Timothy F. Kirn

Cardiopulmonary resuscitation is often done improperly by rescuers who give too few chest compressions and the wrong amount of ventilation.

These findings from two new studies that are among the first to precisely measure the performance of CPR in real-life situations inside and outside the hospital.

Although CPR guidelines are frequently revised, there has not been a reliable, objective way to measure how well it is being performed until now, said Lance B. Becker, M.D., a coauthor of the in-hospital study and a professor of emergency medicine and director of the Emergency Resuscitation Research Center at the University of Chicago.

“Now we find that CPR is not being done very well,” he said.

The two studies' investigators used a new monitor/defibrillator device that can count how often compressions are given and how much pressure is exerted with each compression. The device, developed by a Norwegian company, also records the rate of volume of ventilations.

In the in-hospital study, Dr. Becker and his colleagues examined the first 10, 30-second segments recorded by the device during 67 cardiac arrest rescue attempts made by CPR-trained rescuers.

CPR guidelines call for 100 compressions per minute and 12–16 ventilations per minute. In 28% of the cases, however, the average compression rate was less than 90 compressions per minute during the first 5 minutes of resuscitation. In 61% of the 30-second segments, the ventilation rate was more than 20 ventilations per minute. Moreover, 37% of the compressions were too shallow (JAMA 2005;293:305–10).

The out-of-hospital study looked at the use of the device in 176 patients, treated by paramedics or nurse anesthetists, who went into cardiac arrest in three European cities. The researchers found that in 48% of the times that the rescuers were performing resuscitation, they were not actually giving compressions. When they did perform compressions during the CPR episode, they gave compressions at a rate of 121 per minute—close to the study's target values of 100–120 compressions per minute. But the average number of compressions delivered in a minute was only 64. Rescuers gave an average of 11 ventilations per minute (JAMA 2005;293:299–304).

Neither study was able to look precisely at whether poor performance of the CPR affected patient survival, because neither had enough patients to make that determination. However, in the study performed by Dr. Becker and his colleagues, the investigators did note that patients who had longer intervals without chest compression had worse resuscitation results.

Speaking at the 2004 American College of Emergency Physicians Scientific Assembly, Dr. Becker said that he and his colleagues have performed another study, of 100 patients, in which the compression rate was counted and recorded by a trained nurse at the scene. In that study, he said, those patients who received 80–100 compressions a minute were significantly more likely to survive than those who did not.

The results of the in-hospital and out-of-hospital CPR studies are not surprising, noted an editorial that accompanied the studies (JAMA 2005;293:363–5). Prior studies have shown low chest compression rates and high ventilations rates, and they have also shown that CPR training is poorly retained, said Arthur B. Sanders, M.D., in the editorial.

The studies suggest that CPR and advanced cardiac life support (ACLS) training need to be simplified to stress managing cardiac arrest and to emphasize compression over breathing, said Dr. Sanders of the department of emergency medicine at the University of Arizona, Tucson.

ACLS training has become more and more complicated over time so that it now includes instruction on stroke and shock and even managing electrolyte imbalances and asthma, he said. Both the American Heart Association and the International Liaison Committee on Resuscitation are due to update their CPR and emergency cardiovascular care guidelines in the coming year, Dr. Sanders noted.

He called on the groups to simplify their guidelines, and to “return to the core mission” in ACLS training. “It is time to simplify the CPR guidelines and educational programs so that all patients who sustain cardiac arrest can receive optimal treatment,” Dr. Sanders said.

Dr. Becker said the device used in his study could also be a major aid in improving resuscitation efforts because it can tell someone administering CPR when they need to speed up their compressions and when they need to slow down their breathing.

Dr. Becker disclosed financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

Cardiopulmonary resuscitation is often done improperly by rescuers who give too few chest compressions and the wrong amount of ventilation.

These findings from two new studies that are among the first to precisely measure the performance of CPR in real-life situations inside and outside the hospital.

Although CPR guidelines are frequently revised, there has not been a reliable, objective way to measure how well it is being performed until now, said Lance B. Becker, M.D., a coauthor of the in-hospital study and a professor of emergency medicine and director of the Emergency Resuscitation Research Center at the University of Chicago.

“Now we find that CPR is not being done very well,” he said.

The two studies' investigators used a new monitor/defibrillator device that can count how often compressions are given and how much pressure is exerted with each compression. The device, developed by a Norwegian company, also records the rate of volume of ventilations.

In the in-hospital study, Dr. Becker and his colleagues examined the first 10, 30-second segments recorded by the device during 67 cardiac arrest rescue attempts made by CPR-trained rescuers.

CPR guidelines call for 100 compressions per minute and 12–16 ventilations per minute. In 28% of the cases, however, the average compression rate was less than 90 compressions per minute during the first 5 minutes of resuscitation. In 61% of the 30-second segments, the ventilation rate was more than 20 ventilations per minute. Moreover, 37% of the compressions were too shallow (JAMA 2005;293:305–10).

The out-of-hospital study looked at the use of the device in 176 patients, treated by paramedics or nurse anesthetists, who went into cardiac arrest in three European cities. The researchers found that in 48% of the times that the rescuers were performing resuscitation, they were not actually giving compressions. When they did perform compressions during the CPR episode, they gave compressions at a rate of 121 per minute—close to the study's target values of 100–120 compressions per minute. But the average number of compressions delivered in a minute was only 64. Rescuers gave an average of 11 ventilations per minute (JAMA 2005;293:299–304).

Neither study was able to look precisely at whether poor performance of the CPR affected patient survival, because neither had enough patients to make that determination. However, in the study performed by Dr. Becker and his colleagues, the investigators did note that patients who had longer intervals without chest compression had worse resuscitation results.

Speaking at the 2004 American College of Emergency Physicians Scientific Assembly, Dr. Becker said that he and his colleagues have performed another study, of 100 patients, in which the compression rate was counted and recorded by a trained nurse at the scene. In that study, he said, those patients who received 80–100 compressions a minute were significantly more likely to survive than those who did not.

The results of the in-hospital and out-of-hospital CPR studies are not surprising, noted an editorial that accompanied the studies (JAMA 2005;293:363–5). Prior studies have shown low chest compression rates and high ventilations rates, and they have also shown that CPR training is poorly retained, said Arthur B. Sanders, M.D., in the editorial.

The studies suggest that CPR and advanced cardiac life support (ACLS) training need to be simplified to stress managing cardiac arrest and to emphasize compression over breathing, said Dr. Sanders of the department of emergency medicine at the University of Arizona, Tucson.

ACLS training has become more and more complicated over time so that it now includes instruction on stroke and shock and even managing electrolyte imbalances and asthma, he said. Both the American Heart Association and the International Liaison Committee on Resuscitation are due to update their CPR and emergency cardiovascular care guidelines in the coming year, Dr. Sanders noted.

He called on the groups to simplify their guidelines, and to “return to the core mission” in ACLS training. “It is time to simplify the CPR guidelines and educational programs so that all patients who sustain cardiac arrest can receive optimal treatment,” Dr. Sanders said.

Dr. Becker said the device used in his study could also be a major aid in improving resuscitation efforts because it can tell someone administering CPR when they need to speed up their compressions and when they need to slow down their breathing.

