Kate Johnson

MONTREAL – Psychiatrists can further the quest toward more evidence-based medicine by treating the neurophysiologic origins of behavioral disorders, David Cantor, Ph.D., said at the annual conference of the EEG and Clinical Neuroscience Society.

With the use of quantitative electroencephalography (QEEG) to identify specific abnormalities in brain function, psychiatric therapy can be individualized to address subtleties that may not correlate well with the Diagnostic and Statistical Manual, said Dr. Cantor of Duluth, Ga., who is president of the society.

“Many roads lead to Rome, and there are many different types of abnormal brain physiology that can result in what we call attention-deficit disorder, depression, or any of the other psychiatric disorders,” he said in an interview.

“We need evidence of abnormal brain function in order to show there's a physiologic need for a drug or therapy, and then we need information about the specific nature of the abnormality to help us select” a drug or therapy, Dr. Cantor said.

Using attention-deficit/hyperactivity disorder (ADHD) as an example, he said that most current diagnostic and pharmacotherapeutic approaches fail to distinguish between subtle variations.

“Whether a patient has ADD or strictly a hyperactive impulsive problem, or whether they have a combination of both, all of these subtypes get prescribed Ritalin at first pass. It doesn't take a rocket scientist to realize there's something very wrong there. There are subtle differences between these types of people, and there is a different set of abnormal brain physiology features that's contributing to slightly different aspects of their functioning,” he said.

Dr. Cantor said that a growing cross section of psychiatry, psychology, neurology, and other mental health clinicians is placing much more emphasis on the concept of “brain screening” with QEEG to aid diagnosis and therapy decisions. The paradigm shift, however, seems to be occurring faster in countries outside of North America.

“At least in this country, psychiatrists seem largely to have not gotten the word. They're still relying on just tying symptoms to drugs and calling it a day. But there are thousands of clinicians worldwide who are using this already and have been using it for a number of years. A whole commercial industry is being launched that says if you want to be precise about what you're prescribing, you may need to look at the brain first,” he said.

Dr. Cantor disclosed his partnership with BrainDx LLC, which provides QEEG analytic services for health practitioners worldwide. The company is not yet actively selling or distributing its software.

MONTREAL – Psychiatrists can further the quest toward more evidence-based medicine by treating the neurophysiologic origins of behavioral disorders, David Cantor, Ph.D., said at the annual conference of the EEG and Clinical Neuroscience Society.

With the use of quantitative electroencephalography (QEEG) to identify specific abnormalities in brain function, psychiatric therapy can be individualized to address subtleties that may not correlate well with the Diagnostic and Statistical Manual, said Dr. Cantor of Duluth, Ga., who is president of the society.

“Many roads lead to Rome, and there are many different types of abnormal brain physiology that can result in what we call attention-deficit disorder, depression, or any of the other psychiatric disorders,” he said in an interview.

“We need evidence of abnormal brain function in order to show there's a physiologic need for a drug or therapy, and then we need information about the specific nature of the abnormality to help us select” a drug or therapy, Dr. Cantor said.

Using attention-deficit/hyperactivity disorder (ADHD) as an example, he said that most current diagnostic and pharmacotherapeutic approaches fail to distinguish between subtle variations.

“Whether a patient has ADD or strictly a hyperactive impulsive problem, or whether they have a combination of both, all of these subtypes get prescribed Ritalin at first pass. It doesn't take a rocket scientist to realize there's something very wrong there. There are subtle differences between these types of people, and there is a different set of abnormal brain physiology features that's contributing to slightly different aspects of their functioning,” he said.

Dr. Cantor said that a growing cross section of psychiatry, psychology, neurology, and other mental health clinicians is placing much more emphasis on the concept of “brain screening” with QEEG to aid diagnosis and therapy decisions. The paradigm shift, however, seems to be occurring faster in countries outside of North America.

“At least in this country, psychiatrists seem largely to have not gotten the word. They're still relying on just tying symptoms to drugs and calling it a day. But there are thousands of clinicians worldwide who are using this already and have been using it for a number of years. A whole commercial industry is being launched that says if you want to be precise about what you're prescribing, you may need to look at the brain first,” he said.

