Roxanne Nelson

BOCA RATON, FLA. — The right electronic medical record software can supercharge efficiency, help cap costs, increase the bottom line, reduce medical errors, and provide better care, according to a talk given at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Several products are available, although only a few are designed specifically for dermatology, said Daniel M. Siegel, M.D., professor of clinical dermatology at the State University of New York, Brooklyn.

"No system is perfect and nothing is ideal for everyone," he said. However, he reminded the audience that President Bush had set a 10-year goal of having a secure electronic medical record (EMR) that could be accessed online and would include patient medical histories and electronic prescribing, among other key attributes.

"So just remember, we are 8 years from mandated, required electronic health records," Dr. Siegel said. "It's going to happen."

An optimal system will allow quick access to information, is easy to learn and use, and is inexpensive. The ideal EMR will take advantage of the latest hardware, such as table PCs or PDAs, as well as high-speed networks. It will also allow multiple forms of input, including easily customized templates and speech recognition.

To simplify the process of choosing software from the array of choices that is currently available, Dr. Siegel offered the following suggestions:

▸ Avoid purchasing or signing a lengthy contract without first trying out the software. Visit other offices using the same system and convince the vendors to let you try it out for a week or so, Dr. Siegel said.

▸ Think ease of use. "If, after a 5-, 10-, 30-, [or] 60-minute demo, you still think you need to get a PhD in computer science and astrophysics to use the program, you probably do," he said. "Don't buy a package whose demo gives you a migraine."

▸ Have a customized template. Many vendors are focused on primary care medicine and may have great demos in diabetes and hypertension but not in psoriasis or acne.

▸ Select a system that uses standard PC-compatible software. "This way, if you change dance partners, you can still reuse the dance hall," Dr. Siegel said.

▸ Do your research. "Ask them how long they've been in business."

▸ Dermatologists need to be sure that the program is HL7 compatible. HL7 is an information exchange standard for communications between medical applications. If the system requires an upgrade, the transformation should be as painless as possible, and HL7 will help with that.

▸ Plan an exit strategy. Find out if you can drop the program if it's not working out, and if the information can be transferred, he said. "Alternatively, if you have a subscription to it, can you purchase it?"

Dr. Siegel added that when choosing EMR software, it is important to go slowly and to look for an inexpensive system that meets the needs of the practice. Ask about available demos and trialware, get any money-back guarantees in writing, and identify possible additional costs before purchase.

If you 'think you need to get a PhD in computer science and astrophysics to use the program, you probably do.' DR. SIEGEL

BOCA RATON, FLA. — The right electronic medical record software can supercharge efficiency, help cap costs, increase the bottom line, reduce medical errors, and provide better care, according to a talk given at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Several products are available, although only a few are designed specifically for dermatology, said Daniel M. Siegel, M.D., professor of clinical dermatology at the State University of New York, Brooklyn.

"No system is perfect and nothing is ideal for everyone," he said. However, he reminded the audience that President Bush had set a 10-year goal of having a secure electronic medical record (EMR) that could be accessed online and would include patient medical histories and electronic prescribing, among other key attributes.

"So just remember, we are 8 years from mandated, required electronic health records," Dr. Siegel said. "It's going to happen."

An optimal system will allow quick access to information, is easy to learn and use, and is inexpensive. The ideal EMR will take advantage of the latest hardware, such as table PCs or PDAs, as well as high-speed networks. It will also allow multiple forms of input, including easily customized templates and speech recognition.

To simplify the process of choosing software from the array of choices that is currently available, Dr. Siegel offered the following suggestions:

▸ Avoid purchasing or signing a lengthy contract without first trying out the software. Visit other offices using the same system and convince the vendors to let you try it out for a week or so, Dr. Siegel said.

▸ Think ease of use. "If, after a 5-, 10-, 30-, [or] 60-minute demo, you still think you need to get a PhD in computer science and astrophysics to use the program, you probably do," he said. "Don't buy a package whose demo gives you a migraine."

▸ Have a customized template. Many vendors are focused on primary care medicine and may have great demos in diabetes and hypertension but not in psoriasis or acne.

▸ Select a system that uses standard PC-compatible software. "This way, if you change dance partners, you can still reuse the dance hall," Dr. Siegel said.

▸ Do your research. "Ask them how long they've been in business."

▸ Dermatologists need to be sure that the program is HL7 compatible. HL7 is an information exchange standard for communications between medical applications. If the system requires an upgrade, the transformation should be as painless as possible, and HL7 will help with that.

▸ Plan an exit strategy. Find out if you can drop the program if it's not working out, and if the information can be transferred, he said. "Alternatively, if you have a subscription to it, can you purchase it?"

Dr. Siegel added that when choosing EMR software, it is important to go slowly and to look for an inexpensive system that meets the needs of the practice. Ask about available demos and trialware, get any money-back guarantees in writing, and identify possible additional costs before purchase.

If you 'think you need to get a PhD in computer science and astrophysics to use the program, you probably do.' DR. SIEGEL

BOCA RATON, FLA. — The right electronic medical record software can supercharge efficiency, help cap costs, increase the bottom line, reduce medical errors, and provide better care, according to a talk given at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

Several products are available, although only a few are designed specifically for dermatology, said Daniel M. Siegel, M.D., professor of clinical dermatology at the State University of New York, Brooklyn.

"No system is perfect and nothing is ideal for everyone," he said. However, he reminded the audience that President Bush had set a 10-year goal of having a secure electronic medical record (EMR) that could be accessed online and would include patient medical histories and electronic prescribing, among other key attributes.