Dr. Becker disclosed financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

Cardiopulmonary resuscitation is often done improperly by rescuers who give too few chest compressions and the wrong amount of ventilation.

These findings from two new studies that are among the first to precisely measure the performance of CPR in real-life situations inside and outside the hospital.

Although CPR guidelines are frequently revised, there has not been a reliable, objective way to measure how well it is being performed until now, said Lance B. Becker, M.D., a coauthor of the in-hospital study and a professor of emergency medicine and director of the Emergency Resuscitation Research Center at the University of Chicago.

“Now we find that CPR is not being done very well,” he said.

The two studies' investigators used a new monitor/defibrillator device that can count how often compressions are given and how much pressure is exerted with each compression. The device, developed by a Norwegian company, also records the rate of volume of ventilations.

In the in-hospital study, Dr. Becker and his colleagues examined the first 10, 30-second segments recorded by the device during 67 cardiac arrest rescue attempts made by CPR-trained rescuers.

CPR guidelines call for 100 compressions per minute and 12–16 ventilations per minute. In 28% of the cases, however, the average compression rate was less than 90 compressions per minute during the first 5 minutes of resuscitation. In 61% of the 30-second segments, the ventilation rate was more than 20 ventilations per minute. Moreover, 37% of the compressions were too shallow (JAMA 2005;293:305–10).

The out-of-hospital study looked at the use of the device in 176 patients, treated by paramedics or nurse anesthetists, who went into cardiac arrest in three European cities. The researchers found that in 48% of the times that the rescuers were performing resuscitation, they were not actually giving compressions. When they did perform compressions during the CPR episode, they gave compressions at a rate of 121 per minute—close to the study's target values of 100–120 compressions per minute. But the average number of compressions delivered in a minute was only 64. Rescuers gave an average of 11 ventilations per minute (JAMA 2005;293:299–304).

Neither study was able to look precisely at whether poor performance of the CPR affected patient survival, because neither had enough patients to make that determination. However, in the study performed by Dr. Becker and his colleagues, the investigators did note that patients who had longer intervals without chest compression had worse resuscitation results.

Speaking at the 2004 American College of Emergency Physicians Scientific Assembly, Dr. Becker said that he and his colleagues have performed another study, of 100 patients, in which the compression rate was counted and recorded by a trained nurse at the scene. In that study, he said, those patients who received 80–100 compressions a minute were significantly more likely to survive than those who did not.

The results of the in-hospital and out-of-hospital CPR studies are not surprising, noted an editorial that accompanied the studies (JAMA 2005;293:363–5). Prior studies have shown low chest compression rates and high ventilations rates, and they have also shown that CPR training is poorly retained, said Arthur B. Sanders, M.D., in the editorial.

The studies suggest that CPR and advanced cardiac life support (ACLS) training need to be simplified to stress managing cardiac arrest and to emphasize compression over breathing, said Dr. Sanders of the department of emergency medicine at the University of Arizona, Tucson.

ACLS training has become more and more complicated over time so that it now includes instruction on stroke and shock and even managing electrolyte imbalances and asthma, he said. Both the American Heart Association and the International Liaison Committee on Resuscitation are due to update their CPR and emergency cardiovascular care guidelines in the coming year, Dr. Sanders noted.

He called on the groups to simplify their guidelines, and to “return to the core mission” in ACLS training. “It is time to simplify the CPR guidelines and educational programs so that all patients who sustain cardiac arrest can receive optimal treatment,” Dr. Sanders said.

Dr. Becker said the device used in his study could also be a major aid in improving resuscitation efforts because it can tell someone administering CPR when they need to speed up their compressions and when they need to slow down their breathing.

Dr. Becker disclosed financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN ANTONIO — Prednisone treatment for rheumatoid arthritis patients was associated with an approximately 50% increased risk of stroke, according to figures from the National Data Bank for Rheumatic Diseases.

Treatment with infliximab was associated with a 50% decreased stroke risk. These findings don't in any way prove cause and effect, the study's lead investigator, Frederick Wolfe, M.D., cautioned in an interview. But they are suggestive of a trend.

They may also challenge some assumptions among providers. “There is a belief that low-dose prednisone is a benign drug treatment,” said Dr. Wolfe of the National Data Bank. “I don't think it is.”

Dr. Wolfe, who presented his findings in a poster presentation at the annual meeting of the American College of Rheumatology, said that his look at the incidence rate of stroke in rheumatoid arthritis (RA) patients was prompted by a request from investigators at the National Institutes of Health, who wanted to know about stroke risk and infliximab treatment. The study used data from 15,670 RA patients and 3,083 osteoarthritis patients, who were followed for a 3-year period ending in 2003.

RA patients had a higher incidence of stroke than did the osteoarthritis patients, with a hazard ratio of 1.26. This increased risk was independent of age, gender, diabetes, and hypertension. The incidence rate in the RA patients was equal to 8 cases per 1,000 patient-years.

Among the RA patients, stroke risk was increased in those on prednisone, with a hazard ratio of 1.52, and decreased in those on infliximab, with a hazard ratio of 0.49. Concurrent methotrexate therapy did not appear to have an impact on risk of stroke.

Sulfasalazine treatment was also found to be associated with a 50% decreased risk; however, there were too few patients in the group who took sulfasalazine for that finding to be considered statistically significant, Dr. Wolfe noted.

SAN ANTONIO — Prednisone treatment for rheumatoid arthritis patients was associated with an approximately 50% increased risk of stroke, according to figures from the National Data Bank for Rheumatic Diseases.

Treatment with infliximab was associated with a 50% decreased stroke risk. These findings don't in any way prove cause and effect, the study's lead investigator, Frederick Wolfe, M.D., cautioned in an interview. But they are suggestive of a trend.

They may also challenge some assumptions among providers. “There is a belief that low-dose prednisone is a benign drug treatment,” said Dr. Wolfe of the National Data Bank. “I don't think it is.”

Dr. Wolfe, who presented his findings in a poster presentation at the annual meeting of the American College of Rheumatology, said that his look at the incidence rate of stroke in rheumatoid arthritis (RA) patients was prompted by a request from investigators at the National Institutes of Health, who wanted to know about stroke risk and infliximab treatment. The study used data from 15,670 RA patients and 3,083 osteoarthritis patients, who were followed for a 3-year period ending in 2003.

RA patients had a higher incidence of stroke than did the osteoarthritis patients, with a hazard ratio of 1.26. This increased risk was independent of age, gender, diabetes, and hypertension. The incidence rate in the RA patients was equal to 8 cases per 1,000 patient-years.

Among the RA patients, stroke risk was increased in those on prednisone, with a hazard ratio of 1.52, and decreased in those on infliximab, with a hazard ratio of 0.49. Concurrent methotrexate therapy did not appear to have an impact on risk of stroke.

Sulfasalazine treatment was also found to be associated with a 50% decreased risk; however, there were too few patients in the group who took sulfasalazine for that finding to be considered statistically significant, Dr. Wolfe noted.

SAN ANTONIO — Prednisone treatment for rheumatoid arthritis patients was associated with an approximately 50% increased risk of stroke, according to figures from the National Data Bank for Rheumatic Diseases.

Treatment with infliximab was associated with a 50% decreased stroke risk. These findings don't in any way prove cause and effect, the study's lead investigator, Frederick Wolfe, M.D., cautioned in an interview. But they are suggestive of a trend.

