STEAMBOAT SPRINGS, COLO. – A big bottle of mineral oil is well worth keeping in the office if for no other reason than to help solve one of the most excruciatingly painful common problems in pediatrics: penile zipper entrapment.

Most textbooks advocate cutting the median bar of the zipper as the first-line solution. But that’s not the best method. A mineral oil drenching is the way to go, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

"I’ve done this many times. You want to just pour mineral oil all over the patient’s genitalia and the zipper. Be generous – that’s the key. This is pretty cheap stuff. Then let the patient sit there for 20 or 30 minutes. Pack him in a room somewhere. When you come back, the foreskin will have simply slipped out of that zipper, although in some cases you may need a cotton swab to help it along a bit," he explained at the meeting sponsored by the American Academy of Pediatrics.

Cutting the median bar of a zipper isn’t as easy as it might sound. A metal zipper is a sturdy apparatus.

"We used to call housekeeping stat to the emergency department – ‘and bring wire cutters,’ " Dr. Selbst recalled. "But I can tell you that when you go to the patient holding wire cutters, you’ll see his eyes bulging out."

The injured boy often presents with swelling, maceration, and bleeding as a result of the foreskin being caught in the zipper teeth. It’s often helpful as an initial step to cut away the pants from the zipper area to remove the extra weight dragging downward.

Some texts suggest doing a penile block. Dr. Selbst advised against it.

"Most kids would rather die with that zipper attached to them than have you do a penile block. Most of us aren’t all that comfortable doing them anyway," the pediatrician commented.

After the penis has been freed, it’s important to warn the parents about the risk of infection and the need to keep the area clean. Prophylactic antibiotics are worth considering, although there aren’t good data to support efficacy, Dr. Selbst said.

He reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – A big bottle of mineral oil is well worth keeping in the office if for no other reason than to help solve one of the most excruciatingly painful common problems in pediatrics: penile zipper entrapment.

Most textbooks advocate cutting the median bar of the zipper as the first-line solution. But that’s not the best method. A mineral oil drenching is the way to go, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

"I’ve done this many times. You want to just pour mineral oil all over the patient’s genitalia and the zipper. Be generous – that’s the key. This is pretty cheap stuff. Then let the patient sit there for 20 or 30 minutes. Pack him in a room somewhere. When you come back, the foreskin will have simply slipped out of that zipper, although in some cases you may need a cotton swab to help it along a bit," he explained at the meeting sponsored by the American Academy of Pediatrics.

Cutting the median bar of a zipper isn’t as easy as it might sound. A metal zipper is a sturdy apparatus.

"We used to call housekeeping stat to the emergency department – ‘and bring wire cutters,’ " Dr. Selbst recalled. "But I can tell you that when you go to the patient holding wire cutters, you’ll see his eyes bulging out."

The injured boy often presents with swelling, maceration, and bleeding as a result of the foreskin being caught in the zipper teeth. It’s often helpful as an initial step to cut away the pants from the zipper area to remove the extra weight dragging downward.

Some texts suggest doing a penile block. Dr. Selbst advised against it.

"Most kids would rather die with that zipper attached to them than have you do a penile block. Most of us aren’t all that comfortable doing them anyway," the pediatrician commented.

After the penis has been freed, it’s important to warn the parents about the risk of infection and the need to keep the area clean. Prophylactic antibiotics are worth considering, although there aren’t good data to support efficacy, Dr. Selbst said.

He reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – A big bottle of mineral oil is well worth keeping in the office if for no other reason than to help solve one of the most excruciatingly painful common problems in pediatrics: penile zipper entrapment.

Most textbooks advocate cutting the median bar of the zipper as the first-line solution. But that’s not the best method. A mineral oil drenching is the way to go, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

"I’ve done this many times. You want to just pour mineral oil all over the patient’s genitalia and the zipper. Be generous – that’s the key. This is pretty cheap stuff. Then let the patient sit there for 20 or 30 minutes. Pack him in a room somewhere. When you come back, the foreskin will have simply slipped out of that zipper, although in some cases you may need a cotton swab to help it along a bit," he explained at the meeting sponsored by the American Academy of Pediatrics.

Cutting the median bar of a zipper isn’t as easy as it might sound. A metal zipper is a sturdy apparatus.

"We used to call housekeeping stat to the emergency department – ‘and bring wire cutters,’ " Dr. Selbst recalled. "But I can tell you that when you go to the patient holding wire cutters, you’ll see his eyes bulging out."

The injured boy often presents with swelling, maceration, and bleeding as a result of the foreskin being caught in the zipper teeth. It’s often helpful as an initial step to cut away the pants from the zipper area to remove the extra weight dragging downward.

Some texts suggest doing a penile block. Dr. Selbst advised against it.

"Most kids would rather die with that zipper attached to them than have you do a penile block. Most of us aren’t all that comfortable doing them anyway," the pediatrician commented.

After the penis has been freed, it’s important to warn the parents about the risk of infection and the need to keep the area clean. Prophylactic antibiotics are worth considering, although there aren’t good data to support efficacy, Dr. Selbst said.

He reported having no financial conflicts.

It has been 100 years since Sir William Osler outlined his concept of the relationship of the hospital to the university and to the education of physicians and nurses in an address to the Northumberland and Durham Medical Society in England. He stated that the hospital stands "primarily for the cure of the sick and the relief of suffering; secondly, for the study of the problems of disease; and thirdly, for the training of men and of women to serve the public as doctors and nurses. A majority of hospitals deal only with the first of these objects, and incidentally with the third" (Lancet 1911;177:211-3).

Of course, much has changed over the subsequent century, but much remains the same. The integration of the hospital into its role of a teaching institution was difficult even in the Oslerian age of the early 20th century. That relationship has become even more complex in contemporary medicine, in which the hospital has increasingly become the center of community and national health care.

Dr. Osler’s comments came to mind while I was reading a recent article about the development of concierge care in America’s most prestigious hospitals (New York Times, Jan. 22, 2012, p. 3A). A money manager recuperating from back pain is shown relaxing in a $1,600-a-day luxurious hospital room dressed in a spa-type bathrobe in New York City’s Mount Sinai Medical Center, where amenities include gourmet food service. "I have a primary care physician who acts as ringmaster for all my other doctors. And I see no people in training – only the best of the best," the patient said.

The hospital’s spokesperson indicated that the lack of house staff was a result of training limitations and not the preference of the rich patients. Mount Sinai has a long history of excellence in medical education, but the ambience now provided for its wealthy clientele protects them from any intrusion by medical students and house staff.

The American hospital has evolved over the last century from a place of last resort for the poor sick to a high-technology institution created for intensive medical and surgical therapy. Funded initially by community and religious benevolence, the hospital has now become big business and heavily dependent on private insurers, Medicare and Medicaid, and whatever evolves from the new health care laws.

Now divested of minor illnesses and routine surgical procedures that can be dealt with in the outpatient setting, it is filled with critically sick patients.

There has always been a tenuous balance between the goals of the community hospital and its educational responsibilities. The contemporary community hospital has enjoyed a profitable environment fed by private health insurance and sustained by federal dollars. Medicare, since its inception almost 50 years ago, has generously supported education through indirect funding for house staff education. This support has recently been significantly decreased, and realistic forecasts suggest that the previous profit margins will be a thing of the past as the federal and state budget puts constraints on both Medicare and Medicaid. Dr. Osler argued for the hospital financial supporters of teaching faculty and challenged local communities to dig deep into their pockets to support the education of medical students and house staff.