"So just remember, we are 8 years from mandated, required electronic health records," Dr. Siegel said. "It's going to happen."

An optimal system will allow quick access to information, is easy to learn and use, and is inexpensive. The ideal EMR will take advantage of the latest hardware, such as table PCs or PDAs, as well as high-speed networks. It will also allow multiple forms of input, including easily customized templates and speech recognition.

To simplify the process of choosing software from the array of choices that is currently available, Dr. Siegel offered the following suggestions:

▸ Avoid purchasing or signing a lengthy contract without first trying out the software. Visit other offices using the same system and convince the vendors to let you try it out for a week or so, Dr. Siegel said.

▸ Think ease of use. "If, after a 5-, 10-, 30-, [or] 60-minute demo, you still think you need to get a PhD in computer science and astrophysics to use the program, you probably do," he said. "Don't buy a package whose demo gives you a migraine."

▸ Have a customized template. Many vendors are focused on primary care medicine and may have great demos in diabetes and hypertension but not in psoriasis or acne.

▸ Select a system that uses standard PC-compatible software. "This way, if you change dance partners, you can still reuse the dance hall," Dr. Siegel said.

▸ Do your research. "Ask them how long they've been in business."

▸ Dermatologists need to be sure that the program is HL7 compatible. HL7 is an information exchange standard for communications between medical applications. If the system requires an upgrade, the transformation should be as painless as possible, and HL7 will help with that.

▸ Plan an exit strategy. Find out if you can drop the program if it's not working out, and if the information can be transferred, he said. "Alternatively, if you have a subscription to it, can you purchase it?"

Dr. Siegel added that when choosing EMR software, it is important to go slowly and to look for an inexpensive system that meets the needs of the practice. Ask about available demos and trialware, get any money-back guarantees in writing, and identify possible additional costs before purchase.

If you 'think you need to get a PhD in computer science and astrophysics to use the program, you probably do.' DR. SIEGEL

SAN ANTONIO – Women with fibromyalgia and their siblings experience a generalized sensitivity to pain and lower levels of serum serotonin, according to new research.

These are the preliminary results of an ongoing study, said Dr. Laurence A. Bradley, who presented the study at the annual meeting of the American Pain Society.

Several recent studies have shown that first-degree relatives of women with fibromyalgia have higher lifetime rates of major depressive and anxiety disorders, compared with first-degree relatives of those with rheumatoid arthritis. Other research has found that fibromyalgia and reduced pressure pain thresholds aggregate in families.

“Some studies show that female relatives of the fibromyalgia probands display higher rates of psychiatric disorders than do male relatives,” said Dr. Bradley, who is a professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham.

The goal of the current study was to measure pain sensitivity and blood serum levels of serotonin in female patients with fibromyalgia, sex-matched healthy controls, and the siblings of both the fibromyalgia probands and the controls.

It is unknown if the first-degree relatives of women with fibromyalgia exhibit the same pain sensitivity, Dr. Bradley explained, and if there are differences in the expression of serotonin in these relatives as well as in the patients. It is also unclear to what degree serotonin levels may mediate differences in pain sensitivity, not only in patients vs. controls but also in relatives of patients vs. relatives of controls.

Thus far, the study has enrolled 49 families, and includes 16 probands with fibromyalgia; 5 male and 11 female proband siblings; 23 female, pain-free, control individuals; and 8 male and 15 female control siblings. All of the participants had blood drawn for measurement of serum serotonin, and underwent testing for pain thresholds. Pain sensitivity was measured after stimulation of pressure points and control points. Thermal heat and ischemic pain threshold tolerance was also evaluated in all study participants.

The pain threshold and serum serotonin levels were measured between probands vs. controls and proband siblings vs. control siblings. Dr. Bradley and his colleagues also evaluated the group differences in pain thresholds after controlling for the influence of serotonin.

“We found that not only were pain thresholds lower in probands as compared with healthy controls, but we also saw the same pattern in proband relatives as compared with the relatives of the control group,” Dr. Bradley said. Lower levels of serum serotonin also were seen in both the patients and their siblings, compared with controls.

However, analysis revealed that serum serotonin levels partially mediated these group differences in pain threshold only for ischemic stimulation. Thus, serotonin appears to have a limited influence on pressure and thermal pain thresholds.

“The fact that we found only a modest relationship between ischemic pain thresholds and serotonin in patient probands and controls helps explain why early studies using tricyclic antidepressants and pressure point stimulation found no changes in pain response,” Dr. Bradley said. In future studies, “we need to look at multiple factors such as differences in family environments and gene variances,” he said.

SAN ANTONIO – Women with fibromyalgia and their siblings experience a generalized sensitivity to pain and lower levels of serum serotonin, according to new research.

These are the preliminary results of an ongoing study, said Dr. Laurence A. Bradley, who presented the study at the annual meeting of the American Pain Society.

Several recent studies have shown that first-degree relatives of women with fibromyalgia have higher lifetime rates of major depressive and anxiety disorders, compared with first-degree relatives of those with rheumatoid arthritis. Other research has found that fibromyalgia and reduced pressure pain thresholds aggregate in families.

“Some studies show that female relatives of the fibromyalgia probands display higher rates of psychiatric disorders than do male relatives,” said Dr. Bradley, who is a professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham.

The goal of the current study was to measure pain sensitivity and blood serum levels of serotonin in female patients with fibromyalgia, sex-matched healthy controls, and the siblings of both the fibromyalgia probands and the controls.