They may also challenge some assumptions among providers. “There is a belief that low-dose prednisone is a benign drug treatment,” said Dr. Wolfe of the National Data Bank. “I don't think it is.”

Dr. Wolfe, who presented his findings in a poster presentation at the annual meeting of the American College of Rheumatology, said that his look at the incidence rate of stroke in rheumatoid arthritis (RA) patients was prompted by a request from investigators at the National Institutes of Health, who wanted to know about stroke risk and infliximab treatment. The study used data from 15,670 RA patients and 3,083 osteoarthritis patients, who were followed for a 3-year period ending in 2003.

RA patients had a higher incidence of stroke than did the osteoarthritis patients, with a hazard ratio of 1.26. This increased risk was independent of age, gender, diabetes, and hypertension. The incidence rate in the RA patients was equal to 8 cases per 1,000 patient-years.

Among the RA patients, stroke risk was increased in those on prednisone, with a hazard ratio of 1.52, and decreased in those on infliximab, with a hazard ratio of 0.49. Concurrent methotrexate therapy did not appear to have an impact on risk of stroke.

Sulfasalazine treatment was also found to be associated with a 50% decreased risk; however, there were too few patients in the group who took sulfasalazine for that finding to be considered statistically significant, Dr. Wolfe noted.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

SAN ANTONIO — An analysis of the 2002 National Health Interview Survey data has put a specific figure on what clinicians probably already knew intuitively: Almost 40% of arthritis patients have significant physical limitations.

Findings from the survey, which asked the respondents if a physician had ever diagnosed them as having arthritis, indicated that an estimated 21% of U.S. adults had been told they had arthritis.

If the patients responded that they had arthritis, they were then asked if they had any limitations and were asked 12 specific questions about those limitations.

Overall, 38% of the respondents said that they were limited by their condition.

Extrapolated to the population, the figures translate into an estimated 43 million Americans with arthritis, of whom 16 million have limitations from their disease, said Jennifer M. Hootman, Ph.D., an epidemiologist with the Centers for Disease Control and Prevention, Atlanta, at the annual meeting of the American College of Rheumatology.

Among those who reported limitations, 69% reported at least one of the nine specific functional limitations, and 31% either did not specify or reported only that they had limitations in at least one of three general activities, without being specific.

The most common specific limitation was being unable to stoop or bend, reported by 49% of those with limitations.

Others included: inability to stand for 2 hours (47%), walk a quarter of a mile (37%), push a heavy object (32%), climb stairs (30%), and lift and carry 10 pounds (23%).

The general activity that was reported to be limited most commonly was shopping, reported by 17% of those with limitations.

The good news is that of the factors that were found to be associated with physical limitations from arthritis, the most important one, being overweight, defined as a body mass index of greater than 25, was modifiable, Dr. Hootman noted in her presentation.

“Common sense says reducing weight can improve disability,” Dr. Hootman said.

The survey responses did not identify whether the individuals interviewed had osteoarthritis or rheumatoid arthritis.

A small number of patients using infliximab (Remicade) have had very severe hepatic reactions, according to a revision of the package prescribing information.

In announcing the new safety information, the Food and Drug Administration and Centocor Inc. said there have been 35 cases of severe hepatic reactions in patients using infliximab reported in postmarketing data and 3 cases reported in clinical trials.

The reactions have included acute liver failure, jaundice, hepatitis, and cholestasis. Some cases were fatal or resulted in liver transplantation. They occurred from 2 weeks after starting therapy to more than a year after initiation. A causal relationship with infliximab has not been established, but treatment with the biologic can induce autoantibodies and autoimmune hepatitis has been diagnosed in some of the cases.

According to the warning, patients with signs of liver dysfunction should be evaluated. If jaundice or elevations in liver enzymes (greater than 5 times the upper limit of normal) occur, the biologic should be stopped and an investigation undertaken.

In clinical trials, mild to moderate elevations in liver enzymes were noted, without progression to severe hepatic injury.

In addition to the hepatic-reaction warning, Centocor added a warning that patients receiving infliximab may be at an increased risk of developing pneumonia, based on data from clinical trials data in rheumatoid arthritis patients.

Infliximab is approved for rheumatoid arthritis and Crohn's disease; in December, it was approved for ankylosing spondylitis.

A small number of patients using infliximab (Remicade) have had very severe hepatic reactions, according to a revision of the package prescribing information.

In announcing the new safety information, the Food and Drug Administration and Centocor Inc. said there have been 35 cases of severe hepatic reactions in patients using infliximab reported in postmarketing data and 3 cases reported in clinical trials.

The reactions have included acute liver failure, jaundice, hepatitis, and cholestasis. Some cases were fatal or resulted in liver transplantation. They occurred from 2 weeks after starting therapy to more than a year after initiation. A causal relationship with infliximab has not been established, but treatment with the biologic can induce autoantibodies and autoimmune hepatitis has been diagnosed in some of the cases.

According to the warning, patients with signs of liver dysfunction should be evaluated. If jaundice or elevations in liver enzymes (greater than 5 times the upper limit of normal) occur, the biologic should be stopped and an investigation undertaken.

In clinical trials, mild to moderate elevations in liver enzymes were noted, without progression to severe hepatic injury.

In addition to the hepatic-reaction warning, Centocor added a warning that patients receiving infliximab may be at an increased risk of developing pneumonia, based on data from clinical trials data in rheumatoid arthritis patients.

Infliximab is approved for rheumatoid arthritis and Crohn's disease; in December, it was approved for ankylosing spondylitis.

A small number of patients using infliximab (Remicade) have had very severe hepatic reactions, according to a revision of the package prescribing information.

In announcing the new safety information, the Food and Drug Administration and Centocor Inc. said there have been 35 cases of severe hepatic reactions in patients using infliximab reported in postmarketing data and 3 cases reported in clinical trials.

The reactions have included acute liver failure, jaundice, hepatitis, and cholestasis. Some cases were fatal or resulted in liver transplantation. They occurred from 2 weeks after starting therapy to more than a year after initiation. A causal relationship with infliximab has not been established, but treatment with the biologic can induce autoantibodies and autoimmune hepatitis has been diagnosed in some of the cases.

According to the warning, patients with signs of liver dysfunction should be evaluated. If jaundice or elevations in liver enzymes (greater than 5 times the upper limit of normal) occur, the biologic should be stopped and an investigation undertaken.

In clinical trials, mild to moderate elevations in liver enzymes were noted, without progression to severe hepatic injury.

In addition to the hepatic-reaction warning, Centocor added a warning that patients receiving infliximab may be at an increased risk of developing pneumonia, based on data from clinical trials data in rheumatoid arthritis patients.

Infliximab is approved for rheumatoid arthritis and Crohn's disease; in December, it was approved for ankylosing spondylitis.

SAN ANTONIO — Rheumatoid arthritis patients who are on tumor necrosis factor-inhibitor therapy have a fourfold greater risk of developing deep postoperative infections, according to a Johns Hopkins University review of patients who had undergone orthopedic procedures.

The findings, although not definitive, suggest that these agents should be stopped before surgery, Jon T. Giles, M.D., said at the annual meeting of the American College of Rheumatology.