Now, with the increasing development of hospital-centric health care, the hospital has also become the focus of community health. The need to train more health professionals will put more pressure on hospitals to provide facilities for the whole dimension of caregivers, including medical students, house officers, nurses, and a variety of physician assistants. With increases in both the number of medical schools and the matriculating class sizes of current medical schools, more community hospitals will be called upon to provide clinical facilities to provide the training grounds for these new students. These changes will place financial pressures on the hospitals in order to meet that challenge. Even now, fast-track admissions and discharge practice, already a part of the patient experience in many hospitals and a source of their profit margin, adversely affects the quality of medical education.

To cushion the effects of the decrease in private and governmental support for medical education, hospitals will be have to seek other sources of income – like concierge services – in order to meet their social and educational responsibilities.

How they meet both of these challenges in the contemporary entrepreneurial world of health care will require a great degree of agility. But no matter what changes do occur, there will always be room for concierge care.

It has been 100 years since Sir William Osler outlined his concept of the relationship of the hospital to the university and to the education of physicians and nurses in an address to the Northumberland and Durham Medical Society in England. He stated that the hospital stands "primarily for the cure of the sick and the relief of suffering; secondly, for the study of the problems of disease; and thirdly, for the training of men and of women to serve the public as doctors and nurses. A majority of hospitals deal only with the first of these objects, and incidentally with the third" (Lancet 1911;177:211-3).

Of course, much has changed over the subsequent century, but much remains the same. The integration of the hospital into its role of a teaching institution was difficult even in the Oslerian age of the early 20th century. That relationship has become even more complex in contemporary medicine, in which the hospital has increasingly become the center of community and national health care.

Dr. Osler’s comments came to mind while I was reading a recent article about the development of concierge care in America’s most prestigious hospitals (New York Times, Jan. 22, 2012, p. 3A). A money manager recuperating from back pain is shown relaxing in a $1,600-a-day luxurious hospital room dressed in a spa-type bathrobe in New York City’s Mount Sinai Medical Center, where amenities include gourmet food service. "I have a primary care physician who acts as ringmaster for all my other doctors. And I see no people in training – only the best of the best," the patient said.

The hospital’s spokesperson indicated that the lack of house staff was a result of training limitations and not the preference of the rich patients. Mount Sinai has a long history of excellence in medical education, but the ambience now provided for its wealthy clientele protects them from any intrusion by medical students and house staff.

The American hospital has evolved over the last century from a place of last resort for the poor sick to a high-technology institution created for intensive medical and surgical therapy. Funded initially by community and religious benevolence, the hospital has now become big business and heavily dependent on private insurers, Medicare and Medicaid, and whatever evolves from the new health care laws.

Now divested of minor illnesses and routine surgical procedures that can be dealt with in the outpatient setting, it is filled with critically sick patients.

There has always been a tenuous balance between the goals of the community hospital and its educational responsibilities. The contemporary community hospital has enjoyed a profitable environment fed by private health insurance and sustained by federal dollars. Medicare, since its inception almost 50 years ago, has generously supported education through indirect funding for house staff education. This support has recently been significantly decreased, and realistic forecasts suggest that the previous profit margins will be a thing of the past as the federal and state budget puts constraints on both Medicare and Medicaid. Dr. Osler argued for the hospital financial supporters of teaching faculty and challenged local communities to dig deep into their pockets to support the education of medical students and house staff.

Now, with the increasing development of hospital-centric health care, the hospital has also become the focus of community health. The need to train more health professionals will put more pressure on hospitals to provide facilities for the whole dimension of caregivers, including medical students, house officers, nurses, and a variety of physician assistants. With increases in both the number of medical schools and the matriculating class sizes of current medical schools, more community hospitals will be called upon to provide clinical facilities to provide the training grounds for these new students. These changes will place financial pressures on the hospitals in order to meet that challenge. Even now, fast-track admissions and discharge practice, already a part of the patient experience in many hospitals and a source of their profit margin, adversely affects the quality of medical education.

To cushion the effects of the decrease in private and governmental support for medical education, hospitals will be have to seek other sources of income – like concierge services – in order to meet their social and educational responsibilities.

How they meet both of these challenges in the contemporary entrepreneurial world of health care will require a great degree of agility. But no matter what changes do occur, there will always be room for concierge care.

It has been 100 years since Sir William Osler outlined his concept of the relationship of the hospital to the university and to the education of physicians and nurses in an address to the Northumberland and Durham Medical Society in England. He stated that the hospital stands "primarily for the cure of the sick and the relief of suffering; secondly, for the study of the problems of disease; and thirdly, for the training of men and of women to serve the public as doctors and nurses. A majority of hospitals deal only with the first of these objects, and incidentally with the third" (Lancet 1911;177:211-3).

Of course, much has changed over the subsequent century, but much remains the same. The integration of the hospital into its role of a teaching institution was difficult even in the Oslerian age of the early 20th century. That relationship has become even more complex in contemporary medicine, in which the hospital has increasingly become the center of community and national health care.

Dr. Osler’s comments came to mind while I was reading a recent article about the development of concierge care in America’s most prestigious hospitals (New York Times, Jan. 22, 2012, p. 3A). A money manager recuperating from back pain is shown relaxing in a $1,600-a-day luxurious hospital room dressed in a spa-type bathrobe in New York City’s Mount Sinai Medical Center, where amenities include gourmet food service. "I have a primary care physician who acts as ringmaster for all my other doctors. And I see no people in training – only the best of the best," the patient said.

The hospital’s spokesperson indicated that the lack of house staff was a result of training limitations and not the preference of the rich patients. Mount Sinai has a long history of excellence in medical education, but the ambience now provided for its wealthy clientele protects them from any intrusion by medical students and house staff.

The American hospital has evolved over the last century from a place of last resort for the poor sick to a high-technology institution created for intensive medical and surgical therapy. Funded initially by community and religious benevolence, the hospital has now become big business and heavily dependent on private insurers, Medicare and Medicaid, and whatever evolves from the new health care laws.

Now divested of minor illnesses and routine surgical procedures that can be dealt with in the outpatient setting, it is filled with critically sick patients.

There has always been a tenuous balance between the goals of the community hospital and its educational responsibilities. The contemporary community hospital has enjoyed a profitable environment fed by private health insurance and sustained by federal dollars. Medicare, since its inception almost 50 years ago, has generously supported education through indirect funding for house staff education. This support has recently been significantly decreased, and realistic forecasts suggest that the previous profit margins will be a thing of the past as the federal and state budget puts constraints on both Medicare and Medicaid. Dr. Osler argued for the hospital financial supporters of teaching faculty and challenged local communities to dig deep into their pockets to support the education of medical students and house staff.

Now, with the increasing development of hospital-centric health care, the hospital has also become the focus of community health. The need to train more health professionals will put more pressure on hospitals to provide facilities for the whole dimension of caregivers, including medical students, house officers, nurses, and a variety of physician assistants. With increases in both the number of medical schools and the matriculating class sizes of current medical schools, more community hospitals will be called upon to provide clinical facilities to provide the training grounds for these new students. These changes will place financial pressures on the hospitals in order to meet that challenge. Even now, fast-track admissions and discharge practice, already a part of the patient experience in many hospitals and a source of their profit margin, adversely affects the quality of medical education.

To cushion the effects of the decrease in private and governmental support for medical education, hospitals will be have to seek other sources of income – like concierge services – in order to meet their social and educational responsibilities.

How they meet both of these challenges in the contemporary entrepreneurial world of health care will require a great degree of agility. But no matter what changes do occur, there will always be room for concierge care.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

With a simple blood test, you can screen and potentially improve and extend the lives of children and adolescents with dyslipidemia.