It is unknown if the first-degree relatives of women with fibromyalgia exhibit the same pain sensitivity, Dr. Bradley explained, and if there are differences in the expression of serotonin in these relatives as well as in the patients. It is also unclear to what degree serotonin levels may mediate differences in pain sensitivity, not only in patients vs. controls but also in relatives of patients vs. relatives of controls.

Thus far, the study has enrolled 49 families, and includes 16 probands with fibromyalgia; 5 male and 11 female proband siblings; 23 female, pain-free, control individuals; and 8 male and 15 female control siblings. All of the participants had blood drawn for measurement of serum serotonin, and underwent testing for pain thresholds. Pain sensitivity was measured after stimulation of pressure points and control points. Thermal heat and ischemic pain threshold tolerance was also evaluated in all study participants.

The pain threshold and serum serotonin levels were measured between probands vs. controls and proband siblings vs. control siblings. Dr. Bradley and his colleagues also evaluated the group differences in pain thresholds after controlling for the influence of serotonin.

“We found that not only were pain thresholds lower in probands as compared with healthy controls, but we also saw the same pattern in proband relatives as compared with the relatives of the control group,” Dr. Bradley said. Lower levels of serum serotonin also were seen in both the patients and their siblings, compared with controls.

However, analysis revealed that serum serotonin levels partially mediated these group differences in pain threshold only for ischemic stimulation. Thus, serotonin appears to have a limited influence on pressure and thermal pain thresholds.

“The fact that we found only a modest relationship between ischemic pain thresholds and serotonin in patient probands and controls helps explain why early studies using tricyclic antidepressants and pressure point stimulation found no changes in pain response,” Dr. Bradley said. In future studies, “we need to look at multiple factors such as differences in family environments and gene variances,” he said.

SAN ANTONIO – Women with fibromyalgia and their siblings experience a generalized sensitivity to pain and lower levels of serum serotonin, according to new research.

These are the preliminary results of an ongoing study, said Dr. Laurence A. Bradley, who presented the study at the annual meeting of the American Pain Society.

Several recent studies have shown that first-degree relatives of women with fibromyalgia have higher lifetime rates of major depressive and anxiety disorders, compared with first-degree relatives of those with rheumatoid arthritis. Other research has found that fibromyalgia and reduced pressure pain thresholds aggregate in families.

“Some studies show that female relatives of the fibromyalgia probands display higher rates of psychiatric disorders than do male relatives,” said Dr. Bradley, who is a professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham.

The goal of the current study was to measure pain sensitivity and blood serum levels of serotonin in female patients with fibromyalgia, sex-matched healthy controls, and the siblings of both the fibromyalgia probands and the controls.

It is unknown if the first-degree relatives of women with fibromyalgia exhibit the same pain sensitivity, Dr. Bradley explained, and if there are differences in the expression of serotonin in these relatives as well as in the patients. It is also unclear to what degree serotonin levels may mediate differences in pain sensitivity, not only in patients vs. controls but also in relatives of patients vs. relatives of controls.

Thus far, the study has enrolled 49 families, and includes 16 probands with fibromyalgia; 5 male and 11 female proband siblings; 23 female, pain-free, control individuals; and 8 male and 15 female control siblings. All of the participants had blood drawn for measurement of serum serotonin, and underwent testing for pain thresholds. Pain sensitivity was measured after stimulation of pressure points and control points. Thermal heat and ischemic pain threshold tolerance was also evaluated in all study participants.

The pain threshold and serum serotonin levels were measured between probands vs. controls and proband siblings vs. control siblings. Dr. Bradley and his colleagues also evaluated the group differences in pain thresholds after controlling for the influence of serotonin.

“We found that not only were pain thresholds lower in probands as compared with healthy controls, but we also saw the same pattern in proband relatives as compared with the relatives of the control group,” Dr. Bradley said. Lower levels of serum serotonin also were seen in both the patients and their siblings, compared with controls.

However, analysis revealed that serum serotonin levels partially mediated these group differences in pain threshold only for ischemic stimulation. Thus, serotonin appears to have a limited influence on pressure and thermal pain thresholds.

“The fact that we found only a modest relationship between ischemic pain thresholds and serotonin in patient probands and controls helps explain why early studies using tricyclic antidepressants and pressure point stimulation found no changes in pain response,” Dr. Bradley said. In future studies, “we need to look at multiple factors such as differences in family environments and gene variances,” he said.

SAN ANTONIO – Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster presentation at the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo. (See chart.) The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5-mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO – Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster presentation at the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo. (See chart.) The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5-mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO – Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster presentation at the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo. (See chart.) The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5-mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

ELSEVIER GLOBAL MEDICAL NEWS

BOCA RATON, FLA. — Medical malpractice suits are common, and many physicians are unaware of the procedures and protocols involved in building a strong defense, Cliff Rapp said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

The law is less concerned with rightness or wrongness than it is with justifiability. "You have to understand this going in. The legal system is about money, and you will be the pawn," said Mr. Rapp, vice president of risk management for First Professionals Insurance Co., in Jacksonville, Fla.

Early preparation is the key, he explained. Medical records will become evidence, and early on, the plaintiff's attorney will review the records to see if there are sufficient holes to bring it to court. In fact, a request for medical records is the first indication that something is going on.

It is essential not to ignore or be late with a request for records. "They usually ask you to provide a copy within 10 business days. And never alter your records. It's a crime, so just don't do it," Mr. Rapp said.

Keep the patient's chart separate from other records and create a separate personal file. "And never contact the patient's attorney directly," he said.