Based on each agent's half-life, Dr. Giles recommended that etanercept be discontinued 2 weeks before surgery, infliximab 8 weeks before surgery, and adalimumab 4 weeks before surgery.

“In addition, we recommend avoidance of TNF inhibitors for 2 weeks after surgery,” he said.

Even without adding the biologics, patients with rheumatoid arthritis already have a higher risk of postoperative infection, noted Dr. Giles of Johns Hopkins University, Baltimore. Compared with a 1% rate of infection among people in the general population undergoing orthopedic procedures, infection rates among rheumatoid arthritis patients are two- to fourfold higher.

Dr. Giles's investigation involved 91 RA patients who had undergone a bone or joint surgical procedure in a Johns Hopkins clinic during a 5-year period from the beginning of 1999. Half of those patients had large joint arthroplasty procedures, and the rest were divided between fusion or resection procedures with no implanted materials and small joint procedures.

Among the 35 patients identified to be on biologic therapy at the time of surgery, seven developed early, deep, postoperative infections, including two cases of osteomyelitis, three cases of septic arthritis, and two cases of paraspinal abscess. There were three infections among the 56 patients not taking a biologic.

Patients on TNF-inhibitor therapy had an unadjusted 4.4 odds ratio for developing infection, compared with those patients not on the biologics; after adjustments for age, gender, and disease duration, the odds ratio rose to 4.6. After adjustment for prednisone use, diabetes, and presence of rheumatoid factor, the odds ratio was 5.3.

Given the study's small numbers, it could not be determined if the risk of infection varied by the type of surgery, site of surgery, or particular biologic agent used.

SAN ANTONIO — Rheumatoid arthritis patients who are on tumor necrosis factor-inhibitor therapy have a fourfold greater risk of developing deep postoperative infections, according to a Johns Hopkins University review of patients who had undergone orthopedic procedures.

The findings, although not definitive, suggest that these agents should be stopped before surgery, Jon T. Giles, M.D., said at the annual meeting of the American College of Rheumatology.

Based on each agent's half-life, Dr. Giles recommended that etanercept be discontinued 2 weeks before surgery, infliximab 8 weeks before surgery, and adalimumab 4 weeks before surgery.

“In addition, we recommend avoidance of TNF inhibitors for 2 weeks after surgery,” he said.

Even without adding the biologics, patients with rheumatoid arthritis already have a higher risk of postoperative infection, noted Dr. Giles of Johns Hopkins University, Baltimore. Compared with a 1% rate of infection among people in the general population undergoing orthopedic procedures, infection rates among rheumatoid arthritis patients are two- to fourfold higher.

Dr. Giles's investigation involved 91 RA patients who had undergone a bone or joint surgical procedure in a Johns Hopkins clinic during a 5-year period from the beginning of 1999. Half of those patients had large joint arthroplasty procedures, and the rest were divided between fusion or resection procedures with no implanted materials and small joint procedures.

Among the 35 patients identified to be on biologic therapy at the time of surgery, seven developed early, deep, postoperative infections, including two cases of osteomyelitis, three cases of septic arthritis, and two cases of paraspinal abscess. There were three infections among the 56 patients not taking a biologic.

Patients on TNF-inhibitor therapy had an unadjusted 4.4 odds ratio for developing infection, compared with those patients not on the biologics; after adjustments for age, gender, and disease duration, the odds ratio rose to 4.6. After adjustment for prednisone use, diabetes, and presence of rheumatoid factor, the odds ratio was 5.3.

Given the study's small numbers, it could not be determined if the risk of infection varied by the type of surgery, site of surgery, or particular biologic agent used.

SAN ANTONIO — Rheumatoid arthritis patients who are on tumor necrosis factor-inhibitor therapy have a fourfold greater risk of developing deep postoperative infections, according to a Johns Hopkins University review of patients who had undergone orthopedic procedures.

The findings, although not definitive, suggest that these agents should be stopped before surgery, Jon T. Giles, M.D., said at the annual meeting of the American College of Rheumatology.

Based on each agent's half-life, Dr. Giles recommended that etanercept be discontinued 2 weeks before surgery, infliximab 8 weeks before surgery, and adalimumab 4 weeks before surgery.

“In addition, we recommend avoidance of TNF inhibitors for 2 weeks after surgery,” he said.

Even without adding the biologics, patients with rheumatoid arthritis already have a higher risk of postoperative infection, noted Dr. Giles of Johns Hopkins University, Baltimore. Compared with a 1% rate of infection among people in the general population undergoing orthopedic procedures, infection rates among rheumatoid arthritis patients are two- to fourfold higher.

Dr. Giles's investigation involved 91 RA patients who had undergone a bone or joint surgical procedure in a Johns Hopkins clinic during a 5-year period from the beginning of 1999. Half of those patients had large joint arthroplasty procedures, and the rest were divided between fusion or resection procedures with no implanted materials and small joint procedures.

Among the 35 patients identified to be on biologic therapy at the time of surgery, seven developed early, deep, postoperative infections, including two cases of osteomyelitis, three cases of septic arthritis, and two cases of paraspinal abscess. There were three infections among the 56 patients not taking a biologic.

Patients on TNF-inhibitor therapy had an unadjusted 4.4 odds ratio for developing infection, compared with those patients not on the biologics; after adjustments for age, gender, and disease duration, the odds ratio rose to 4.6. After adjustment for prednisone use, diabetes, and presence of rheumatoid factor, the odds ratio was 5.3.

Given the study's small numbers, it could not be determined if the risk of infection varied by the type of surgery, site of surgery, or particular biologic agent used.

SAN ANTONIO — Physicians tend to be skeptical of arthritis patients' claims that they can feel bad weather coming on, but maybe they shouldn't be, Timothy E. McAlindon, M.D., said at the annual meeting of the American College of Rheumatology.

Findings from a study by Dr. McAlindon and his colleagues at Tufts-New England Medical Center, Boston, suggest that persons with knee osteoarthritis do have greater pain when there are changes in barometric pressure.

Previous studies probably have failed to document this phenomenon because they have not been able to be as precise in their weather measurements as this study, surmised Dr. McAlindon, chief of the division of rheumatology at Tufts.

The investigators collected data on 205 patients who took part in a 3-month trial of glucosamine that tracked participants using the Internet, which enabled them to be from a variety of regions within the U.S. The subjects lived in 41 different states; almost all of them experienced very different weather.

During the initial study, which found no positive effect from glucosamine, subjects completed Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index pain questionnaires every 2 weeks.

Corresponding weather data were collected from the National Oceanic and Atmospheric Administration stations, which in some instances were less than a mile from the subject's house, Dr. McAlindon said.

In all, the investigators identified more than 900 pain reports that correlated with weather. The data indicated that there was no significant association between pain scores and either the dew point or precipitation, which may be another reason previous studies have been confounded, he said.

It did, however, find a weak but consistent association between pain and temperature: Each degree (Fahrenheit) drop was associated with a one-degree increase in pain on the WOMAC scale. Similarly, the investigators found a strong association between pain and change in barometric pressure; this association was more pronounced with lower temperatures.

In keeping with the fact that patients tend to say they have greater pain before the weather changes, the pain-barometric pressure association did not occur so much with the drop in barometric pressure that accompanies a change in weather, but rather with the increase in barometric pressure that generally precedes a change in weather. Patients also often reported feeling better after a rain, which again is consistent with the fact that barometric pressure drops once a storm arrives, he added.