Dr. Cantor disclosed his partnership with BrainDx LLC, which provides QEEG analytic services for health practitioners worldwide. The company is not yet actively selling or distributing its software.

MONTREAL – Psychiatrists can further the quest toward more evidence-based medicine by treating the neurophysiologic origins of behavioral disorders, David Cantor, Ph.D., said at the annual conference of the EEG and Clinical Neuroscience Society.

With the use of quantitative electroencephalography (QEEG) to identify specific abnormalities in brain function, psychiatric therapy can be individualized to address subtleties that may not correlate well with the Diagnostic and Statistical Manual, said Dr. Cantor of Duluth, Ga., who is president of the society.

“Many roads lead to Rome, and there are many different types of abnormal brain physiology that can result in what we call attention-deficit disorder, depression, or any of the other psychiatric disorders,” he said in an interview.

“We need evidence of abnormal brain function in order to show there's a physiologic need for a drug or therapy, and then we need information about the specific nature of the abnormality to help us select” a drug or therapy, Dr. Cantor said.

Using attention-deficit/hyperactivity disorder (ADHD) as an example, he said that most current diagnostic and pharmacotherapeutic approaches fail to distinguish between subtle variations.

“Whether a patient has ADD or strictly a hyperactive impulsive problem, or whether they have a combination of both, all of these subtypes get prescribed Ritalin at first pass. It doesn't take a rocket scientist to realize there's something very wrong there. There are subtle differences between these types of people, and there is a different set of abnormal brain physiology features that's contributing to slightly different aspects of their functioning,” he said.

Dr. Cantor said that a growing cross section of psychiatry, psychology, neurology, and other mental health clinicians is placing much more emphasis on the concept of “brain screening” with QEEG to aid diagnosis and therapy decisions. The paradigm shift, however, seems to be occurring faster in countries outside of North America.

“At least in this country, psychiatrists seem largely to have not gotten the word. They're still relying on just tying symptoms to drugs and calling it a day. But there are thousands of clinicians worldwide who are using this already and have been using it for a number of years. A whole commercial industry is being launched that says if you want to be precise about what you're prescribing, you may need to look at the brain first,” he said.

Dr. Cantor disclosed his partnership with BrainDx LLC, which provides QEEG analytic services for health practitioners worldwide. The company is not yet actively selling or distributing its software.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, Dr. Eriksson said. However, there was a 24% rate of recurrence within the 5-year follow-up.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, Dr. Eriksson said. However, there was a 24% rate of recurrence within the 5-year follow-up.

MONTREAL — Antibiotic therapy is largely successful for treating acute, nonperforated appendicitis, but unlike surgery, it carries a risk of recurrence, according to long-term follow-up on the first randomized comparison of both treatments, Dr. Staffan Eriksson said at a meeting sponsored by the International Society of Surgery.

“This is a treatment with quite a high number of recurrences, but the treatment may have some advantages. It can be used in patients who do not want surgery, or in patients who are not fit for surgery,” said Dr. Eriksson of Uppsala (Sweden) University. It might also be useful for postponing night surgery until the next day, as has been shown in children, he said.

The multicenter study randomized 252 men, aged 15–50 years, from six Swedish centers, to surgery (124 patients) or antibiotic therapy (128 patients). Excluded from the study were patients in whom there was a high suspicion of perforation.

Patients in the antibiotic group received 2 days of intravenous therapy consisting of cefotaxime 2 g twice daily and tinidazole 0.8 g once daily. This was followed by 10 days of oral antibiotic therapy consisting of ofloxacin 0.2 g twice daily and tinidazole 0.5 g twice daily, he said.

In the surgery group, there was a 5% perforation rate and a 14% complication rate, mainly from wound infection.

The same rate of perforation was noted in the antibiotic group, in which 15 patients were treated surgically, 7 of whom had perforations. The remainder of patients in the antibiotic group (88%) recovered without surgery, Dr. Eriksson said. However, there was a 24% rate of recurrence within the 5-year follow-up.

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey. “This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said.

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey. “This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said.

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim given the fact that overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the study's authors wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, neurologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the study authors stated.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital setting, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when they are caring for uninsured patients. Specialists are also concerned that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, according to the report.