This is one of the few areas of cardiovascular medicine where your initial diagnosis will make such a significant difference into adulthood. Dyslipidemia occurs more frequently than does structural congenital disease, heart rhythm disorders, heart failure, and most other conditions pediatric cardiologists manage.

In addition, you no longer have to wonder if you should evaluate your patients for dyslipidemia. In December 2011, the National Heart, Lung, and Blood Institute published guidelines on dyslipidemia in pediatric patients. Universal screening for dyslipidemia is now expected when children are 9-11 years old, even if they have no risk factors. The American Academy of Pediatrics endorsed this guidance.

Of course, there are situations where you might want to check earlier. If you identify any risk factor – relevant family history, obesity, or diabetes – you don’t have to wait until a child is 9 years old. You can screen these children when they are as young as 2 or 3 years.

The good news is that the guidelines do not require a fasting lipid profile ("Doctors Advised to Test Cholesterol in All Children Aged 9-11 Years," Pediatric News, Nov. 15, 2011). A nonfasting lipid profile reveals relevant information (except regarding HDL cholesterol), and is therefore an appropriate initial, universal screening tool. If you get a result out of the normal range or identify any new risk factors, a follow-up fasting lipid profile is warranted.

I’m glad to see that the guideline experts do not require a fasting assay. As many pediatricians can attest, overnight fasting can be very onerous for young patients and their families – especially if the well child visit is in the afternoon.

Once dyslipidemia is diagnosed, pediatricians can effectively manage most children with this condition. However, there also is a general consensus among these experts that the most severe childhood lipid abnormalities should be managed by lipid specialists. Hypercholesterolemia with a genetic etiology is worrisome, for example, especially if it’s heterozygous familial hypercholesterolemia.

Affected children will have significant elevations of LDL cholesterol – easily over 160 mg/dL and usually over 200 mg/dL. This condition affects about 1 in 500 people in the United States. Left undiagnosed and untreated, over their lifetimes about 50% of the men and 25% of the women will experience an important event – such as peripheral arterial disease or a heart attack – by the time they are 50.

If a person unknowingly grows to adulthood with heterozygous familial hypercholesterolemia, that person might experience a heart attack with no warning at age 30 (for men) or age 40 (for women).

This is all about prevention on the part of the pediatrician. Your early identification of patients with lipid abnormalities ties into "primordial prevention." In contrast to treating adults after they’ve developed cardiovascular disease, or performing "primary prevention" to prevent disease in a patient with known risk factors, pediatricians can prevent risk factors from developing in the first place. This means screening and counseling patients before they become obese, develop prehypertension, or present with prediabetes. Primordial prevention can delay or prevent a lot of these risk factors from becoming real issues.

If you identify and treat these patients with statins, you can restore normal longevity. Researchers have shown that these agents are just as safe and effective for children as they are for adults.

Dyslipidemia screening, diagnosis, and management are clinical areas where pediatricians and cardiologists can work together and make a real difference. I can’t think of anything better for pediatricians to do.

Dr. Hardin is director of the division of pediatric cardiology, and associate professor of pediatrics, at Loyola University Health System in Maywood, Ill. He had no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Replacing a knocked-out permanent tooth is a far-less-daunting proposition than it sounds, according to Dr. Steven M. Selbst.

"This is an easy procedure that I hope every pediatrician would be comfortable in doing," he said at the meeting sponsored by the American Academy of Pediatrics.

Time is critical. A tooth reinserted within 30 minutes after being knocked out has a 90% chance of survival. After that, the success rate drops off considerably.

A common scenario is for a parent to phone the pediatrician from the scene of the mishap, perhaps a playground, the backyard trampoline, or a baseball diamond. The parent should be instructed to immerse the tooth in milk, if immediately available, while transporting the youth to the physician’s office. If milk is not at hand, water is the next best. Failing that, the adult should put the tooth under his or her own tongue, according to Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and an authority on emergency pediatrics.

It’s an excellent idea for every pediatrician’s office – and school nurses’ offices as well – to stock a container of the balanced salt solution known as Save-a-Tooth emergency tooth-preserving system filled with Hank’s balanced salt solution (HBSS). It’s inexpensive, available on the Internet, and extends the salvage time by several hours. As soon as the patient arrives at the office, the tooth can be placed in the HBSS while the treatment team assembles.

The tooth should always be handled by the crown, not the root. And even though the tooth may have been kicked around in the dirt, it shouldn’t be scrubbed clean; that would damage the fine root fibers that are essential to successful reattachment. Instead, the tooth can be gently irrigated with saline or tap water to clean it up.

The tooth socket is a gaping hole, often filled with a blood clot. This, too, should be gently irrigated. Wet gauze can be used to wipe away the clot.

There’s no need to anesthetize the tooth socket with a lidocaine injection.

"When the tooth got knocked out, most of the pain-carrying nerve fibers got knocked out along with it. It’s really not that painful to replace the tooth. The teenager is desperate for this procedure to be successful. He or she is going to do everything possible to help you along the way. They’ll tolerate a bit of pain or discomfort," Dr. Selbst explained.

The procedure itself is remarkably straightforward.

"You don’t need fancy equipment. You don’t need any anesthesia. You just need to have the courage to stick the tooth right back up in that big hole after you’ve cleaned it off," the pediatrician continued.

But first, make sure the tooth is correctly oriented: right side up, front facing forward.

Pretty much the only complication that can occur is if the nervous physician drops the tooth and the patient then swallows it. It’s game over at that point. For this reason, Dr. Selbst said he always has the patient sitting up to at least a 45-degree angle for the procedure rather than lying down.

The patient needs to go from the pediatrician to a dentist straight away so the tooth can be further stabilized. Have the youth bite down on a big wad of gauze to keep the loose tooth from moving around while in transit, he advised.

Dr. Selbst reported that he had no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Replacing a knocked-out permanent tooth is a far-less-daunting proposition than it sounds, according to Dr. Steven M. Selbst.

"This is an easy procedure that I hope every pediatrician would be comfortable in doing," he said at the meeting sponsored by the American Academy of Pediatrics.

Time is critical. A tooth reinserted within 30 minutes after being knocked out has a 90% chance of survival. After that, the success rate drops off considerably.

A common scenario is for a parent to phone the pediatrician from the scene of the mishap, perhaps a playground, the backyard trampoline, or a baseball diamond. The parent should be instructed to immerse the tooth in milk, if immediately available, while transporting the youth to the physician’s office. If milk is not at hand, water is the next best. Failing that, the adult should put the tooth under his or her own tongue, according to Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and an authority on emergency pediatrics.

It’s an excellent idea for every pediatrician’s office – and school nurses’ offices as well – to stock a container of the balanced salt solution known as Save-a-Tooth emergency tooth-preserving system filled with Hank’s balanced salt solution (HBSS). It’s inexpensive, available on the Internet, and extends the salvage time by several hours. As soon as the patient arrives at the office, the tooth can be placed in the HBSS while the treatment team assembles.

The tooth should always be handled by the crown, not the root. And even though the tooth may have been kicked around in the dirt, it shouldn’t be scrubbed clean; that would damage the fine root fibers that are essential to successful reattachment. Instead, the tooth can be gently irrigated with saline or tap water to clean it up.

The tooth socket is a gaping hole, often filled with a blood clot. This, too, should be gently irrigated. Wet gauze can be used to wipe away the clot.

There’s no need to anesthetize the tooth socket with a lidocaine injection.