In a related report comparing 42 control subjects with 92 rheumatic disease patients, 80 of whom had osteoarthritis and 12 of whom had rheumatoid arthritis, José Vergés, M.D., of Bioiberica SA, a pharmaceutical company in Barcelona, Spain, found that patients with osteoarthritis, in particular, had more joint pain when atmospheric pressure was low.

Dr. Vergés concluded that “it may be possible to modulate pharmacological and nonpharmacological treatments for some osteoarthritic patients, depending on the predictable weather conditions in order to avoid, as much as possible, the disease-associated joint pain and functional incapacity” (Proc. West Pharmacol. Soc. 2004;47:134–6).

SAN ANTONIO — Physicians tend to be skeptical of arthritis patients' claims that they can feel bad weather coming on, but maybe they shouldn't be, Timothy E. McAlindon, M.D., said at the annual meeting of the American College of Rheumatology.

Findings from a study by Dr. McAlindon and his colleagues at Tufts-New England Medical Center, Boston, suggest that persons with knee osteoarthritis do have greater pain when there are changes in barometric pressure.

Previous studies probably have failed to document this phenomenon because they have not been able to be as precise in their weather measurements as this study, surmised Dr. McAlindon, chief of the division of rheumatology at Tufts.

The investigators collected data on 205 patients who took part in a 3-month trial of glucosamine that tracked participants using the Internet, which enabled them to be from a variety of regions within the U.S. The subjects lived in 41 different states; almost all of them experienced very different weather.

During the initial study, which found no positive effect from glucosamine, subjects completed Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index pain questionnaires every 2 weeks.

Corresponding weather data were collected from the National Oceanic and Atmospheric Administration stations, which in some instances were less than a mile from the subject's house, Dr. McAlindon said.

In all, the investigators identified more than 900 pain reports that correlated with weather. The data indicated that there was no significant association between pain scores and either the dew point or precipitation, which may be another reason previous studies have been confounded, he said.

It did, however, find a weak but consistent association between pain and temperature: Each degree (Fahrenheit) drop was associated with a one-degree increase in pain on the WOMAC scale. Similarly, the investigators found a strong association between pain and change in barometric pressure; this association was more pronounced with lower temperatures.

In keeping with the fact that patients tend to say they have greater pain before the weather changes, the pain-barometric pressure association did not occur so much with the drop in barometric pressure that accompanies a change in weather, but rather with the increase in barometric pressure that generally precedes a change in weather. Patients also often reported feeling better after a rain, which again is consistent with the fact that barometric pressure drops once a storm arrives, he added.

In a related report comparing 42 control subjects with 92 rheumatic disease patients, 80 of whom had osteoarthritis and 12 of whom had rheumatoid arthritis, José Vergés, M.D., of Bioiberica SA, a pharmaceutical company in Barcelona, Spain, found that patients with osteoarthritis, in particular, had more joint pain when atmospheric pressure was low.

Dr. Vergés concluded that “it may be possible to modulate pharmacological and nonpharmacological treatments for some osteoarthritic patients, depending on the predictable weather conditions in order to avoid, as much as possible, the disease-associated joint pain and functional incapacity” (Proc. West Pharmacol. Soc. 2004;47:134–6).

SAN ANTONIO — Physicians tend to be skeptical of arthritis patients' claims that they can feel bad weather coming on, but maybe they shouldn't be, Timothy E. McAlindon, M.D., said at the annual meeting of the American College of Rheumatology.

Findings from a study by Dr. McAlindon and his colleagues at Tufts-New England Medical Center, Boston, suggest that persons with knee osteoarthritis do have greater pain when there are changes in barometric pressure.

Previous studies probably have failed to document this phenomenon because they have not been able to be as precise in their weather measurements as this study, surmised Dr. McAlindon, chief of the division of rheumatology at Tufts.

The investigators collected data on 205 patients who took part in a 3-month trial of glucosamine that tracked participants using the Internet, which enabled them to be from a variety of regions within the U.S. The subjects lived in 41 different states; almost all of them experienced very different weather.

During the initial study, which found no positive effect from glucosamine, subjects completed Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index pain questionnaires every 2 weeks.

Corresponding weather data were collected from the National Oceanic and Atmospheric Administration stations, which in some instances were less than a mile from the subject's house, Dr. McAlindon said.

In all, the investigators identified more than 900 pain reports that correlated with weather. The data indicated that there was no significant association between pain scores and either the dew point or precipitation, which may be another reason previous studies have been confounded, he said.

It did, however, find a weak but consistent association between pain and temperature: Each degree (Fahrenheit) drop was associated with a one-degree increase in pain on the WOMAC scale. Similarly, the investigators found a strong association between pain and change in barometric pressure; this association was more pronounced with lower temperatures.

In keeping with the fact that patients tend to say they have greater pain before the weather changes, the pain-barometric pressure association did not occur so much with the drop in barometric pressure that accompanies a change in weather, but rather with the increase in barometric pressure that generally precedes a change in weather. Patients also often reported feeling better after a rain, which again is consistent with the fact that barometric pressure drops once a storm arrives, he added.

In a related report comparing 42 control subjects with 92 rheumatic disease patients, 80 of whom had osteoarthritis and 12 of whom had rheumatoid arthritis, José Vergés, M.D., of Bioiberica SA, a pharmaceutical company in Barcelona, Spain, found that patients with osteoarthritis, in particular, had more joint pain when atmospheric pressure was low.

Dr. Vergés concluded that “it may be possible to modulate pharmacological and nonpharmacological treatments for some osteoarthritic patients, depending on the predictable weather conditions in order to avoid, as much as possible, the disease-associated joint pain and functional incapacity” (Proc. West Pharmacol. Soc. 2004;47:134–6).

SAN ANTONIO — Glucosamine appears superior to many other osteoarthritis agents in reducing pain and disability, according to the findings of a 5-year observational study.

Among 1,376 patients with osteoarthritis, those who took glucosamine consistently had Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index scores that were a mean 1.8 points lower than the scores of similar patients not taking glucosamine, Elizabeth Badley, Ph.D., reported at the annual meeting of the American College of Rheumatology.

At baseline, 9% of participants were using glucosamine, 42% were using NSAIDs, 62% were taking other pain medications, 2% were using steroid injections, 50% were using walking aids, and 92% were using lower-extremity devices.

Compared with glucosamine, none of the other treatments was associated with comparable improvements in WOMAC scores, which reflect disability and pain based on responses to a 24-item questionnaire, said Dr. Badley, director of the arthritis community research and evaluation unit at the University of Toronto.

All patients had knee or hip osteoarthritis, and their mean age at baseline was 72 years.

By the end of the 5-year period, 17% of patients were taking glucosamine. No dosage information was available.

“Whether it was the glucosamine or whether it was the people who take glucosamine, we don't know,” Dr. Badley said in an interview. “But clearly, we need to investigate this finding further.”

Some of the other factors associated with the lower WOMAC scores included younger age, higher level of education, and male gender. The men's WOMAC scores were on average 4 points lower than those of women with similar demographic profiles and treatments.

Dr. Badley reported no financial interest in glucosamine or in companies that manufacture the dietary supplement.