As a result, adverse patient outcomes are reported. One study found that 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability, noted the report. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry, he said, because the risks of liability were more than he could justify.

For Dr. Taylor, it is these very liability risks that are at the root of the current on-call crisis. “The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Until and unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey. “This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said.

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

Emergency on-call coverage from specialist physicians is “unraveling” at hospitals across the country, resulting in delayed treatment, patient transfers, permanent injuries, and even death, according to a study from the Center for Studying Health System Change, a nonpartisan policy research group in Washington.

While the problem is predominantly an issue for hospital emergency departments, it also is becoming increasingly problematic for inpatients who need urgent specialty care, according to the report. The findings are based on 2007 data from 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

The picture is particularly grim because overall ED utilization rates have risen by 7% in the past decade, from 36.9 to 39.6 visits per 100 people, according to the report. While insured people account for the vast majority of ED visits, “the proportion of visits by uninsured people is rising at a relatively higher rate,” the researchers wrote.

Citing a 2006 paper from the American College of Emergency Physicians, the study reported that 73% of emergency departments in the United States report inadequate on-call coverage by specialist physicians. In particularly short supply are neurologists, neurosurgeons, orthopedic surgeons, plastic surgeons, trauma surgeons, hand surgeons, obstetrician-gynecologists, ophthalmologists, and dermatologists. While an actual shortage of such physicians may sometimes be to blame, “physician unwillingness to take call appears to be a more pressing issue for many hospitals,” the authors said.

Although unwillingness to accept on-call duty is largely influenced by quality of life issues, the requirement to provide on-call coverage has traditionally been mandated by hospitals under the Emergency Medical Treatment and Labor Act. However, many specialists are now shifting their practices away from the hospital, and are no longer obligated by medical staff privileges, noted the report's authors.

Many physicians also believe payment for on-call care is inadequate, especially when caring for the uninsured. Specialists also worry that providing emergency care may increase their exposure to medical liability and drive up the cost of their malpractice premiums, the report stated.

One study found 21% of patient deaths or permanent injuries related to ED treatment delays are attributed to lack of specialists' availability. Complete lack of access to specialty care in some EDs is forcing either travel or transfer of patients. And for the physicians who continue to provide on-call coverage, increasing workload and decreasing morale may put patients further at risk.

Crisis May Drive Physicians Away

“It's not a surprise that we're having this problem—it's a surprise to me that we have any on-call specialists at all,” Dr. Todd Taylor, previously an emergency physician and speaker for the ACEP Council, said in an interview. Dr. Taylor left clinical medicine last summer to work in the computer industry because of the risks of liability.

“The liability issue has become the overriding barrier to physicians being willing to put themselves at risk,” he said. “Unless you solve the liability crisis in emergency care and health care in general, nothing else you do matters.”

More troubling than the lack of emergency on-call specialists, he added, is the lack of emergency physicians in general—a newer phenomenon reported earlier this year in the 2007 Daniel Stern & Associates Emergency Medicine Compensation and Benefits Survey.

“This has applied to on-call specialists for years, but the phenomenon is now spreading to core emergency physicians, who are increasingly seeking alternative careers,” Dr. Taylor said, noting 30% of study respondents were considering leaving medicine because of the malpractice climate.

Most on-call specialists have a private practice outside of the emergency department—they don't need the ED—so it's not suprising that they were first to leave, he explained. “But now that core emergency physicians, who were trained to practice only emergency medicine, are making the same choices, that should be a wake-up call,” Dr. Taylor said. “That's what's different now compared to 2 or 3 years ago.”

On-Call Shortage Cripples Trauma Care

Lack of optimal on-call coverage is what will ultimately “cripple” trauma and emergency care, agreed Dr. L.D. Britt, professor of surgery at the Eastern Virginia Medical School in Norfolk. “Some of the specialists are asking for unbelievably exorbitant fees to provide coverage, and hospitals are being held hostage. That's unsustainable for many hospitals—it's a major crisis,” he said in an interview.

While Dr. Britt sympathizes with physicians' struggles with payment and liability issues, he believes the true bottom line is simply that obligations are being overlooked.