"When the tooth got knocked out, most of the pain-carrying nerve fibers got knocked out along with it. It’s really not that painful to replace the tooth. The teenager is desperate for this procedure to be successful. He or she is going to do everything possible to help you along the way. They’ll tolerate a bit of pain or discomfort," Dr. Selbst explained.

The procedure itself is remarkably straightforward.

"You don’t need fancy equipment. You don’t need any anesthesia. You just need to have the courage to stick the tooth right back up in that big hole after you’ve cleaned it off," the pediatrician continued.

But first, make sure the tooth is correctly oriented: right side up, front facing forward.

Pretty much the only complication that can occur is if the nervous physician drops the tooth and the patient then swallows it. It’s game over at that point. For this reason, Dr. Selbst said he always has the patient sitting up to at least a 45-degree angle for the procedure rather than lying down.

The patient needs to go from the pediatrician to a dentist straight away so the tooth can be further stabilized. Have the youth bite down on a big wad of gauze to keep the loose tooth from moving around while in transit, he advised.

Dr. Selbst reported that he had no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Replacing a knocked-out permanent tooth is a far-less-daunting proposition than it sounds, according to Dr. Steven M. Selbst.

"This is an easy procedure that I hope every pediatrician would be comfortable in doing," he said at the meeting sponsored by the American Academy of Pediatrics.

Time is critical. A tooth reinserted within 30 minutes after being knocked out has a 90% chance of survival. After that, the success rate drops off considerably.

A common scenario is for a parent to phone the pediatrician from the scene of the mishap, perhaps a playground, the backyard trampoline, or a baseball diamond. The parent should be instructed to immerse the tooth in milk, if immediately available, while transporting the youth to the physician’s office. If milk is not at hand, water is the next best. Failing that, the adult should put the tooth under his or her own tongue, according to Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and an authority on emergency pediatrics.

It’s an excellent idea for every pediatrician’s office – and school nurses’ offices as well – to stock a container of the balanced salt solution known as Save-a-Tooth emergency tooth-preserving system filled with Hank’s balanced salt solution (HBSS). It’s inexpensive, available on the Internet, and extends the salvage time by several hours. As soon as the patient arrives at the office, the tooth can be placed in the HBSS while the treatment team assembles.

The tooth should always be handled by the crown, not the root. And even though the tooth may have been kicked around in the dirt, it shouldn’t be scrubbed clean; that would damage the fine root fibers that are essential to successful reattachment. Instead, the tooth can be gently irrigated with saline or tap water to clean it up.

The tooth socket is a gaping hole, often filled with a blood clot. This, too, should be gently irrigated. Wet gauze can be used to wipe away the clot.

There’s no need to anesthetize the tooth socket with a lidocaine injection.

"When the tooth got knocked out, most of the pain-carrying nerve fibers got knocked out along with it. It’s really not that painful to replace the tooth. The teenager is desperate for this procedure to be successful. He or she is going to do everything possible to help you along the way. They’ll tolerate a bit of pain or discomfort," Dr. Selbst explained.

The procedure itself is remarkably straightforward.

"You don’t need fancy equipment. You don’t need any anesthesia. You just need to have the courage to stick the tooth right back up in that big hole after you’ve cleaned it off," the pediatrician continued.

But first, make sure the tooth is correctly oriented: right side up, front facing forward.

Pretty much the only complication that can occur is if the nervous physician drops the tooth and the patient then swallows it. It’s game over at that point. For this reason, Dr. Selbst said he always has the patient sitting up to at least a 45-degree angle for the procedure rather than lying down.

The patient needs to go from the pediatrician to a dentist straight away so the tooth can be further stabilized. Have the youth bite down on a big wad of gauze to keep the loose tooth from moving around while in transit, he advised.

Dr. Selbst reported that he had no relevant financial disclosures.

At a recent forum, Virginia Attorney General Ken Cuccinelli and Massachusetts Attorney General Martha Coakley offered contrasting perspectives on the constitutionality of the federal Affordable Care Act's requirement that individuals must purchase health insurance.

Reporter Alicia Ault has this video report:

At a recent forum, Virginia Attorney General Ken Cuccinelli and Massachusetts Attorney General Martha Coakley offered contrasting perspectives on the constitutionality of the federal Affordable Care Act's requirement that individuals must purchase health insurance.

Reporter Alicia Ault has this video report:

At a recent forum, Virginia Attorney General Ken Cuccinelli and Massachusetts Attorney General Martha Coakley offered contrasting perspectives on the constitutionality of the federal Affordable Care Act's requirement that individuals must purchase health insurance.

Reporter Alicia Ault has this video report:

Hospitals are a place where people go to get healthy, but the same can't be said about all hospital cafeterias, according to a recent study by the Physicians Committee for Responsible Medicine (PCRM).

The study analyzed food served to patients, staff, and visitors at U.S. hospitals in all 50 states and the District of Columbia and found that some hospitals housed as many as five fast-food outlets and featured menus that were dominated by foods high in fat, cholesterol, sugar, and sodium. For hospitalists, many of whom spend 50, 70, and even 90 hours per week in the hospital, the lack of healthy eating options can be especially problematic.

"We relied on menus that were provided, and while we don't have the recipes in hand, we can tell a lot just by the fundamental ingredients," says Susan Levin, RD, PCRM's director of nutrition education and lead author of the study.

Levin says the presence of these kinds of foods in hospitals is "irresponsible," and suggests hospitals ban fast-food outlets and fill menus with low-fat, plant-based options as a way to "reverse and prevent disease."

Many hospital cafeterias around the country are doing just that. MetroWest Medical Center, just outside of Boston, has formed a "Go Green" committee that plans to group and label healthy versus nonhealthy drinks and snacks, and will reward patients and hospital staff for choosing water and other healthy options. Benioff Children's Hospital at the University of California at San Francisco (UCSF) Medical Center now offers nutritional information for entrees, and food-purchase receipts note calories and fat content.

PCRM hopes the study will encourage hospitals to lead the way in promoting healthful eating habits. "I hope that something is changing and people are thinking bigger picture and better care," Levin says.

Hospitals are a place where people go to get healthy, but the same can't be said about all hospital cafeterias, according to a recent study by the Physicians Committee for Responsible Medicine (PCRM).

The study analyzed food served to patients, staff, and visitors at U.S. hospitals in all 50 states and the District of Columbia and found that some hospitals housed as many as five fast-food outlets and featured menus that were dominated by foods high in fat, cholesterol, sugar, and sodium. For hospitalists, many of whom spend 50, 70, and even 90 hours per week in the hospital, the lack of healthy eating options can be especially problematic.

"We relied on menus that were provided, and while we don't have the recipes in hand, we can tell a lot just by the fundamental ingredients," says Susan Levin, RD, PCRM's director of nutrition education and lead author of the study.

Levin says the presence of these kinds of foods in hospitals is "irresponsible," and suggests hospitals ban fast-food outlets and fill menus with low-fat, plant-based options as a way to "reverse and prevent disease."

Many hospital cafeterias around the country are doing just that. MetroWest Medical Center, just outside of Boston, has formed a "Go Green" committee that plans to group and label healthy versus nonhealthy drinks and snacks, and will reward patients and hospital staff for choosing water and other healthy options. Benioff Children's Hospital at the University of California at San Francisco (UCSF) Medical Center now offers nutritional information for entrees, and food-purchase receipts note calories and fat content.

PCRM hopes the study will encourage hospitals to lead the way in promoting healthful eating habits. "I hope that something is changing and people are thinking bigger picture and better care," Levin says.

Hospitals are a place where people go to get healthy, but the same can't be said about all hospital cafeterias, according to a recent study by the Physicians Committee for Responsible Medicine (PCRM).