SAN ANTONIO — Glucosamine appears superior to many other osteoarthritis agents in reducing pain and disability, according to the findings of a 5-year observational study.

Among 1,376 patients with osteoarthritis, those who took glucosamine consistently had Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index scores that were a mean 1.8 points lower than the scores of similar patients not taking glucosamine, Elizabeth Badley, Ph.D., reported at the annual meeting of the American College of Rheumatology.

At baseline, 9% of participants were using glucosamine, 42% were using NSAIDs, 62% were taking other pain medications, 2% were using steroid injections, 50% were using walking aids, and 92% were using lower-extremity devices.

Compared with glucosamine, none of the other treatments was associated with comparable improvements in WOMAC scores, which reflect disability and pain based on responses to a 24-item questionnaire, said Dr. Badley, director of the arthritis community research and evaluation unit at the University of Toronto.

All patients had knee or hip osteoarthritis, and their mean age at baseline was 72 years.

By the end of the 5-year period, 17% of patients were taking glucosamine. No dosage information was available.

“Whether it was the glucosamine or whether it was the people who take glucosamine, we don't know,” Dr. Badley said in an interview. “But clearly, we need to investigate this finding further.”

Some of the other factors associated with the lower WOMAC scores included younger age, higher level of education, and male gender. The men's WOMAC scores were on average 4 points lower than those of women with similar demographic profiles and treatments.

Dr. Badley reported no financial interest in glucosamine or in companies that manufacture the dietary supplement.

SAN ANTONIO — Glucosamine appears superior to many other osteoarthritis agents in reducing pain and disability, according to the findings of a 5-year observational study.

Among 1,376 patients with osteoarthritis, those who took glucosamine consistently had Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index scores that were a mean 1.8 points lower than the scores of similar patients not taking glucosamine, Elizabeth Badley, Ph.D., reported at the annual meeting of the American College of Rheumatology.

At baseline, 9% of participants were using glucosamine, 42% were using NSAIDs, 62% were taking other pain medications, 2% were using steroid injections, 50% were using walking aids, and 92% were using lower-extremity devices.

Compared with glucosamine, none of the other treatments was associated with comparable improvements in WOMAC scores, which reflect disability and pain based on responses to a 24-item questionnaire, said Dr. Badley, director of the arthritis community research and evaluation unit at the University of Toronto.

All patients had knee or hip osteoarthritis, and their mean age at baseline was 72 years.

By the end of the 5-year period, 17% of patients were taking glucosamine. No dosage information was available.

“Whether it was the glucosamine or whether it was the people who take glucosamine, we don't know,” Dr. Badley said in an interview. “But clearly, we need to investigate this finding further.”

Some of the other factors associated with the lower WOMAC scores included younger age, higher level of education, and male gender. The men's WOMAC scores were on average 4 points lower than those of women with similar demographic profiles and treatments.

Dr. Badley reported no financial interest in glucosamine or in companies that manufacture the dietary supplement.

LOS CABOS, MEXICO—Ten simple practices can significantly reduce the likelihood that a pediatrician will make a mistake and be sued, Ramon W. Johnson, M.D., said at a pediatric conference sponsored by Symposia Medicus.

The conventional wisdom among medicolegal experts is that the emotional cost of a malpractice lawsuit is so profound, even the physician who wins a case actually loses, noted Dr. Johnson, director of pediatric emergency medicine at Mission Hospital Regional Medical Center, Mission Viejo, Calif.

Therefore, it is better to avoid suits. And, one way to avoid suits is to reduce the likelihood of any mishaps or mistakes.

The following are Dr. Johnson's suggestions made for reducing common mistakes:

▸ Stated protocols. Physicians should have a policies and procedures manual in the office that addresses common pediatric issues, such as a triage protocol, a fever protocol, and a sedations protocol.

“Whatever it is that you decide is a situation where you do not want to have any gray zone, put it down in a policies and procedures manual,” Dr. Johnson said.

A manual can come back to haunt you if you somehow deviate from your own stated procedure and a suit arises, but proper documentation explaining why you deviated from that protocol can defend you.

“I do think that for many, many patients, it is better to have a system where everybody is on the same page and knows how to get that child through the system,” Dr. Johnson said.

▸ Use kilograms. Since drug doses are given in mg/kg, using pounds in the chart anywhere is asking for trouble. “Get rid of that pound scale if you have it,” Dr. Johnson said.

▸ Broselow tape. Having a Broselow tape that you can lay down next to a child and get a drug dosage without having to make any mental calculation is crucial anyplace where one might do urgent care. “In the heat of battle, nobody can multiply or divide, even by 10,” he said.

▸ Rectal temperature. Ear and axillary thermometers are notoriously inaccurate in reflecting actual core temperature, and missing a fever could cost millions in a lawsuit.

Therefore, everyone should have electronic thermometers, oral for older children and rectal for younger children. “Anyone who is not using rectal temperatures in children under 2 [years] is not doing the right thing,” Dr. Johnson said.

▸ Urine catheters. Urine collected by a bag is almost always contaminated with skin bacteria. Therefore, if you don't use a catheter to collect urine and it proves to be positive, you can't really be sure, Dr. Johnson said.

Urinary tract infections may be more common than once thought, he noted.

▸ Pulse oximetry. It is impossible to predict mild to moderate hypoxia in a child, and attorneys frequently pounce on whether or not a child had pulse oximetry done, and what the value was because this can be an initial sign that a child really was ill.

“The pulse ox should be the fifth vital sign,” he said.

▸ Decimal points. Zeros should be used before a decimal point, and never after, when recording medication dosages. A dose of 1.0 mg can look like 10 mg when it is handwritten. If everyone in the office knows the standard for writing doses, mistakes are less likely to happen.

▸ Equipment. Get equipment that is properly fitted for children, and make sure your local hospital has such equipment. A well-equipped Broselow bag that is kept handy will help solve this problem.

▸ Drug concentration. Keep only one concentration of the important medications on hand. If there are two concentrations, “I guarantee you that sooner or later someone is going to receive the wrong concentration,” Dr. Johnson said.

▸ Gowns. If there is a major problem in health care, it is the failure to undress the patient, Dr. Johnson said. Regardless of the chief complaint, almost all children should have a brief physical examination during an office visit. At the very least, bruises and other possible signs of physical abuse may be missed.

“As you know, a lot of things hide below the diaper,” he added. “A lot can be learned from looking at the skin, and that goes for any age group.”

LOS CABOS, MEXICO—Ten simple practices can significantly reduce the likelihood that a pediatrician will make a mistake and be sued, Ramon W. Johnson, M.D., said at a pediatric conference sponsored by Symposia Medicus.

The conventional wisdom among medicolegal experts is that the emotional cost of a malpractice lawsuit is so profound, even the physician who wins a case actually loses, noted Dr. Johnson, director of pediatric emergency medicine at Mission Hospital Regional Medical Center, Mission Viejo, Calif.

Therefore, it is better to avoid suits. And, one way to avoid suits is to reduce the likelihood of any mishaps or mistakes.

The following are Dr. Johnson's suggestions made for reducing common mistakes:

▸ Stated protocols. Physicians should have a policies and procedures manual in the office that addresses common pediatric issues, such as a triage protocol, a fever protocol, and a sedations protocol.