“It cannot be everyone saying, 'I can't do this.' Something has to give,” Dr. Britt said. “I consider it my obligation to provide emergency coverage if I am on call. I know that's my responsibility—and I'm a chairman of a department. Some people can find ways out of it, but I'm saying we cannot have all those options out there.”

In addition, high fees charged by specialists and paid by hospitals for on-call coverage are not justified based on the premise that on-call coverage increases a physician's liability exposure, he said. “Being on call doesn't give you more litigation than being in general surgery—that's well documented,” he said.

Dr. Taylor disagreed. “The literature is very clear that emergency care is one of the highest liability environments in health care,” he said. “You only have to look at what's happened to emergency physician malpractice premiums relative to others not involved in emergency care. Mine almost doubled the last 3 years I worked.”

Dr. Britt pointed out that no other country “is spending what we're spending on health care, and yet we're not getting what we should.” But he doubted more spending could solve the problem. “We have an obligation to provide care for the injured and the ill—and if the specialists, rightly or wrongly, say they can't provide that, then we need to come up with a different idea.”

MONTREAL — When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things—like raw meat—that they would not normally eat in the daytime.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders—making the treatment of these conditions quite different, he said. “The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said.

In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight.

MONTREAL — When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things—like raw meat—that they would not normally eat in the daytime.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders—making the treatment of these conditions quite different, he said. “The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said.

In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight.

MONTREAL — When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things—like raw meat—that they would not normally eat in the daytime.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders—making the treatment of these conditions quite different, he said. “The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said.

In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

MONTREAL – When night eating becomes pathological, with harmful effects on sleep and body weight, it is important to differentiate between sleep-related eating disorder and night-eating syndrome, said Dr. Jonathan Fleming, a psychiatrist at the University of British Columbia, Vancouver.

One key difference is that awareness of the awakenings and eating is seen in night-eating syndrome, but not in sleep-related eating disorder, he said at the annual conference of the Canadian Psychiatric Association. Another difference is that sleep-related eating disorder (SRED) is characterized by bizarre eating behavior, which can put the patient in danger.

“A recent patient of mine was found by his wife with the Christmas turkey, which was frozen, trying to carve it with a butter knife,” Dr. Fleming said. “People eat very unusual things–like raw meat–that they would not normally eat in the daytime. They can get up and drive in a confused state, and go pick up food from the store. Or they can cut or burn themselves trying to prepare something.”

Night-eating syndrome (NES) is considered largely an affective illness, but sleep-related eating disorder tends to be associated with sleep disorders–making the treatment of these conditions quite different, Dr. Fleming said.

“The major thought is that NES may be a variant of affective illness with an admixture of a circadian disorder, whereas SRED is particularly associated with sleep apnea and periodic limb movement disorder,” he said.

NES was first described in 1955, in patients seeking weight loss treatment. It occurs in about 1.5% of the population but is particularly prevalent in obese (6%–14%) and morbidly obese (42%) patients. It is characterized by evening hyperphagia, morning anorexia, initial insomnia, and awakenings throughout the night, with clear recall of being hungry and snacking.

There are no randomized controlled trials of treatments, but it is not surprising that case reports suggest chronobiotics (melatonin), antidepressants, appetite suppressants, and even light therapy have all been effective, he said. In contrast, night eating is involuntary and largely unremembered in SRED, and morning anorexia is often characterized by nausea resulting from the unusual foods or toxic substances consumed overnight. Because the underlying etiology is sleep disorder, this is where treatment of SRED is directed, Dr. Fleming said.

Dr. Fleming said he advises use of the parasomnia protocol for SRED patients, which can be remembered with the mnemonic SIS: Secure the bedroom and home environment; avoid intoxicant use; and keep the sleep schedule constant.

MONTREAL — The higher incidence of primary hyperparathyroidism in women, compared with men, appears to be unrelated to the onset of menopause, according to a study of more than 11,000 patients who were surgically treated for the condition.

Previous studies have reported a female-to-male ratio ranging from 3:1 to 5:1 for the condition, and the disproportionate number of women, particularly those over the age of 50, “has been attributed, at least in part, to changes in estrogen and other hormones that occur at the onset of menopause,” said Dr. Barbra Miller, who presented results of a new analysis at a meeting sponsored by the International Society of Surgery.