The 90-day presuit screening process begins with the notice of intent letter. During this period, the physician can admit guilt, deny any wrongdoing, or arbitrate. At the conclusion of the presuit, the claimant has 60 days or the remainder of the statute of limitations to file suit.

"Usually, if you don't settle, this will be the end of the lawsuit," Mr. Rapp said.

If the patient does pursue it, the physician must become his or her own best expert. Educate your defense team, Mr. Rapp pointed out. Invest the time to conduct research, evaluate medical literature, and obtain current seminar material.

You also need to work with your attorney, he explained, and should be honest, up front, and participate in your defense.

"The No. 1 mistake made during the deposition is being unprepared," Mr. Rapp explained. "The No. 2 mistake is not listening to the question, and the No. 3 mistake is trying to 'outsnake' the plaintiff's attorney."

Mr. Rapp strongly suggests that the physician visit the courtroom ahead of time and scope it out. Don't let the day of the trial be your first time there, he advised.

Attendance is mandatory at the trial, and it is important to give the right impression, he said. This means appearing on time, being conservative in dress and demeanor, and not arriving at the courthouse in a flashy, expensive automobile. "Arrive and leave with your attorney," he said.

Once the trial is underway, participate in your defense. It is important to pay attention to every detail, Mr. Rapp emphasized, and to take notes as well as to alert your attorney to any mistakes.

BOCA RATON, FLA. — Medical malpractice suits are common, and many physicians are unaware of the procedures and protocols involved in building a strong defense, Cliff Rapp said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

The law is less concerned with rightness or wrongness than it is with justifiability. "You have to understand this going in. The legal system is about money, and you will be the pawn," said Mr. Rapp, vice president of risk management for First Professionals Insurance Co., in Jacksonville, Fla.

Early preparation is the key, he explained. Medical records will become evidence, and early on, the plaintiff's attorney will review the records to see if there are sufficient holes to bring it to court. In fact, a request for medical records is the first indication that something is going on.

It is essential not to ignore or be late with a request for records. "They usually ask you to provide a copy within 10 business days. And never alter your records. It's a crime, so just don't do it," Mr. Rapp said.

Keep the patient's chart separate from other records and create a separate personal file. "And never contact the patient's attorney directly," he said.

The 90-day presuit screening process begins with the notice of intent letter. During this period, the physician can admit guilt, deny any wrongdoing, or arbitrate. At the conclusion of the presuit, the claimant has 60 days or the remainder of the statute of limitations to file suit.

"Usually, if you don't settle, this will be the end of the lawsuit," Mr. Rapp said.

If the patient does pursue it, the physician must become his or her own best expert. Educate your defense team, Mr. Rapp pointed out. Invest the time to conduct research, evaluate medical literature, and obtain current seminar material.

You also need to work with your attorney, he explained, and should be honest, up front, and participate in your defense.

"The No. 1 mistake made during the deposition is being unprepared," Mr. Rapp explained. "The No. 2 mistake is not listening to the question, and the No. 3 mistake is trying to 'outsnake' the plaintiff's attorney."

Mr. Rapp strongly suggests that the physician visit the courtroom ahead of time and scope it out. Don't let the day of the trial be your first time there, he advised.

Attendance is mandatory at the trial, and it is important to give the right impression, he said. This means appearing on time, being conservative in dress and demeanor, and not arriving at the courthouse in a flashy, expensive automobile. "Arrive and leave with your attorney," he said.

Once the trial is underway, participate in your defense. It is important to pay attention to every detail, Mr. Rapp emphasized, and to take notes as well as to alert your attorney to any mistakes.

BOCA RATON, FLA. — Medical malpractice suits are common, and many physicians are unaware of the procedures and protocols involved in building a strong defense, Cliff Rapp said at the annual meeting of the Florida Society for Dermatology and Dermatologic Surgery.

The law is less concerned with rightness or wrongness than it is with justifiability. "You have to understand this going in. The legal system is about money, and you will be the pawn," said Mr. Rapp, vice president of risk management for First Professionals Insurance Co., in Jacksonville, Fla.

Early preparation is the key, he explained. Medical records will become evidence, and early on, the plaintiff's attorney will review the records to see if there are sufficient holes to bring it to court. In fact, a request for medical records is the first indication that something is going on.

It is essential not to ignore or be late with a request for records. "They usually ask you to provide a copy within 10 business days. And never alter your records. It's a crime, so just don't do it," Mr. Rapp said.

Keep the patient's chart separate from other records and create a separate personal file. "And never contact the patient's attorney directly," he said.

The 90-day presuit screening process begins with the notice of intent letter. During this period, the physician can admit guilt, deny any wrongdoing, or arbitrate. At the conclusion of the presuit, the claimant has 60 days or the remainder of the statute of limitations to file suit.

"Usually, if you don't settle, this will be the end of the lawsuit," Mr. Rapp said.

If the patient does pursue it, the physician must become his or her own best expert. Educate your defense team, Mr. Rapp pointed out. Invest the time to conduct research, evaluate medical literature, and obtain current seminar material.

You also need to work with your attorney, he explained, and should be honest, up front, and participate in your defense.

"The No. 1 mistake made during the deposition is being unprepared," Mr. Rapp explained. "The No. 2 mistake is not listening to the question, and the No. 3 mistake is trying to 'outsnake' the plaintiff's attorney."

Mr. Rapp strongly suggests that the physician visit the courtroom ahead of time and scope it out. Don't let the day of the trial be your first time there, he advised.

Attendance is mandatory at the trial, and it is important to give the right impression, he said. This means appearing on time, being conservative in dress and demeanor, and not arriving at the courthouse in a flashy, expensive automobile. "Arrive and leave with your attorney," he said.