The study analyzed food served to patients, staff, and visitors at U.S. hospitals in all 50 states and the District of Columbia and found that some hospitals housed as many as five fast-food outlets and featured menus that were dominated by foods high in fat, cholesterol, sugar, and sodium. For hospitalists, many of whom spend 50, 70, and even 90 hours per week in the hospital, the lack of healthy eating options can be especially problematic.

"We relied on menus that were provided, and while we don't have the recipes in hand, we can tell a lot just by the fundamental ingredients," says Susan Levin, RD, PCRM's director of nutrition education and lead author of the study.

Levin says the presence of these kinds of foods in hospitals is "irresponsible," and suggests hospitals ban fast-food outlets and fill menus with low-fat, plant-based options as a way to "reverse and prevent disease."

Many hospital cafeterias around the country are doing just that. MetroWest Medical Center, just outside of Boston, has formed a "Go Green" committee that plans to group and label healthy versus nonhealthy drinks and snacks, and will reward patients and hospital staff for choosing water and other healthy options. Benioff Children's Hospital at the University of California at San Francisco (UCSF) Medical Center now offers nutritional information for entrees, and food-purchase receipts note calories and fat content.

PCRM hopes the study will encourage hospitals to lead the way in promoting healthful eating habits. "I hope that something is changing and people are thinking bigger picture and better care," Levin says.

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

MIAMI BEACH – Patients with head and neck cancers who develop alcohol withdrawal syndrome perioperatively experience significantly more complications after undergoing surgery, a large database analysis indicates.

The presence of withdrawal symptoms was associated with a 25% incidence of postoperative complications, compared with 14% among patients who abused alcohol and 7% among those without alcohol abuse, Dr. Dane J. Genther said at the Triological Society’s Combined Sections Meeting. The risk for wound complications was nearly double in this population (odds ratio, 1.9).

Dr. Genther, a resident in otolaryngologyhead and neck surgery at Johns Hopkins Hospital in Baltimore, and his associates used ICD-9 codes in the Nationwide Inpatient Sample discharge database to identify more than 92,000 patients who underwent an ablative procedure for head and neck cancer in 2003-2008. The retrospective, cross-sectional study included patients with malignant oral cavity, laryngeal, hypopharyngeal, and oropharyngeal neoplasms.

In a multivariate analysis, alcohol withdrawal syndrome was significantly more likely for patients undergoing a major procedure (OR, 2.0) and was significantly associated with Medicare payer status and a need for additional health care following discharge, Dr. Genther said.

The researchers found no significant association between alcohol withdrawal syndrome and increased risk for postoperative infections or in-hospital mortality, but there was a significant increase in hospital stay and related costs associated with the syndrome.

Having a major procedure and experiencing alcohol withdrawal contributed approximately $15,000 per admission in 2011 U.S. dollars, Dr. Genther said.

The findings point to a need for alternatives to current alcohol withdrawal prevention therapies, Dr. Genther said. "Despite prophylaxis, which is our current treatment to attempt to stem the onset of alcohol withdrawal syndrome, complications do occur and they are no less severe or frequent than in the absence of prophylaxis."

Abstinence from alcohol for at least 4 weeks is another strategy proposed to minimize risk of alcohol withdrawal syndrome for any at-risk surgical patient, said Dr. Genther. However, he added, "for many cancer patients, especially those with more advanced disease, waiting a prolonged period of time to possibly gain that benefit from abstinence is not necessarily a viable option."

Another aim of the study was to assess factors contributing to alcohol abuse. Patients aged 40-64 years had the highest proportion of alcohol abuse, and this age range was a significant factor (OR, 2.37). Those who abused alcohol were more often male and more often underwent major procedures, Dr. Genther said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. In addition, alcohol abuse was significantly associated with pneumonia and need for additional postdischarge health care.

Dr. Genther received a G. Slaughter Fitz-Hugh Resident Research Award for this study from the Triological Society. He reported having no financial disclosures.

MIAMI BEACH – Patients with head and neck cancers who develop alcohol withdrawal syndrome perioperatively experience significantly more complications after undergoing surgery, a large database analysis indicates.

The presence of withdrawal symptoms was associated with a 25% incidence of postoperative complications, compared with 14% among patients who abused alcohol and 7% among those without alcohol abuse, Dr. Dane J. Genther said at the Triological Society’s Combined Sections Meeting. The risk for wound complications was nearly double in this population (odds ratio, 1.9).

Dr. Genther, a resident in otolaryngologyhead and neck surgery at Johns Hopkins Hospital in Baltimore, and his associates used ICD-9 codes in the Nationwide Inpatient Sample discharge database to identify more than 92,000 patients who underwent an ablative procedure for head and neck cancer in 2003-2008. The retrospective, cross-sectional study included patients with malignant oral cavity, laryngeal, hypopharyngeal, and oropharyngeal neoplasms.

In a multivariate analysis, alcohol withdrawal syndrome was significantly more likely for patients undergoing a major procedure (OR, 2.0) and was significantly associated with Medicare payer status and a need for additional health care following discharge, Dr. Genther said.

The researchers found no significant association between alcohol withdrawal syndrome and increased risk for postoperative infections or in-hospital mortality, but there was a significant increase in hospital stay and related costs associated with the syndrome.

Having a major procedure and experiencing alcohol withdrawal contributed approximately $15,000 per admission in 2011 U.S. dollars, Dr. Genther said.

The findings point to a need for alternatives to current alcohol withdrawal prevention therapies, Dr. Genther said. "Despite prophylaxis, which is our current treatment to attempt to stem the onset of alcohol withdrawal syndrome, complications do occur and they are no less severe or frequent than in the absence of prophylaxis."

Abstinence from alcohol for at least 4 weeks is another strategy proposed to minimize risk of alcohol withdrawal syndrome for any at-risk surgical patient, said Dr. Genther. However, he added, "for many cancer patients, especially those with more advanced disease, waiting a prolonged period of time to possibly gain that benefit from abstinence is not necessarily a viable option."

Another aim of the study was to assess factors contributing to alcohol abuse. Patients aged 40-64 years had the highest proportion of alcohol abuse, and this age range was a significant factor (OR, 2.37). Those who abused alcohol were more often male and more often underwent major procedures, Dr. Genther said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. In addition, alcohol abuse was significantly associated with pneumonia and need for additional postdischarge health care.

Dr. Genther received a G. Slaughter Fitz-Hugh Resident Research Award for this study from the Triological Society. He reported having no financial disclosures.

MIAMI BEACH – Patients with head and neck cancers who develop alcohol withdrawal syndrome perioperatively experience significantly more complications after undergoing surgery, a large database analysis indicates.

The presence of withdrawal symptoms was associated with a 25% incidence of postoperative complications, compared with 14% among patients who abused alcohol and 7% among those without alcohol abuse, Dr. Dane J. Genther said at the Triological Society’s Combined Sections Meeting. The risk for wound complications was nearly double in this population (odds ratio, 1.9).

Dr. Genther, a resident in otolaryngologyhead and neck surgery at Johns Hopkins Hospital in Baltimore, and his associates used ICD-9 codes in the Nationwide Inpatient Sample discharge database to identify more than 92,000 patients who underwent an ablative procedure for head and neck cancer in 2003-2008. The retrospective, cross-sectional study included patients with malignant oral cavity, laryngeal, hypopharyngeal, and oropharyngeal neoplasms.

In a multivariate analysis, alcohol withdrawal syndrome was significantly more likely for patients undergoing a major procedure (OR, 2.0) and was significantly associated with Medicare payer status and a need for additional health care following discharge, Dr. Genther said.