Dr. Miller, of the University of Michigan Health System in Ann Arbor, said her analysis shows a gradual increase in the female-to-male ratio starting around the age of 26 years and plateauing around the age of 50 years. “We saw no significant change in ratio after the age of 50. This tells us that if hormonal changes were responsible for an increase in females' having primary hyperparathyroidism, we should see a divergence around the age of 50, and instead we see a plateau where the ratio stabilizes,” she said.

The study analyzed 10,190 patients (74% female) from the Nationwide Inpatient Sample (a 20% random sample of all hospital discharges containing multiple data points between 1995 and 1999) and 1,066 patients (74% female) from the University of Michigan endocrine surgery database (1999–2005).

“Since there is no national database that accurately reflects the incidence of primary hyperparathyroidism in the United States, we used surgically treated hyperparathyroidism as a surrogate marker for the condition,” said Dr. Miller, acknowledging that this was one of the study's limitations, along with the fact that the analysis did not capture patients treated nonsurgically.

Both data sets showed an overall female-to-male incidence ratio of 2.8:1, with the ratio beginning a slow divergence at 1.6:1 around the age of 26 years, and continuing until it reached 3:1 at around age 50 years, she said.

The peak incidence for both genders occurred between the ages of 56 and 60 years, reaching 13% among women and 12.2% among men.

“This study sheds new light on the age and sex distribution of primary hyperparathyroidism, and should stimulate new hypotheses regarding the female-to-male ratio,” concluded Dr. Miller.

MONTREAL — The higher incidence of primary hyperparathyroidism in women, compared with men, appears to be unrelated to the onset of menopause, according to a study of more than 11,000 patients who were surgically treated for the condition.

Previous studies have reported a female-to-male ratio ranging from 3:1 to 5:1 for the condition, and the disproportionate number of women, particularly those over the age of 50, “has been attributed, at least in part, to changes in estrogen and other hormones that occur at the onset of menopause,” said Dr. Barbra Miller, who presented results of a new analysis at a meeting sponsored by the International Society of Surgery.

Dr. Miller, of the University of Michigan Health System in Ann Arbor, said her analysis shows a gradual increase in the female-to-male ratio starting around the age of 26 years and plateauing around the age of 50 years. “We saw no significant change in ratio after the age of 50. This tells us that if hormonal changes were responsible for an increase in females' having primary hyperparathyroidism, we should see a divergence around the age of 50, and instead we see a plateau where the ratio stabilizes,” she said.

The study analyzed 10,190 patients (74% female) from the Nationwide Inpatient Sample (a 20% random sample of all hospital discharges containing multiple data points between 1995 and 1999) and 1,066 patients (74% female) from the University of Michigan endocrine surgery database (1999–2005).

“Since there is no national database that accurately reflects the incidence of primary hyperparathyroidism in the United States, we used surgically treated hyperparathyroidism as a surrogate marker for the condition,” said Dr. Miller, acknowledging that this was one of the study's limitations, along with the fact that the analysis did not capture patients treated nonsurgically.

Both data sets showed an overall female-to-male incidence ratio of 2.8:1, with the ratio beginning a slow divergence at 1.6:1 around the age of 26 years, and continuing until it reached 3:1 at around age 50 years, she said.

The peak incidence for both genders occurred between the ages of 56 and 60 years, reaching 13% among women and 12.2% among men.

“This study sheds new light on the age and sex distribution of primary hyperparathyroidism, and should stimulate new hypotheses regarding the female-to-male ratio,” concluded Dr. Miller.

MONTREAL — The higher incidence of primary hyperparathyroidism in women, compared with men, appears to be unrelated to the onset of menopause, according to a study of more than 11,000 patients who were surgically treated for the condition.

Previous studies have reported a female-to-male ratio ranging from 3:1 to 5:1 for the condition, and the disproportionate number of women, particularly those over the age of 50, “has been attributed, at least in part, to changes in estrogen and other hormones that occur at the onset of menopause,” said Dr. Barbra Miller, who presented results of a new analysis at a meeting sponsored by the International Society of Surgery.