Once the trial is underway, participate in your defense. It is important to pay attention to every detail, Mr. Rapp emphasized, and to take notes as well as to alert your attorney to any mistakes.

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop GI adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.” The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

Alvimopan's efficacy was evaluated in a 6-week study of 522 patients receiving opioids for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase in the placebo group. (See chart.) The increase in SBMs was apparent in the first week of the study, was sustained throughout the entire treatment period, and returned towards baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop GI adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.” The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

Alvimopan's efficacy was evaluated in a 6-week study of 522 patients receiving opioids for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase in the placebo group. (See chart.) The increase in SBMs was apparent in the first week of the study, was sustained throughout the entire treatment period, and returned towards baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop GI adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.” The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

Alvimopan's efficacy was evaluated in a 6-week study of 522 patients receiving opioids for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase in the placebo group. (See chart.) The increase in SBMs was apparent in the first week of the study, was sustained throughout the entire treatment period, and returned towards baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said.

ELSEVIER GLOBAL MEDICAL NEWS

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo.

The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo.

The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

SAN ANTONIO — Alvimopan is effective in relieving gastrointestinal adverse events associated with opioid administration, according to preliminary data.

“We were able to demonstrate that alvimopan, a μ-opioid receptor antagonist that is taken orally, was able to increase bowel function significantly,” lead investigator Dr. Lynn Webster reported in a poster during the annual meeting of the American Pain Society Meeting. “At several different doses, the side effects were similar to what was seen with placebo.”

Patients using opioids to treat chronic moderate to severe pain often develop gastrointestinal adverse events, including constipation, abdominal pain and discomfort, and bloating. These side effects can prevent some patients from adequately managing their pain.

“There is a very significant need for this type of agent,” said Dr. Webster, medical director of a group practice in Salt Lake City. “About 50% of my patients have a significant bowel dysfunction from opioid use, and it sometimes limits the amount of opioids that they can be given.”

The problem can be life threatening, causing complications such as bowel perforation in some patients, he added.

The efficacy of alvimopan was evaluated in a 6-week study of 522 patients receiving opioid treatment for persistent noncancer pain. The phase IIb double-blind design randomized patients to 0.5 mg alvimopan twice daily, 1 mg alvimopan once daily, 1 mg alvimopan twice daily, or placebo.

Patients in all of the groups reported an average frequency of one spontaneous bowel movement (SBM) per week during the baseline period. The average increase in SBMs per week during the treatment period was about 3.5 in the two daily alvimopan groups, and 4.3 in the twice daily group; the increases were significantly greater than the 1.7 increase seen among patients given placebo.

The increase in SBMs was apparent within the first week of the study, was sustained throughout the entire treatment period, and returned toward baseline when alvimopan was discontinued.

Patients on active therapy also reported improvements in straining, stool consistency, completeness of evacuation, and abdominal pain and bloating, compared with placebo. Overall, 40% of the patients who received alvimopan reported moderate to substantial improvement in constipation, vs. 14% with placebo. Patients using alvimopan also reported a significantly lower need for rescue laxatives.

The most common adverse events reported in the trial were abdominal pain, nausea, and diarrhea, occurring in 30%–43% of patients on active therapy and 36% of those on placebo. Overall, withdrawal rates for adverse events were 13% or lower across all treatment groups. The best benefit-to-risk profile was seen with the 0.5 mg twice-daily dose.

“The important thing is that we demonstrated efficacy with a low risk of adverse events,” Dr. Webster said. “Any opportunity that we have to restore as much normal bowel function as possible, with very little side effect and risk, presents a great opportunity.”

SEATTLE — Preterm birth is the most frequent cause of infant mortality in the United States, accounting for one-third of infant deaths in 2002, according to data presented at a meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Prematurity remains a major cause of infant morbidity and mortality in the United States, and rates continue to rise. Across the board, the rate of premature births rose 13% between 1992 and 2002, with seven states showing increases of 30% or higher, according to the March of Dimes.

“As of yet we do not have good predictors and prevention for preterm birth,” Dr. William Callaghan said in an interview.

“We decided to reassess the contribution of preterm birth to infant mortality, in light of the strong connection between prematurity and infant death and the rising rates of preterm birth,” explained Dr. Callaghan, a senior scientist in the Maternal and Infant Health Branch, Division of Reproductive Health, at the CDC.

Although about two-thirds of infant deaths occur in those born at less than 37 weeks' gestation, fewer than 20% of infant deaths are classified as being due to preterm birth using the standard National Center for Health Statistics' classification of “leading cause of death.”

This seeming contradiction can be explained, Dr. Callaghan said. “Among all infants who died, 65% were born preterm. However, just because the association exists does not mean that being preterm was necessarily the cause of death.”

As an example, if a preterm infant with a lethal congenital anomaly dies, one cannot say with any certainty that the death was caused by preterm birth or by the congenital anomaly.

Dr. Callaghan explained that he and his coauthors took a very conservative strategy and looked only at the 20 leading causes of infant death. Of 27,970 records in the linked birth/infant death file for 2002, the 20 leading causes accounted for 22,273 or 80% of all infant deaths. Within this group, they assessed the contributing role of preterm birth for each of the causes of death that are embedded in the standard categories.

The methodology was broken down into three basic steps to determine whether the cause of death was actually related to prematurity. First, the cause of death had to be statistically associated with preterm birth. If preterm infants contributed to at least 75% of the mortality due to a specific cause, the death was considered as potentially due to preterm birth.