“Whatever it is that you decide is a situation where you do not want to have any gray zone, put it down in a policies and procedures manual,” Dr. Johnson said.

A manual can come back to haunt you if you somehow deviate from your own stated procedure and a suit arises, but proper documentation explaining why you deviated from that protocol can defend you.

“I do think that for many, many patients, it is better to have a system where everybody is on the same page and knows how to get that child through the system,” Dr. Johnson said.

▸ Use kilograms. Since drug doses are given in mg/kg, using pounds in the chart anywhere is asking for trouble. “Get rid of that pound scale if you have it,” Dr. Johnson said.

▸ Broselow tape. Having a Broselow tape that you can lay down next to a child and get a drug dosage without having to make any mental calculation is crucial anyplace where one might do urgent care. “In the heat of battle, nobody can multiply or divide, even by 10,” he said.

▸ Rectal temperature. Ear and axillary thermometers are notoriously inaccurate in reflecting actual core temperature, and missing a fever could cost millions in a lawsuit.

Therefore, everyone should have electronic thermometers, oral for older children and rectal for younger children. “Anyone who is not using rectal temperatures in children under 2 [years] is not doing the right thing,” Dr. Johnson said.

▸ Urine catheters. Urine collected by a bag is almost always contaminated with skin bacteria. Therefore, if you don't use a catheter to collect urine and it proves to be positive, you can't really be sure, Dr. Johnson said.

Urinary tract infections may be more common than once thought, he noted.

▸ Pulse oximetry. It is impossible to predict mild to moderate hypoxia in a child, and attorneys frequently pounce on whether or not a child had pulse oximetry done, and what the value was because this can be an initial sign that a child really was ill.

“The pulse ox should be the fifth vital sign,” he said.

▸ Decimal points. Zeros should be used before a decimal point, and never after, when recording medication dosages. A dose of 1.0 mg can look like 10 mg when it is handwritten. If everyone in the office knows the standard for writing doses, mistakes are less likely to happen.

▸ Equipment. Get equipment that is properly fitted for children, and make sure your local hospital has such equipment. A well-equipped Broselow bag that is kept handy will help solve this problem.

▸ Drug concentration. Keep only one concentration of the important medications on hand. If there are two concentrations, “I guarantee you that sooner or later someone is going to receive the wrong concentration,” Dr. Johnson said.

▸ Gowns. If there is a major problem in health care, it is the failure to undress the patient, Dr. Johnson said. Regardless of the chief complaint, almost all children should have a brief physical examination during an office visit. At the very least, bruises and other possible signs of physical abuse may be missed.

“As you know, a lot of things hide below the diaper,” he added. “A lot can be learned from looking at the skin, and that goes for any age group.”

LOS CABOS, MEXICO—Ten simple practices can significantly reduce the likelihood that a pediatrician will make a mistake and be sued, Ramon W. Johnson, M.D., said at a pediatric conference sponsored by Symposia Medicus.

The conventional wisdom among medicolegal experts is that the emotional cost of a malpractice lawsuit is so profound, even the physician who wins a case actually loses, noted Dr. Johnson, director of pediatric emergency medicine at Mission Hospital Regional Medical Center, Mission Viejo, Calif.

Therefore, it is better to avoid suits. And, one way to avoid suits is to reduce the likelihood of any mishaps or mistakes.

The following are Dr. Johnson's suggestions made for reducing common mistakes:

▸ Stated protocols. Physicians should have a policies and procedures manual in the office that addresses common pediatric issues, such as a triage protocol, a fever protocol, and a sedations protocol.

“Whatever it is that you decide is a situation where you do not want to have any gray zone, put it down in a policies and procedures manual,” Dr. Johnson said.

A manual can come back to haunt you if you somehow deviate from your own stated procedure and a suit arises, but proper documentation explaining why you deviated from that protocol can defend you.

“I do think that for many, many patients, it is better to have a system where everybody is on the same page and knows how to get that child through the system,” Dr. Johnson said.

▸ Use kilograms. Since drug doses are given in mg/kg, using pounds in the chart anywhere is asking for trouble. “Get rid of that pound scale if you have it,” Dr. Johnson said.

▸ Broselow tape. Having a Broselow tape that you can lay down next to a child and get a drug dosage without having to make any mental calculation is crucial anyplace where one might do urgent care. “In the heat of battle, nobody can multiply or divide, even by 10,” he said.

▸ Rectal temperature. Ear and axillary thermometers are notoriously inaccurate in reflecting actual core temperature, and missing a fever could cost millions in a lawsuit.

Therefore, everyone should have electronic thermometers, oral for older children and rectal for younger children. “Anyone who is not using rectal temperatures in children under 2 [years] is not doing the right thing,” Dr. Johnson said.

▸ Urine catheters. Urine collected by a bag is almost always contaminated with skin bacteria. Therefore, if you don't use a catheter to collect urine and it proves to be positive, you can't really be sure, Dr. Johnson said.

Urinary tract infections may be more common than once thought, he noted.

▸ Pulse oximetry. It is impossible to predict mild to moderate hypoxia in a child, and attorneys frequently pounce on whether or not a child had pulse oximetry done, and what the value was because this can be an initial sign that a child really was ill.

“The pulse ox should be the fifth vital sign,” he said.

▸ Decimal points. Zeros should be used before a decimal point, and never after, when recording medication dosages. A dose of 1.0 mg can look like 10 mg when it is handwritten. If everyone in the office knows the standard for writing doses, mistakes are less likely to happen.

▸ Equipment. Get equipment that is properly fitted for children, and make sure your local hospital has such equipment. A well-equipped Broselow bag that is kept handy will help solve this problem.

▸ Drug concentration. Keep only one concentration of the important medications on hand. If there are two concentrations, “I guarantee you that sooner or later someone is going to receive the wrong concentration,” Dr. Johnson said.

▸ Gowns. If there is a major problem in health care, it is the failure to undress the patient, Dr. Johnson said. Regardless of the chief complaint, almost all children should have a brief physical examination during an office visit. At the very least, bruises and other possible signs of physical abuse may be missed.

“As you know, a lot of things hide below the diaper,” he added. “A lot can be learned from looking at the skin, and that goes for any age group.”

SAN ANTONIO — A single, intravenous injection of methylprednisolone performed just slightly better than placebo in alleviating pain from acute discogenic sciatica, Axel Finckh, M.D., said at the annual meeting of the American College of Rheumatology.

Dr. Finckh presented a study in which 59 patients with radiographically confirmed discogenic sciatica were randomized to either a single, 500-mg, intravenous bolus of methylprednisolone or to placebo, and then followed for 10 days.

Both groups had significant improvement in pain on the first day, as shown with a 100-point, visual analog scale, with a greater mean improvement for the methylprednisolone group.

However, mean scores in both groups were about the same by the third day and remained comparable through day 10. Both groups had gradual diminishment of pain from day 3 onward, said Dr. Finckh, of Brigham and Women's Hospital, Boston.

Nor were response rates significantly different on a straight leg test for radicular irritation, a McGill Pain Score for global pain, a flexibility score, and a functional disability questionnaire.

Patients in the study had all had sciatica for at least 1 week and not more than 6 weeks before treatment. Use of NSAIDs was permitted.

