suppl.]:105S). “The factors we tend to lean on should not necessarily drive our decisions, especially in these populations,” he said.

Dr. Tillotson emphasized that although there may be a need for more specific scoring systems for CAP patients who are either young or frail and elderly, the science of scoring systems must always bow to the art of clinical judgment for all CAP patients.

“It's not always possible to articulate what marks a stay-at-home type patient versus someone who needs to go to hospital. There may be occasions when you should admit someone—not because they're severely ill, but simply because they need some TLC. One or 2 days in hospital could make all the difference,” he said.

He noted a study of almost 2,000 low-risk CAP patients in which 45% were treated as inpatients (J. Gen. Intern. Med. 2006;21:745–52). Among the hospitalized patients, about one-fifth had no identifiable risk factor according to the PSI. “An overnight stay in hospital can sometimes just get somebody over that hump. They're feeling sick; they have chest pains, fever, and coughing. They're not really sick enough to be admitted, but 24 hours in an observation ward can make a big difference,” he said.

Weighing against this idea are the known risks of hospitalization. “It's often better to manage someone in the community because they're less likely to acquire resistant pathogens, or they're less likely to have thromboembolic events,” Dr. Tillotson said.

MONTREAL — New guidelines for the management of community-acquired pneumonia provide an excellent framework for site-of-care decisions, but they must be augmented with a good dose of clinical judgment, according to Glenn Tillotson, Ph.D.

The consensus guidelines from the Infectious Diseases Society of America and the American Thoracic Society hinge on two severity scoring systems to aid in the decision about whether to hospitalize patients with community-acquired pneumonia (CAP) or treat them as outpatients (CID 2007;44[suppl. 2]:S29).

However, although the well-established Pneumonia Severity Index (PSI) and the CURB-65 (confusion, uremia, respiratory rate, blood pressure, age 65 years or older) scoring systems are excellent tools, “clinical judgment based on more subjective criteria should override the rules,” Dr. Tillotson said at an international conference on community-acquired pneumonia.

Disease severity scoring systems adequately classify most patients with CAP into either hospital or outpatient treatment, but such systems may be less reliable for young adults (aged 17–40 years) and the frail elderly, said Dr. Tillotson, who is executive director of scientific affairs at Replidyne Inc.

He outlined one study of young CAP patients (median age 20 years) in which previous pulmonary disease, initial vital signs, and lab values were not predictive of mortality or length of stay (Chest 2006;130[suppl.]:105S). Another study found that in frail elderly patients with CAP, chronic comorbidities were not predictive of disease severity (Chest 2006;130[suppl.]:105S). “The factors we tend to lean on should not necessarily drive our decisions, especially in these populations,” he said.

Dr. Tillotson emphasized that although there may be a need for more specific scoring systems for CAP patients who are either young or frail and elderly, the science of scoring systems must always bow to the art of clinical judgment for all CAP patients.

“It's not always possible to articulate what marks a stay-at-home type patient versus someone who needs to go to hospital. There may be occasions when you should admit someone—not because they're severely ill, but simply because they need some TLC. One or 2 days in hospital could make all the difference,” he said.

He noted a study of almost 2,000 low-risk CAP patients in which 45% were treated as inpatients (J. Gen. Intern. Med. 2006;21:745–52). Among the hospitalized patients, about one-fifth had no identifiable risk factor according to the PSI. “An overnight stay in hospital can sometimes just get somebody over that hump. They're feeling sick; they have chest pains, fever, and coughing. They're not really sick enough to be admitted, but 24 hours in an observation ward can make a big difference,” he said.

Weighing against this idea are the known risks of hospitalization. “It's often better to manage someone in the community because they're less likely to acquire resistant pathogens, or they're less likely to have thromboembolic events,” Dr. Tillotson said.

MONTREAL — New guidelines for the management of community-acquired pneumonia provide an excellent framework for site-of-care decisions, but they must be augmented with a good dose of clinical judgment, according to Glenn Tillotson, Ph.D.

The consensus guidelines from the Infectious Diseases Society of America and the American Thoracic Society hinge on two severity scoring systems to aid in the decision about whether to hospitalize patients with community-acquired pneumonia (CAP) or treat them as outpatients (CID 2007;44[suppl. 2]:S29).

However, although the well-established Pneumonia Severity Index (PSI) and the CURB-65 (confusion, uremia, respiratory rate, blood pressure, age 65 years or older) scoring systems are excellent tools, “clinical judgment based on more subjective criteria should override the rules,” Dr. Tillotson said at an international conference on community-acquired pneumonia.