Second, information about the condition had to be sufficient in order to determine if preterm birth actually led to that condition, or if the condition designated as the cause of death led to preterm birth.

Finally, it had to be determined whether the infant who died from the proposed cause was actually preterm.

Not surprisingly, the earliest infants had the highest rate of mortality, said Dr. Callaghan. Infants born at less than 32 weeks' gestation and who weighed less than 1,500 g accounted for 88% of the total 9,596 deaths attributed to preterm birth.

“If you look at all infant deaths in total, preterm births account for 34% of them,” Dr. Callaghan said. “But if you look at infant deaths confined to the 20 leading causes, then that rate is 43%.”

The majority of the infants die within the first week of life, with two-thirds of these deaths occurring during the first 24 hours after birth. “Prevention of preterm birth, especially at the earliest gestations, is crucial if we are going to further reduce the infant mortality rate,” he said.

SEATTLE — Preterm birth is the most frequent cause of infant mortality in the United States, accounting for one-third of infant deaths in 2002, according to data presented at a meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Prematurity remains a major cause of infant morbidity and mortality in the United States, and rates continue to rise. Across the board, the rate of premature births rose 13% between 1992 and 2002, with seven states showing increases of 30% or higher, according to the March of Dimes.

“As of yet we do not have good predictors and prevention for preterm birth,” Dr. William Callaghan said in an interview.

“We decided to reassess the contribution of preterm birth to infant mortality, in light of the strong connection between prematurity and infant death and the rising rates of preterm birth,” explained Dr. Callaghan, a senior scientist in the Maternal and Infant Health Branch, Division of Reproductive Health, at the CDC.

Although about two-thirds of infant deaths occur in those born at less than 37 weeks' gestation, fewer than 20% of infant deaths are classified as being due to preterm birth using the standard National Center for Health Statistics' classification of “leading cause of death.”

This seeming contradiction can be explained, Dr. Callaghan said. “Among all infants who died, 65% were born preterm. However, just because the association exists does not mean that being preterm was necessarily the cause of death.”

As an example, if a preterm infant with a lethal congenital anomaly dies, one cannot say with any certainty that the death was caused by preterm birth or by the congenital anomaly.

Dr. Callaghan explained that he and his coauthors took a very conservative strategy and looked only at the 20 leading causes of infant death. Of 27,970 records in the linked birth/infant death file for 2002, the 20 leading causes accounted for 22,273 or 80% of all infant deaths. Within this group, they assessed the contributing role of preterm birth for each of the causes of death that are embedded in the standard categories.

The methodology was broken down into three basic steps to determine whether the cause of death was actually related to prematurity. First, the cause of death had to be statistically associated with preterm birth. If preterm infants contributed to at least 75% of the mortality due to a specific cause, the death was considered as potentially due to preterm birth.

Second, information about the condition had to be sufficient in order to determine if preterm birth actually led to that condition, or if the condition designated as the cause of death led to preterm birth.

Finally, it had to be determined whether the infant who died from the proposed cause was actually preterm.

Not surprisingly, the earliest infants had the highest rate of mortality, said Dr. Callaghan. Infants born at less than 32 weeks' gestation and who weighed less than 1,500 g accounted for 88% of the total 9,596 deaths attributed to preterm birth.

“If you look at all infant deaths in total, preterm births account for 34% of them,” Dr. Callaghan said. “But if you look at infant deaths confined to the 20 leading causes, then that rate is 43%.”

The majority of the infants die within the first week of life, with two-thirds of these deaths occurring during the first 24 hours after birth. “Prevention of preterm birth, especially at the earliest gestations, is crucial if we are going to further reduce the infant mortality rate,” he said.

SEATTLE — Preterm birth is the most frequent cause of infant mortality in the United States, accounting for one-third of infant deaths in 2002, according to data presented at a meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

Prematurity remains a major cause of infant morbidity and mortality in the United States, and rates continue to rise. Across the board, the rate of premature births rose 13% between 1992 and 2002, with seven states showing increases of 30% or higher, according to the March of Dimes.

“As of yet we do not have good predictors and prevention for preterm birth,” Dr. William Callaghan said in an interview.

“We decided to reassess the contribution of preterm birth to infant mortality, in light of the strong connection between prematurity and infant death and the rising rates of preterm birth,” explained Dr. Callaghan, a senior scientist in the Maternal and Infant Health Branch, Division of Reproductive Health, at the CDC.

Although about two-thirds of infant deaths occur in those born at less than 37 weeks' gestation, fewer than 20% of infant deaths are classified as being due to preterm birth using the standard National Center for Health Statistics' classification of “leading cause of death.”

This seeming contradiction can be explained, Dr. Callaghan said. “Among all infants who died, 65% were born preterm. However, just because the association exists does not mean that being preterm was necessarily the cause of death.”

As an example, if a preterm infant with a lethal congenital anomaly dies, one cannot say with any certainty that the death was caused by preterm birth or by the congenital anomaly.

Dr. Callaghan explained that he and his coauthors took a very conservative strategy and looked only at the 20 leading causes of infant death. Of 27,970 records in the linked birth/infant death file for 2002, the 20 leading causes accounted for 22,273 or 80% of all infant deaths. Within this group, they assessed the contributing role of preterm birth for each of the causes of death that are embedded in the standard categories.

The methodology was broken down into three basic steps to determine whether the cause of death was actually related to prematurity. First, the cause of death had to be statistically associated with preterm birth. If preterm infants contributed to at least 75% of the mortality due to a specific cause, the death was considered as potentially due to preterm birth.