The researchers found no significant association between alcohol withdrawal syndrome and increased risk for postoperative infections or in-hospital mortality, but there was a significant increase in hospital stay and related costs associated with the syndrome.

Having a major procedure and experiencing alcohol withdrawal contributed approximately $15,000 per admission in 2011 U.S. dollars, Dr. Genther said.

The findings point to a need for alternatives to current alcohol withdrawal prevention therapies, Dr. Genther said. "Despite prophylaxis, which is our current treatment to attempt to stem the onset of alcohol withdrawal syndrome, complications do occur and they are no less severe or frequent than in the absence of prophylaxis."

Abstinence from alcohol for at least 4 weeks is another strategy proposed to minimize risk of alcohol withdrawal syndrome for any at-risk surgical patient, said Dr. Genther. However, he added, "for many cancer patients, especially those with more advanced disease, waiting a prolonged period of time to possibly gain that benefit from abstinence is not necessarily a viable option."

Another aim of the study was to assess factors contributing to alcohol abuse. Patients aged 40-64 years had the highest proportion of alcohol abuse, and this age range was a significant factor (OR, 2.37). Those who abused alcohol were more often male and more often underwent major procedures, Dr. Genther said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. In addition, alcohol abuse was significantly associated with pneumonia and need for additional postdischarge health care.

Dr. Genther received a G. Slaughter Fitz-Hugh Resident Research Award for this study from the Triological Society. He reported having no financial disclosures.

SNOWMASS, COLO. – A disturbing proportion of gout cases are mismanaged by primary care physicians, and the blame falls squarely upon rheumatologists, according to one prominent gout expert.

"As rheumatologists, gout is our disease. The cause and pathophysiology are well understood, we can make the diagnosis with absolute certainty, and we’ve got great medicines. Yet today we all see people with tophi. That’s tragic. It shouldn’t exist. One of our biggest mistakes has been not being able to educate primary care physicians that having a tophus is bad, that it’s eroding cartilage and bone, and that it’s something we can prevent if we start urate-lowering therapy soon enough," Dr. Robert L. Wortmann said at the conference.

An estimated 8.3 million Americans have gout. Yet, the pharmaceutical industry says only 3.1 million of them are prescribed urate-lowering drugs. Five different studies show that a mere 40% of those on allopurinol are prescribed a dose sufficient to drive serum uric acid below 6 mg/dL, a key tenet of gout management, noted Dr. Wortmann, professor of medicine at Dartmouth Medical School in Hanover, N.H.

Moreover, poor treatment adherence is a huge problem in gout. A study of close to 4,200 gout patients started on urate-lowering drug therapy found that 56% of them were nonadherent (Arthritis Res. Ther. 2009;11(2):R46).

"I charge you all to go back from this meeting and try to communicate with all the primary care physicians you can about the principles of managing gout. People shouldn’t suffer from this," the rheumatologist declared.

He offered these major take home points:

Don’t prescribe urate-lowering drugs for asymptomatic hyperuricemia: This practice hasn’t been shown to prevent the future development of gout, yet it exposes patients to the risk of drug toxicities.

But don’t ignore asymptomatic hyperuricemia, either: Epidemiologic studies have linked asymptomatic hyperuricemia, defined by a serum urate in excess of 6.8 mg/dL, to increased risks of hypertension, cardiovascular disease, diabetes, chronic kidney disease, and all-cause mortality. The big unanswered question is whether using medications to lower serum urate in individuals with asymptomatic hyperuricemia reduces the risk of any of these conditions. That’s the subject of ongoing large clinical trials in high-risk patients. If those studies prove positive, clinical practice will change.

While awaiting the outcome of the prevention trials, it’s worth bearing in mind that Framingham Heart Study data indicate that individuals with a serum uric acid level above 9 mg/dL have a 22% chance of developing gout within the next 5 years. The major contributors to asymptomatic hyperuricemia include obesity, metabolic syndrome, and heavy consumption of fructose-containing beverages or alcohol. Those issues should be addressed.

Losartan is the only antihypertensive agent that’s uricosuric. Fenofibrate is the sole uricosuric drug indicated for dyslipidemia. Preferential consideration could be given to the use of these drugs in hypertensive and/or hyperlipidemic patients with asymptomatic hyperuricemia.

The important thing is not which oral agent you use for treatment of acute gout, it’s to initiate therapy as early as possible, at the first hint of an attack. Colchicine, maximum-dose NSAIDs, and oral prednisone dosed at 20 mg BID until symptoms have been gone for 1 week followed by another week at 20 mg/day – they’re all effective. And since they work by different mechanisms, they can beneficially be combined in refractory patients.

The old-school colchicine dosing regimen most physicians were taught has been cast aside of late. It had a high rate of diarrhea, an inhumane side effect in gout patients hobbled by a foot too sore to walk on. The former regimen has been replaced by 1.2 mg, given in a single dose, followed by 0.6 mg 1 hour later.

"This lower dose is just as effective as the old high-dose regimen of two 0.6-mg pills given at once and then one per hour for the next 5 hours. And the lower-dose program has the same side effect profile as placebo," Dr. Wortmann said.

Get the gout patient’s serum urate below 6 mg/dL using the lowest effective dose of the urate-lowering drug you’ve selected. Physicians have traditionally started gout patients on allopurinol at the standard dose of 300 mg/day. Recently, it has been demonstrated that the risk of developing allopurinol hypersensitivity syndrome is greatly reduced by starting off at 150 mg/day, checking the urate level 2 weeks later, then increasing to 300 mg/day if the serum urate isn’t below 6 mg/dL. After 2 weeks at 300 mg/day, check the urate again, and if it still isn’t below 6 mg/dL then bump the dose to 400 mg/day. Continue testing and titrating every 2 weeks until the serum urate is less than 6 mg/dL – and preferably less than 4 mg/dL if the patient has tophi – or until the maximum approved dose of 800 mg/day is reached.

The same start-low-and-titrate strategy applies to febuxostat, with a maximum approved dose of 80 mg/day.

"We have to educate primary care physicians to check the serum urate after starting therapy, and that, if it’s not below 6 mg/dL, they need to increase the dose. And if they don’t feel comfortable with that, they need to send the patient to us," the rheumatologist said.

Fortunately, patients who have a hypersensitivity reaction to allopurinol are very unlikely to experience one with febuxostat, and vice versa.

For patients who can’t reach the target serum urate with maximum-dose therapy, take heart: Second-line agents with impressive potency are well-along in the developmental pipeline.

Many labs now list the upper limit of normal for serum urate as 8 mg/dL or 8.5 mg/dL. Ignore that. This raised ceiling is simply the result of the changing demographics among the increasingly obese U.S. population in the last several decades. The definition of asymptomatic hyperuricemia remains unchanged: a serum urate greater than 6.8 mg/dL. And the target in patients with gout is still a serum urate less than 6 mg/dL. Merely dropping a gout patient’s urate from 10 to 8 or even 6.6 mg/dL isn’t doing any favors; the disease will continue to progress if the urate is above 6 mg/dL.

All gout is tophaceous. Even if tophi aren’t apparent on clinical examination, often they are radiographically. "This is a message that has to get out," Dr. Wortmann insisted.

Proposed American College of Rheumatology gout management guidelines call for starting urate-lowering drug therapy when a patient is experiencing three attacks per year. Dr. Wortmann takes issue with that.

"I would argue that once you’ve had a third attack of gout, period, you should be treated. Maybe even sooner. We need to prevent the erosion and bony destruction that occur with tophi," he said.