Dr. Miller, of the University of Michigan Health System in Ann Arbor, said her analysis shows a gradual increase in the female-to-male ratio starting around the age of 26 years and plateauing around the age of 50 years. “We saw no significant change in ratio after the age of 50. This tells us that if hormonal changes were responsible for an increase in females' having primary hyperparathyroidism, we should see a divergence around the age of 50, and instead we see a plateau where the ratio stabilizes,” she said.

The study analyzed 10,190 patients (74% female) from the Nationwide Inpatient Sample (a 20% random sample of all hospital discharges containing multiple data points between 1995 and 1999) and 1,066 patients (74% female) from the University of Michigan endocrine surgery database (1999–2005).

“Since there is no national database that accurately reflects the incidence of primary hyperparathyroidism in the United States, we used surgically treated hyperparathyroidism as a surrogate marker for the condition,” said Dr. Miller, acknowledging that this was one of the study's limitations, along with the fact that the analysis did not capture patients treated nonsurgically.

Both data sets showed an overall female-to-male incidence ratio of 2.8:1, with the ratio beginning a slow divergence at 1.6:1 around the age of 26 years, and continuing until it reached 3:1 at around age 50 years, she said.

The peak incidence for both genders occurred between the ages of 56 and 60 years, reaching 13% among women and 12.2% among men.

“This study sheds new light on the age and sex distribution of primary hyperparathyroidism, and should stimulate new hypotheses regarding the female-to-male ratio,” concluded Dr. Miller.

TORONTO – Parental discord as seemingly innocuous as frequent belittlement can significantly increase a child's risk of psychological maltreatment, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

Even when children manage to escape the direct consequences of their parents' arguments, simply witnessing parental abuse can cause a ripple effect that seeps into a child's adolescent romances, results of a second study suggested.

“They're witnessing it young, and they're being abused young–and that's where the cycle is starting,” said Christine Forke, R.N., of the Children's Hospital of Philadelphia. “I think we have to intervene very early, as opposed to working with adolescents,” she said in an interview.

Psychological maltreatment–defined as threatening to kick or lock a child out of the house, threatening to leave or abandon a child, or calling a child stupid, ugly, or useless–is the most common form of child abuse linked to intimate partner violence (IPV), reported Dr. Adam J. Zolotor of the family medicine department at the University of North Carolina at Chapel Hill.

In his survey of 1,232 mothers with partners, he found that, compared with nonviolent homes, those with IPV raised the risk of child physical, psychological, and sexual abuse and neglect. (See chart.)

Although physical violence and verbal threatening between partners posed the greatest risk of child psychological maltreatment, with an odds ratio of between 6.67 when the mother was the victim and 8.44 when the partner was the victim, the risks associated with frequent belittling between partners were not that much less, with an odds ratio of 4.88 and 5.83, respectively.

“I actually think it's critical to get at the belittling part when we're talking to parents, but I don't know that there's a standard question or tool,” Dr. Zolotor said in an interview.

Even children who are not themselves abused by their fighting parents seem to be scarred simply by witnessing the abuse, according to Ms. Forke's survey of 901 college students whose mean age was 20 years. She found that 23% reported witnessing adult physical, sexual, or emotional abuse as children (mean age 8 years); of those witnesses, 67% had since experienced intimate partner violence as an adult–either as a victim or a perpetrator.

Compared with nonwitnesses, witnesses were more likely to be victims of physical (29% vs. 14%), sexual (30% vs. 20%), and emotional (38% vs. 22%) abuse. They also were more likely to be perpetrators of physical (24% vs. 8%), sexual (7% vs. 3%), and emotional (12% vs. 5%) abuse. A total of 27% of witnesses reported being both victims and perpetrators of abuse, compared with 11% of nonwitnesses.

The effects of childhood witnessing alone may be subtly different from the reported effects of direct child abuse. “There's clear evidence in the literature that if you're abused as a child, and you are a boy, you grow up to abuse women. And if you're a girl and you're abused as a child, you tend to grow up to be a victim. But our results suggest that if you witness abuse as a child, you could be either a victim or a perpetrator, and gender doesn't seem to be as important,” she said.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Parental discord as seemingly innocuous as frequent belittlement can significantly increase a child's risk of psychological maltreatment, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

Even when children manage to escape the direct consequences of their parents' arguments, simply witnessing parental abuse can cause a ripple effect that seeps into a child's adolescent romances, results of a second study suggested.