Second, information about the condition had to be sufficient in order to determine if preterm birth actually led to that condition, or if the condition designated as the cause of death led to preterm birth.

Finally, it had to be determined whether the infant who died from the proposed cause was actually preterm.

Not surprisingly, the earliest infants had the highest rate of mortality, said Dr. Callaghan. Infants born at less than 32 weeks' gestation and who weighed less than 1,500 g accounted for 88% of the total 9,596 deaths attributed to preterm birth.

“If you look at all infant deaths in total, preterm births account for 34% of them,” Dr. Callaghan said. “But if you look at infant deaths confined to the 20 leading causes, then that rate is 43%.”

The majority of the infants die within the first week of life, with two-thirds of these deaths occurring during the first 24 hours after birth. “Prevention of preterm birth, especially at the earliest gestations, is crucial if we are going to further reduce the infant mortality rate,” he said.

SAN ANTONIO — Lack of nearby pain practices helps explain why only about 5% of U.S. adults with chronic pain ever see a pain specialist, Brenda Breuer, Ph.D., reported at the annual meeting of the American Pain Society.

The finding comes from a survey of 748 pain specialists who responded to a survey that was sent to about 2,500 pain specialists certified by the American Board of Medical Specialties or the American Board of Pain Medicine.

“We felt that if we identified any deficiencies, that would be a first step towards improvement,” explained Dr. Brenda Breuer of the department of pain medicine and palliative care at Beth Israel Medical Center, New York.

The specialties, age, and geographic location of the physicians who responded to the survey were similar to those of the nonresponders. Most (74%) had their primary training in anesthesiology, whereas others were trained in physiatry (15.4%), neurology (5.3%), psychiatry (3.0%), and other areas (10.9%)

Overall, analysis of census data showed that individuals residing near pain practices were similar to the general U.S. population. Pain practices were underrepresented in rural areas, and people living near pain specialists tended to have higher incomes and higher education levels that the general population.

Academic physicians, who accounted for about one third of the respondents, were more likely than others to have had their primary training in neurology, and were more likely to have completed a pain fellowship. They were also more likely to be associated with a facility involved in research, to hospitalize patients for aggressive treatment of severe pain, and to have interdisciplinary practices.

Respondents whose practices were modality-oriented (29.2%) were more likely than others to have had their primary training in anesthesiology, and were significantly less likely to have interdisciplinary practices, to prescribe and maintain patients on controlled substances, to follow patients longitudinally, and to hospitalize for aggressive treatment of severe pain. They were also more likely than others to treat pain in only one part of the body, such as headaches.

Conversely, multimodality physicians were more likely to use opioids and to collaborate with specialists. They were also likely to have an integrated practice, which included not only physicians who practiced in different specialties, but also a psychologist, a physician assistant, and a social worker.

Board certification does not imply a uniform approach to chronic pain treatment, Dr. Breuer said. Nationally, there are only six board-certified pain physicians per 100,000 adult chronic pain patients, but it is as yet unclear if there is a shortage of pain specialists, she said.

“Future surveys of pain patients are needed to complement physicians' surveys to assess the actual efficacy of pain management,” Dr. Breuer said.

SAN ANTONIO — Lack of nearby pain practices helps explain why only about 5% of U.S. adults with chronic pain ever see a pain specialist, Brenda Breuer, Ph.D., reported at the annual meeting of the American Pain Society.

The finding comes from a survey of 748 pain specialists who responded to a survey that was sent to about 2,500 pain specialists certified by the American Board of Medical Specialties or the American Board of Pain Medicine.

“We felt that if we identified any deficiencies, that would be a first step towards improvement,” explained Dr. Brenda Breuer of the department of pain medicine and palliative care at Beth Israel Medical Center, New York.

The specialties, age, and geographic location of the physicians who responded to the survey were similar to those of the nonresponders. Most (74%) had their primary training in anesthesiology, whereas others were trained in physiatry (15.4%), neurology (5.3%), psychiatry (3.0%), and other areas (10.9%)

Overall, analysis of census data showed that individuals residing near pain practices were similar to the general U.S. population. Pain practices were underrepresented in rural areas, and people living near pain specialists tended to have higher incomes and higher education levels that the general population.

Academic physicians, who accounted for about one third of the respondents, were more likely than others to have had their primary training in neurology, and were more likely to have completed a pain fellowship. They were also more likely to be associated with a facility involved in research, to hospitalize patients for aggressive treatment of severe pain, and to have interdisciplinary practices.

Respondents whose practices were modality-oriented (29.2%) were more likely than others to have had their primary training in anesthesiology, and were significantly less likely to have interdisciplinary practices, to prescribe and maintain patients on controlled substances, to follow patients longitudinally, and to hospitalize for aggressive treatment of severe pain. They were also more likely than others to treat pain in only one part of the body, such as headaches.

Conversely, multimodality physicians were more likely to use opioids and to collaborate with specialists. They were also likely to have an integrated practice, which included not only physicians who practiced in different specialties, but also a psychologist, a physician assistant, and a social worker.

Board certification does not imply a uniform approach to chronic pain treatment, Dr. Breuer said. Nationally, there are only six board-certified pain physicians per 100,000 adult chronic pain patients, but it is as yet unclear if there is a shortage of pain specialists, she said.

“Future surveys of pain patients are needed to complement physicians' surveys to assess the actual efficacy of pain management,” Dr. Breuer said.

SAN ANTONIO — Lack of nearby pain practices helps explain why only about 5% of U.S. adults with chronic pain ever see a pain specialist, Brenda Breuer, Ph.D., reported at the annual meeting of the American Pain Society.