One audience member complained that his gout patients with comorbid renal insufficiency and/or cardiovascular disease often get caught in a revolving door. He titrates their allopurinol to an effective dose, but when they are later admitted to the hospital because of their comorbid condition the hospitalists, nephrologists, and/or cardiologists are shocked at the allopurinol dose and either reduce it or stop it altogether. The first that the rheumatologist learns of it is when patients reappear in his office with active gout. He then resumes their allopurinol at the previous dose, and they remain well controlled until the next hospitalization, when the same thing happens.

Dr. Wortmann responded that the solution requires convincing the nonrheumatologists in one-on-one conversation that urate-lowering therapy is not a one-size-fits-all matter. They need to understand that to get rid of gout, it’s necessary to drive the serum urate to the target of less than 6 mg/dL, and it helps to reassure them that that this will be accomplished using the lowest effective dose.

He reported serving as a consultant to Savient, Takeda, URL Pharmaceuticals, Novartis, and Ardea Biosciences.

SNOWMASS, COLO. – A disturbing proportion of gout cases are mismanaged by primary care physicians, and the blame falls squarely upon rheumatologists, according to one prominent gout expert.

"As rheumatologists, gout is our disease. The cause and pathophysiology are well understood, we can make the diagnosis with absolute certainty, and we’ve got great medicines. Yet today we all see people with tophi. That’s tragic. It shouldn’t exist. One of our biggest mistakes has been not being able to educate primary care physicians that having a tophus is bad, that it’s eroding cartilage and bone, and that it’s something we can prevent if we start urate-lowering therapy soon enough," Dr. Robert L. Wortmann said at the conference.

An estimated 8.3 million Americans have gout. Yet, the pharmaceutical industry says only 3.1 million of them are prescribed urate-lowering drugs. Five different studies show that a mere 40% of those on allopurinol are prescribed a dose sufficient to drive serum uric acid below 6 mg/dL, a key tenet of gout management, noted Dr. Wortmann, professor of medicine at Dartmouth Medical School in Hanover, N.H.

Moreover, poor treatment adherence is a huge problem in gout. A study of close to 4,200 gout patients started on urate-lowering drug therapy found that 56% of them were nonadherent (Arthritis Res. Ther. 2009;11(2):R46).

"I charge you all to go back from this meeting and try to communicate with all the primary care physicians you can about the principles of managing gout. People shouldn’t suffer from this," the rheumatologist declared.

He offered these major take home points:

Don’t prescribe urate-lowering drugs for asymptomatic hyperuricemia: This practice hasn’t been shown to prevent the future development of gout, yet it exposes patients to the risk of drug toxicities.

But don’t ignore asymptomatic hyperuricemia, either: Epidemiologic studies have linked asymptomatic hyperuricemia, defined by a serum urate in excess of 6.8 mg/dL, to increased risks of hypertension, cardiovascular disease, diabetes, chronic kidney disease, and all-cause mortality. The big unanswered question is whether using medications to lower serum urate in individuals with asymptomatic hyperuricemia reduces the risk of any of these conditions. That’s the subject of ongoing large clinical trials in high-risk patients. If those studies prove positive, clinical practice will change.

While awaiting the outcome of the prevention trials, it’s worth bearing in mind that Framingham Heart Study data indicate that individuals with a serum uric acid level above 9 mg/dL have a 22% chance of developing gout within the next 5 years. The major contributors to asymptomatic hyperuricemia include obesity, metabolic syndrome, and heavy consumption of fructose-containing beverages or alcohol. Those issues should be addressed.

Losartan is the only antihypertensive agent that’s uricosuric. Fenofibrate is the sole uricosuric drug indicated for dyslipidemia. Preferential consideration could be given to the use of these drugs in hypertensive and/or hyperlipidemic patients with asymptomatic hyperuricemia.

The important thing is not which oral agent you use for treatment of acute gout, it’s to initiate therapy as early as possible, at the first hint of an attack. Colchicine, maximum-dose NSAIDs, and oral prednisone dosed at 20 mg BID until symptoms have been gone for 1 week followed by another week at 20 mg/day – they’re all effective. And since they work by different mechanisms, they can beneficially be combined in refractory patients.

The old-school colchicine dosing regimen most physicians were taught has been cast aside of late. It had a high rate of diarrhea, an inhumane side effect in gout patients hobbled by a foot too sore to walk on. The former regimen has been replaced by 1.2 mg, given in a single dose, followed by 0.6 mg 1 hour later.

"This lower dose is just as effective as the old high-dose regimen of two 0.6-mg pills given at once and then one per hour for the next 5 hours. And the lower-dose program has the same side effect profile as placebo," Dr. Wortmann said.

Get the gout patient’s serum urate below 6 mg/dL using the lowest effective dose of the urate-lowering drug you’ve selected. Physicians have traditionally started gout patients on allopurinol at the standard dose of 300 mg/day. Recently, it has been demonstrated that the risk of developing allopurinol hypersensitivity syndrome is greatly reduced by starting off at 150 mg/day, checking the urate level 2 weeks later, then increasing to 300 mg/day if the serum urate isn’t below 6 mg/dL. After 2 weeks at 300 mg/day, check the urate again, and if it still isn’t below 6 mg/dL then bump the dose to 400 mg/day. Continue testing and titrating every 2 weeks until the serum urate is less than 6 mg/dL – and preferably less than 4 mg/dL if the patient has tophi – or until the maximum approved dose of 800 mg/day is reached.

The same start-low-and-titrate strategy applies to febuxostat, with a maximum approved dose of 80 mg/day.

"We have to educate primary care physicians to check the serum urate after starting therapy, and that, if it’s not below 6 mg/dL, they need to increase the dose. And if they don’t feel comfortable with that, they need to send the patient to us," the rheumatologist said.

Fortunately, patients who have a hypersensitivity reaction to allopurinol are very unlikely to experience one with febuxostat, and vice versa.

For patients who can’t reach the target serum urate with maximum-dose therapy, take heart: Second-line agents with impressive potency are well-along in the developmental pipeline.

Many labs now list the upper limit of normal for serum urate as 8 mg/dL or 8.5 mg/dL. Ignore that. This raised ceiling is simply the result of the changing demographics among the increasingly obese U.S. population in the last several decades. The definition of asymptomatic hyperuricemia remains unchanged: a serum urate greater than 6.8 mg/dL. And the target in patients with gout is still a serum urate less than 6 mg/dL. Merely dropping a gout patient’s urate from 10 to 8 or even 6.6 mg/dL isn’t doing any favors; the disease will continue to progress if the urate is above 6 mg/dL.

All gout is tophaceous. Even if tophi aren’t apparent on clinical examination, often they are radiographically. "This is a message that has to get out," Dr. Wortmann insisted.

Proposed American College of Rheumatology gout management guidelines call for starting urate-lowering drug therapy when a patient is experiencing three attacks per year. Dr. Wortmann takes issue with that.

"I would argue that once you’ve had a third attack of gout, period, you should be treated. Maybe even sooner. We need to prevent the erosion and bony destruction that occur with tophi," he said.

One audience member complained that his gout patients with comorbid renal insufficiency and/or cardiovascular disease often get caught in a revolving door. He titrates their allopurinol to an effective dose, but when they are later admitted to the hospital because of their comorbid condition the hospitalists, nephrologists, and/or cardiologists are shocked at the allopurinol dose and either reduce it or stop it altogether. The first that the rheumatologist learns of it is when patients reappear in his office with active gout. He then resumes their allopurinol at the previous dose, and they remain well controlled until the next hospitalization, when the same thing happens.