Disease severity scoring systems adequately classify most patients with CAP into either hospital or outpatient treatment, but such systems may be less reliable for young adults (aged 17–40 years) and the frail elderly, said Dr. Tillotson, who is executive director of scientific affairs at Replidyne Inc.

He outlined one study of young CAP patients (median age 20 years) in which previous pulmonary disease, initial vital signs, and lab values were not predictive of mortality or length of stay (Chest 2006;130[suppl.]:105S). Another study found that in frail elderly patients with CAP, chronic comorbidities were not predictive of disease severity (Chest 2006;130[suppl.]:105S). “The factors we tend to lean on should not necessarily drive our decisions, especially in these populations,” he said.

Dr. Tillotson emphasized that although there may be a need for more specific scoring systems for CAP patients who are either young or frail and elderly, the science of scoring systems must always bow to the art of clinical judgment for all CAP patients.

“It's not always possible to articulate what marks a stay-at-home type patient versus someone who needs to go to hospital. There may be occasions when you should admit someone—not because they're severely ill, but simply because they need some TLC. One or 2 days in hospital could make all the difference,” he said.

He noted a study of almost 2,000 low-risk CAP patients in which 45% were treated as inpatients (J. Gen. Intern. Med. 2006;21:745–52). Among the hospitalized patients, about one-fifth had no identifiable risk factor according to the PSI. “An overnight stay in hospital can sometimes just get somebody over that hump. They're feeling sick; they have chest pains, fever, and coughing. They're not really sick enough to be admitted, but 24 hours in an observation ward can make a big difference,” he said.

Weighing against this idea are the known risks of hospitalization. “It's often better to manage someone in the community because they're less likely to acquire resistant pathogens, or they're less likely to have thromboembolic events,” Dr. Tillotson said.

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10). Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital. The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the upfront cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said.

Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10). Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital. The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the upfront cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said.

Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.

MONTREAL — Hospitalization can be reduced by more than half among nursing home residents with pneumonia and other lower respiratory tract infections, with no compromise in morbidity or mortality, Dr. Mark Loeb said at an international conference on community-acquired pneumonia.

“Pneumonia is the most important reason why residents are transferred to hospital, but hospitalization can lead to functional decline, infection with multiresistant organisms, urinary tract infections, and delirium,” said Dr. Loeb of the department of pathology and molecular medicine at McMaster University, Hamilton, Ont.

Reducing the rate of hospitalization in this population would not only avoid these potential hazards, but also reduce the overall burden on the health care system, an issue “which has particular relevance for pandemic planning,” he noted at the conference, which was sponsored by the International Society for Chemotherapy. “Most pandemic plans tend to ignore the long-term care facilities—they basically focus on the acute care setting—but a very relevant issue is when there's a pandemic, what happens to nursing home residents? Do they get sent to the acute care hospital for management, or do we just manage them on-site?”

A study by Dr. Loeb and his colleagues randomized 680 nursing home residents with pneumonia or other lower respiratory tract infections to either usual care or treatment according to a clinical algorithm designed to encourage on-site care (JAMA 2006;295:2503–10). Patients were eligible to be treated on-site only if they could eat and drink and had stable vital signs; otherwise, they were transferred to a hospital. The clinical algorithm involved the use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse.

Only 10% of patients randomized to the algorithm were hospitalized, compared with 22% of the usual care patients, Dr. Loeb said at the meeting. Over the 30-day follow-up, there were no significant differences in quality of life scores, functional status, or mortality (8% in the algorithm group vs. 9% in the usual care group), but there was a marked reduction in cost associated with the treatment algorithm.

Although the initial cost was $87 more per resident in the algorithm vs. usual care groups (because of the upfront cost of oxygen and hydration therapy, mobile radiographs, and administration), this was offset by reduced professional billing, transportation, and hospitalization costs, he said.

Overall, the algorithm resulted in a saving of $1,016 (in U.S. dollars) per patient, based on the Canadian health care costs. Using U.S. prices, the saving was $1,517 (in U.S. dollars). The researchers estimated that the clinical algorithm could save $831 million annually among the approximately 1.5 million elderly residents in U.S. nursing homes.

Dr. Loeb and his coauthors acknowledged that health care funding in the United States could pose a barrier to the implementation of such an algorithm because, unlike in Canada, the costs of implementation would be shouldered by the nursing home, while the resulting savings would be realized by the hospital.