“They're witnessing it young, and they're being abused young–and that's where the cycle is starting,” said Christine Forke, R.N., of the Children's Hospital of Philadelphia. “I think we have to intervene very early, as opposed to working with adolescents,” she said in an interview.

Psychological maltreatment–defined as threatening to kick or lock a child out of the house, threatening to leave or abandon a child, or calling a child stupid, ugly, or useless–is the most common form of child abuse linked to intimate partner violence (IPV), reported Dr. Adam J. Zolotor of the family medicine department at the University of North Carolina at Chapel Hill.

In his survey of 1,232 mothers with partners, he found that, compared with nonviolent homes, those with IPV raised the risk of child physical, psychological, and sexual abuse and neglect. (See chart.)

Although physical violence and verbal threatening between partners posed the greatest risk of child psychological maltreatment, with an odds ratio of between 6.67 when the mother was the victim and 8.44 when the partner was the victim, the risks associated with frequent belittling between partners were not that much less, with an odds ratio of 4.88 and 5.83, respectively.

“I actually think it's critical to get at the belittling part when we're talking to parents, but I don't know that there's a standard question or tool,” Dr. Zolotor said in an interview.

Even children who are not themselves abused by their fighting parents seem to be scarred simply by witnessing the abuse, according to Ms. Forke's survey of 901 college students whose mean age was 20 years. She found that 23% reported witnessing adult physical, sexual, or emotional abuse as children (mean age 8 years); of those witnesses, 67% had since experienced intimate partner violence as an adult–either as a victim or a perpetrator.

Compared with nonwitnesses, witnesses were more likely to be victims of physical (29% vs. 14%), sexual (30% vs. 20%), and emotional (38% vs. 22%) abuse. They also were more likely to be perpetrators of physical (24% vs. 8%), sexual (7% vs. 3%), and emotional (12% vs. 5%) abuse. A total of 27% of witnesses reported being both victims and perpetrators of abuse, compared with 11% of nonwitnesses.

The effects of childhood witnessing alone may be subtly different from the reported effects of direct child abuse. “There's clear evidence in the literature that if you're abused as a child, and you are a boy, you grow up to abuse women. And if you're a girl and you're abused as a child, you tend to grow up to be a victim. But our results suggest that if you witness abuse as a child, you could be either a victim or a perpetrator, and gender doesn't seem to be as important,” she said.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO – Parental discord as seemingly innocuous as frequent belittlement can significantly increase a child's risk of psychological maltreatment, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

Even when children manage to escape the direct consequences of their parents' arguments, simply witnessing parental abuse can cause a ripple effect that seeps into a child's adolescent romances, results of a second study suggested.

“They're witnessing it young, and they're being abused young–and that's where the cycle is starting,” said Christine Forke, R.N., of the Children's Hospital of Philadelphia. “I think we have to intervene very early, as opposed to working with adolescents,” she said in an interview.

Psychological maltreatment–defined as threatening to kick or lock a child out of the house, threatening to leave or abandon a child, or calling a child stupid, ugly, or useless–is the most common form of child abuse linked to intimate partner violence (IPV), reported Dr. Adam J. Zolotor of the family medicine department at the University of North Carolina at Chapel Hill.

In his survey of 1,232 mothers with partners, he found that, compared with nonviolent homes, those with IPV raised the risk of child physical, psychological, and sexual abuse and neglect. (See chart.)

Although physical violence and verbal threatening between partners posed the greatest risk of child psychological maltreatment, with an odds ratio of between 6.67 when the mother was the victim and 8.44 when the partner was the victim, the risks associated with frequent belittling between partners were not that much less, with an odds ratio of 4.88 and 5.83, respectively.

“I actually think it's critical to get at the belittling part when we're talking to parents, but I don't know that there's a standard question or tool,” Dr. Zolotor said in an interview.

Even children who are not themselves abused by their fighting parents seem to be scarred simply by witnessing the abuse, according to Ms. Forke's survey of 901 college students whose mean age was 20 years. She found that 23% reported witnessing adult physical, sexual, or emotional abuse as children (mean age 8 years); of those witnesses, 67% had since experienced intimate partner violence as an adult–either as a victim or a perpetrator.