The use of corticosteroids in sciatica is controversial, Dr. Finckh said. Most studies of oral administration have not demonstrated any benefit. Some studies of epidural administration, however, have shown positive findings. His group conducted the study because they hypothesized that giving the corticosteroid intravenously might be a way to achieve high drug levels quickly, without the risks and pain typically associated with epidural administration.

SAN ANTONIO — A single, intravenous injection of methylprednisolone performed just slightly better than placebo in alleviating pain from acute discogenic sciatica, Axel Finckh, M.D., said at the annual meeting of the American College of Rheumatology.

Dr. Finckh presented a study in which 59 patients with radiographically confirmed discogenic sciatica were randomized to either a single, 500-mg, intravenous bolus of methylprednisolone or to placebo, and then followed for 10 days.

Both groups had significant improvement in pain on the first day, as shown with a 100-point, visual analog scale, with a greater mean improvement for the methylprednisolone group.

However, mean scores in both groups were about the same by the third day and remained comparable through day 10. Both groups had gradual diminishment of pain from day 3 onward, said Dr. Finckh, of Brigham and Women's Hospital, Boston.

Nor were response rates significantly different on a straight leg test for radicular irritation, a McGill Pain Score for global pain, a flexibility score, and a functional disability questionnaire.

Patients in the study had all had sciatica for at least 1 week and not more than 6 weeks before treatment. Use of NSAIDs was permitted.

The use of corticosteroids in sciatica is controversial, Dr. Finckh said. Most studies of oral administration have not demonstrated any benefit. Some studies of epidural administration, however, have shown positive findings. His group conducted the study because they hypothesized that giving the corticosteroid intravenously might be a way to achieve high drug levels quickly, without the risks and pain typically associated with epidural administration.

SAN ANTONIO — A single, intravenous injection of methylprednisolone performed just slightly better than placebo in alleviating pain from acute discogenic sciatica, Axel Finckh, M.D., said at the annual meeting of the American College of Rheumatology.

Dr. Finckh presented a study in which 59 patients with radiographically confirmed discogenic sciatica were randomized to either a single, 500-mg, intravenous bolus of methylprednisolone or to placebo, and then followed for 10 days.

Both groups had significant improvement in pain on the first day, as shown with a 100-point, visual analog scale, with a greater mean improvement for the methylprednisolone group.

However, mean scores in both groups were about the same by the third day and remained comparable through day 10. Both groups had gradual diminishment of pain from day 3 onward, said Dr. Finckh, of Brigham and Women's Hospital, Boston.

Nor were response rates significantly different on a straight leg test for radicular irritation, a McGill Pain Score for global pain, a flexibility score, and a functional disability questionnaire.

Patients in the study had all had sciatica for at least 1 week and not more than 6 weeks before treatment. Use of NSAIDs was permitted.

The use of corticosteroids in sciatica is controversial, Dr. Finckh said. Most studies of oral administration have not demonstrated any benefit. Some studies of epidural administration, however, have shown positive findings. His group conducted the study because they hypothesized that giving the corticosteroid intravenously might be a way to achieve high drug levels quickly, without the risks and pain typically associated with epidural administration.

SEATTLE — Even after older men fracture their bones, osteoporosis is rarely diagnosed and rarely treated, according to the findings of a Kaiser Permanente study of 1,171 men.

Of men over the age of 65 years with a fracture, only 3.3% had a diagnosis of primary osteoporosis and only 7% received treatment with a bisphosphonate or calcitonin before or after their fractures, Adrianne C. Feldstein, M.D., reported at the annual meeting of the American Society for Bone and Mineral Research.

Another 15% either had a diagnosis of secondary osteoporosis or received treatment for secondary osteoporosis, said Dr. Feldstein, a clinical investigator for Kaiser Permanente Northwest, Portland, Ore.

Only 1% of the men had a bone mineral density test. The study included all men in the system who had at least one fracture over a 3.5-year period that ended in 2001. The investigation excluded any patient with a fracture that was unlikely to be associated with brittle bones, such as skull, face, finger, or ankle fractures. The mean age of the men included was 76 years.

The rates at which treatments were prescribed varied, depending on the type of fracture. Among men who fractured their vertebrae, 30% had or were given a prescription for a bisphosphonate, but only 1% of those with an upper extremity fracture received a bisphosphonate. Only 2.2% of those with a hip fracture had or were given a prescription.

During the course of the study, there appeared to be a slight increase in awareness. Of men who had a fracture in the last year of the study, 10% either had or were given bisphosphonate or calcitonin treatment.

SEATTLE — Even after older men fracture their bones, osteoporosis is rarely diagnosed and rarely treated, according to the findings of a Kaiser Permanente study of 1,171 men.

Of men over the age of 65 years with a fracture, only 3.3% had a diagnosis of primary osteoporosis and only 7% received treatment with a bisphosphonate or calcitonin before or after their fractures, Adrianne C. Feldstein, M.D., reported at the annual meeting of the American Society for Bone and Mineral Research.

Another 15% either had a diagnosis of secondary osteoporosis or received treatment for secondary osteoporosis, said Dr. Feldstein, a clinical investigator for Kaiser Permanente Northwest, Portland, Ore.

Only 1% of the men had a bone mineral density test. The study included all men in the system who had at least one fracture over a 3.5-year period that ended in 2001. The investigation excluded any patient with a fracture that was unlikely to be associated with brittle bones, such as skull, face, finger, or ankle fractures. The mean age of the men included was 76 years.

The rates at which treatments were prescribed varied, depending on the type of fracture. Among men who fractured their vertebrae, 30% had or were given a prescription for a bisphosphonate, but only 1% of those with an upper extremity fracture received a bisphosphonate. Only 2.2% of those with a hip fracture had or were given a prescription.

During the course of the study, there appeared to be a slight increase in awareness. Of men who had a fracture in the last year of the study, 10% either had or were given bisphosphonate or calcitonin treatment.

SEATTLE — Even after older men fracture their bones, osteoporosis is rarely diagnosed and rarely treated, according to the findings of a Kaiser Permanente study of 1,171 men.

Of men over the age of 65 years with a fracture, only 3.3% had a diagnosis of primary osteoporosis and only 7% received treatment with a bisphosphonate or calcitonin before or after their fractures, Adrianne C. Feldstein, M.D., reported at the annual meeting of the American Society for Bone and Mineral Research.

Another 15% either had a diagnosis of secondary osteoporosis or received treatment for secondary osteoporosis, said Dr. Feldstein, a clinical investigator for Kaiser Permanente Northwest, Portland, Ore.

Only 1% of the men had a bone mineral density test. The study included all men in the system who had at least one fracture over a 3.5-year period that ended in 2001. The investigation excluded any patient with a fracture that was unlikely to be associated with brittle bones, such as skull, face, finger, or ankle fractures. The mean age of the men included was 76 years.

The rates at which treatments were prescribed varied, depending on the type of fracture. Among men who fractured their vertebrae, 30% had or were given a prescription for a bisphosphonate, but only 1% of those with an upper extremity fracture received a bisphosphonate. Only 2.2% of those with a hip fracture had or were given a prescription.

During the course of the study, there appeared to be a slight increase in awareness. Of men who had a fracture in the last year of the study, 10% either had or were given bisphosphonate or calcitonin treatment.