The finding comes from a survey of 748 pain specialists who responded to a survey that was sent to about 2,500 pain specialists certified by the American Board of Medical Specialties or the American Board of Pain Medicine.

“We felt that if we identified any deficiencies, that would be a first step towards improvement,” explained Dr. Brenda Breuer of the department of pain medicine and palliative care at Beth Israel Medical Center, New York.

The specialties, age, and geographic location of the physicians who responded to the survey were similar to those of the nonresponders. Most (74%) had their primary training in anesthesiology, whereas others were trained in physiatry (15.4%), neurology (5.3%), psychiatry (3.0%), and other areas (10.9%)

Overall, analysis of census data showed that individuals residing near pain practices were similar to the general U.S. population. Pain practices were underrepresented in rural areas, and people living near pain specialists tended to have higher incomes and higher education levels that the general population.

Academic physicians, who accounted for about one third of the respondents, were more likely than others to have had their primary training in neurology, and were more likely to have completed a pain fellowship. They were also more likely to be associated with a facility involved in research, to hospitalize patients for aggressive treatment of severe pain, and to have interdisciplinary practices.

Respondents whose practices were modality-oriented (29.2%) were more likely than others to have had their primary training in anesthesiology, and were significantly less likely to have interdisciplinary practices, to prescribe and maintain patients on controlled substances, to follow patients longitudinally, and to hospitalize for aggressive treatment of severe pain. They were also more likely than others to treat pain in only one part of the body, such as headaches.

Conversely, multimodality physicians were more likely to use opioids and to collaborate with specialists. They were also likely to have an integrated practice, which included not only physicians who practiced in different specialties, but also a psychologist, a physician assistant, and a social worker.

Board certification does not imply a uniform approach to chronic pain treatment, Dr. Breuer said. Nationally, there are only six board-certified pain physicians per 100,000 adult chronic pain patients, but it is as yet unclear if there is a shortage of pain specialists, she said.

“Future surveys of pain patients are needed to complement physicians' surveys to assess the actual efficacy of pain management,” Dr. Breuer said.

SAN ANTONIO — Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

The American Pain Society and American Academy of Pain Medicine concluded in a joint consensus statement that undertreatment of pain is unjustified and that chronic pain is often inadequately managed. Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped create a confusing environment for chronic pain management.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids. A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”).

They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists).

In addition, physicians expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).

“Education was the main concern in primary care” that was expressed by the physicians, Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

SAN ANTONIO — Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

The American Pain Society and American Academy of Pain Medicine concluded in a joint consensus statement that undertreatment of pain is unjustified and that chronic pain is often inadequately managed. Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped create a confusing environment for chronic pain management.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids. A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”).

They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists).

In addition, physicians expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).

“Education was the main concern in primary care” that was expressed by the physicians, Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

SAN ANTONIO — Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

The American Pain Society and American Academy of Pain Medicine concluded in a joint consensus statement that undertreatment of pain is unjustified and that chronic pain is often inadequately managed. Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped create a confusing environment for chronic pain management.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids. A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”).

They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists).

In addition, physicians expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).

“Education was the main concern in primary care” that was expressed by the physicians, Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

SAN ANTONIO – Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped to create a confusing environment for chronic pain management, he wrote.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids.

A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”). They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

“Education was the main concern in primary care,” Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists). Physicians also expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).

SAN ANTONIO – Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped to create a confusing environment for chronic pain management, he wrote.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids.

A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”). They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

“Education was the main concern in primary care,” Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists). Physicians also expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).

SAN ANTONIO – Clinicians in the field vary greatly in their comfort and confidence in assessing and managing chronic pain, according to a survey presented at a poster session at the annual meeting of the American Pain Society.

“Primary care providers are uncomfortable in treating pain and desire help, especially in opioid management,” Dr. William McCarberg, director of the chronic pain management program at Kaiser Permanente in Escondido, Calif., said in an interview. “Specialists are more comfortable but also would like help.”

Recent warnings from the Food and Drug Administration and increased investigations by the Drug Enforcement Agency have helped to create a confusing environment for chronic pain management, he wrote.

The primary objective of the survey was to confirm the perception that there are gaps in education, comfort, and regulatory understanding among practitioners when it comes to prescribing opioids.

A secondary objective was to evaluate physicians' perceived need for improved assessment, management, and documentation of chronic pain.

Physicians in 133 practices (49% primary care physicians, 36% pain specialists, and 15% other), located in five U.S. regions, evaluated their level of knowledge and comfort in assessing and managing patients with chronic pain, using a scale of 1 to 6 (with 1 being “not at all” and 6 being “extremely”). They also rated their interest in additional resources in the areas of time management, patient counseling, and treatment documentation.

“Education was the main concern in primary care,” Dr. McCarberg said. “Regulatory oversight was judged as an issue as well. Primary care practitioners also felt they did not have enough time to take care of pain patients adequately.”

Overall, the pain specialists generally felt more informed on current trends in chronic pain, while the primary care physicians offered far more varied responses, ranging from extremely well informed to very uncomfortable.

A strong interest in greater access to educational tools was observed for both physician education (rated 4.68 by primary care physicians and 5.12 by pain specialists) and patient education (4.82 for primary care and 5.02 for pain specialists), as well as a need for patient counseling resources (5.14 for primary care and 5.39 for pain specialists). Physicians also expressed a strong interest in treatment documentation resources (5.29 for primary care and 5.45 for pain specialists).