Dr. Wortmann responded that the solution requires convincing the nonrheumatologists in one-on-one conversation that urate-lowering therapy is not a one-size-fits-all matter. They need to understand that to get rid of gout, it’s necessary to drive the serum urate to the target of less than 6 mg/dL, and it helps to reassure them that that this will be accomplished using the lowest effective dose.

He reported serving as a consultant to Savient, Takeda, URL Pharmaceuticals, Novartis, and Ardea Biosciences.

SNOWMASS, COLO. – A disturbing proportion of gout cases are mismanaged by primary care physicians, and the blame falls squarely upon rheumatologists, according to one prominent gout expert.

"As rheumatologists, gout is our disease. The cause and pathophysiology are well understood, we can make the diagnosis with absolute certainty, and we’ve got great medicines. Yet today we all see people with tophi. That’s tragic. It shouldn’t exist. One of our biggest mistakes has been not being able to educate primary care physicians that having a tophus is bad, that it’s eroding cartilage and bone, and that it’s something we can prevent if we start urate-lowering therapy soon enough," Dr. Robert L. Wortmann said at the conference.

An estimated 8.3 million Americans have gout. Yet, the pharmaceutical industry says only 3.1 million of them are prescribed urate-lowering drugs. Five different studies show that a mere 40% of those on allopurinol are prescribed a dose sufficient to drive serum uric acid below 6 mg/dL, a key tenet of gout management, noted Dr. Wortmann, professor of medicine at Dartmouth Medical School in Hanover, N.H.

Moreover, poor treatment adherence is a huge problem in gout. A study of close to 4,200 gout patients started on urate-lowering drug therapy found that 56% of them were nonadherent (Arthritis Res. Ther. 2009;11(2):R46).

"I charge you all to go back from this meeting and try to communicate with all the primary care physicians you can about the principles of managing gout. People shouldn’t suffer from this," the rheumatologist declared.

He offered these major take home points:

Don’t prescribe urate-lowering drugs for asymptomatic hyperuricemia: This practice hasn’t been shown to prevent the future development of gout, yet it exposes patients to the risk of drug toxicities.

But don’t ignore asymptomatic hyperuricemia, either: Epidemiologic studies have linked asymptomatic hyperuricemia, defined by a serum urate in excess of 6.8 mg/dL, to increased risks of hypertension, cardiovascular disease, diabetes, chronic kidney disease, and all-cause mortality. The big unanswered question is whether using medications to lower serum urate in individuals with asymptomatic hyperuricemia reduces the risk of any of these conditions. That’s the subject of ongoing large clinical trials in high-risk patients. If those studies prove positive, clinical practice will change.

While awaiting the outcome of the prevention trials, it’s worth bearing in mind that Framingham Heart Study data indicate that individuals with a serum uric acid level above 9 mg/dL have a 22% chance of developing gout within the next 5 years. The major contributors to asymptomatic hyperuricemia include obesity, metabolic syndrome, and heavy consumption of fructose-containing beverages or alcohol. Those issues should be addressed.

Losartan is the only antihypertensive agent that’s uricosuric. Fenofibrate is the sole uricosuric drug indicated for dyslipidemia. Preferential consideration could be given to the use of these drugs in hypertensive and/or hyperlipidemic patients with asymptomatic hyperuricemia.

The important thing is not which oral agent you use for treatment of acute gout, it’s to initiate therapy as early as possible, at the first hint of an attack. Colchicine, maximum-dose NSAIDs, and oral prednisone dosed at 20 mg BID until symptoms have been gone for 1 week followed by another week at 20 mg/day – they’re all effective. And since they work by different mechanisms, they can beneficially be combined in refractory patients.

The old-school colchicine dosing regimen most physicians were taught has been cast aside of late. It had a high rate of diarrhea, an inhumane side effect in gout patients hobbled by a foot too sore to walk on. The former regimen has been replaced by 1.2 mg, given in a single dose, followed by 0.6 mg 1 hour later.

"This lower dose is just as effective as the old high-dose regimen of two 0.6-mg pills given at once and then one per hour for the next 5 hours. And the lower-dose program has the same side effect profile as placebo," Dr. Wortmann said.

Get the gout patient’s serum urate below 6 mg/dL using the lowest effective dose of the urate-lowering drug you’ve selected. Physicians have traditionally started gout patients on allopurinol at the standard dose of 300 mg/day. Recently, it has been demonstrated that the risk of developing allopurinol hypersensitivity syndrome is greatly reduced by starting off at 150 mg/day, checking the urate level 2 weeks later, then increasing to 300 mg/day if the serum urate isn’t below 6 mg/dL. After 2 weeks at 300 mg/day, check the urate again, and if it still isn’t below 6 mg/dL then bump the dose to 400 mg/day. Continue testing and titrating every 2 weeks until the serum urate is less than 6 mg/dL – and preferably less than 4 mg/dL if the patient has tophi – or until the maximum approved dose of 800 mg/day is reached.

The same start-low-and-titrate strategy applies to febuxostat, with a maximum approved dose of 80 mg/day.

"We have to educate primary care physicians to check the serum urate after starting therapy, and that, if it’s not below 6 mg/dL, they need to increase the dose. And if they don’t feel comfortable with that, they need to send the patient to us," the rheumatologist said.

Fortunately, patients who have a hypersensitivity reaction to allopurinol are very unlikely to experience one with febuxostat, and vice versa.

For patients who can’t reach the target serum urate with maximum-dose therapy, take heart: Second-line agents with impressive potency are well-along in the developmental pipeline.

Many labs now list the upper limit of normal for serum urate as 8 mg/dL or 8.5 mg/dL. Ignore that. This raised ceiling is simply the result of the changing demographics among the increasingly obese U.S. population in the last several decades. The definition of asymptomatic hyperuricemia remains unchanged: a serum urate greater than 6.8 mg/dL. And the target in patients with gout is still a serum urate less than 6 mg/dL. Merely dropping a gout patient’s urate from 10 to 8 or even 6.6 mg/dL isn’t doing any favors; the disease will continue to progress if the urate is above 6 mg/dL.

All gout is tophaceous. Even if tophi aren’t apparent on clinical examination, often they are radiographically. "This is a message that has to get out," Dr. Wortmann insisted.

Proposed American College of Rheumatology gout management guidelines call for starting urate-lowering drug therapy when a patient is experiencing three attacks per year. Dr. Wortmann takes issue with that.

"I would argue that once you’ve had a third attack of gout, period, you should be treated. Maybe even sooner. We need to prevent the erosion and bony destruction that occur with tophi," he said.

One audience member complained that his gout patients with comorbid renal insufficiency and/or cardiovascular disease often get caught in a revolving door. He titrates their allopurinol to an effective dose, but when they are later admitted to the hospital because of their comorbid condition the hospitalists, nephrologists, and/or cardiologists are shocked at the allopurinol dose and either reduce it or stop it altogether. The first that the rheumatologist learns of it is when patients reappear in his office with active gout. He then resumes their allopurinol at the previous dose, and they remain well controlled until the next hospitalization, when the same thing happens.

Dr. Wortmann responded that the solution requires convincing the nonrheumatologists in one-on-one conversation that urate-lowering therapy is not a one-size-fits-all matter. They need to understand that to get rid of gout, it’s necessary to drive the serum urate to the target of less than 6 mg/dL, and it helps to reassure them that that this will be accomplished using the lowest effective dose.

He reported serving as a consultant to Savient, Takeda, URL Pharmaceuticals, Novartis, and Ardea Biosciences.