Compared with nonwitnesses, witnesses were more likely to be victims of physical (29% vs. 14%), sexual (30% vs. 20%), and emotional (38% vs. 22%) abuse. They also were more likely to be perpetrators of physical (24% vs. 8%), sexual (7% vs. 3%), and emotional (12% vs. 5%) abuse. A total of 27% of witnesses reported being both victims and perpetrators of abuse, compared with 11% of nonwitnesses.

The effects of childhood witnessing alone may be subtly different from the reported effects of direct child abuse. “There's clear evidence in the literature that if you're abused as a child, and you are a boy, you grow up to abuse women. And if you're a girl and you're abused as a child, you tend to grow up to be a victim. But our results suggest that if you witness abuse as a child, you could be either a victim or a perpetrator, and gender doesn't seem to be as important,” she said.”

ELSEVIER GLOBAL MEDICAL NEWS

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, the schedule can be found at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine is newly recommneded for persons aged 60 years or more, regardless of whether they report a prior episode of herpes zoster. However, the vaccine is contraindicated in pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts of fewer than 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts, according to the document.

Varicella vaccine is now recommended for persons of any age in whom there is no evidence of immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Influenza vaccine recommendations now include people with asplenia.

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, the schedule can be found at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine is newly recommneded for persons aged 60 years or more, regardless of whether they report a prior episode of herpes zoster. However, the vaccine is contraindicated in pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts of fewer than 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts, according to the document.

Varicella vaccine is now recommended for persons of any age in whom there is no evidence of immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Influenza vaccine recommendations now include people with asplenia.

Updated adult immunization recommendations for the October 2007 through September 2008 season include the addition of zoster vaccine and the differentiation of HIV patients based on their CD4+ T-lymphocyte counts.

Developed by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, the schedule can be found at www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Zoster vaccine is newly recommneded for persons aged 60 years or more, regardless of whether they report a prior episode of herpes zoster. However, the vaccine is contraindicated in pregnancy, immunocompromising conditions, and HIV patients with CD4+ T-lymphocyte counts of fewer than 200 cells/mcL. The vaccine is neither recommended nor contraindicated for HIV patients with higher CD4+ T-lymphocyte counts, according to the document.

Varicella vaccine is now recommended for persons of any age in whom there is no evidence of immunity. This recommendation includes persons infected with HIV if their CD4+ T-lymphocyte counts are at least 200 cells/mcL; the vaccine is contraindicated in HIV-infected patients with lower counts, as well as in pregnant women and in patients with other immunocompromising conditions.

Influenza vaccine recommendations now include people with asplenia.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.

Detection rates for advanced colorectal neoplasia were similar in a comparison of screening computed tomographic colonography versus optical colonoscopy, but the numbers of polypectomies and complications were significantly lower with CT colonography, Dr. David H. Kim and colleagues reported.

“CTC [computed tomographic colonography] may provide a more targeted screening approach for detection of advanced neoplasia,” they wrote, describing CTC as “an effective filter for therapeutic OC [optical colonoscopy]” (N. Engl. J. Med. 2007;357:1403–12).

Universal polypectomy at the time of screening OC is widely considered the most effective means of capturing advanced adenomas—benign lesions with a high risk of progression to cancer, according to Dr. Kim, of the University of Wisconsin (Madison) and his colleagues. However, most subcentimeter polyps are not adenomatous, suggesting a need for more selective alternatives to the practice of universal polypectomy, they wrote.

Their study compared results from 3,163 consecutive patients undergoing OC screening and universal polypectomy with 3,120 consecutive patients undergoing CTC screening followed by a choice of same-day therapeutic OC for all polyps of at least 6 mm or CTC surveillance for one or two polyps of 6–9 mm. Within the CTC group, a total of 246 patients (7.9%) were referred for therapeutic OC, whereas 158 patients (5.1%) with a total of 193 polyps chose CTC surveillance.

Detection of polyps measuring 6 mm or more occurred in 12.9% of the CTC group and 13.4% of the OC group, and the prevalence and detection of advanced neoplasms also was similar, at 3.2% in the CTC group and 3.4% in the OC group; the differences were not significant.

However, these detection rates were achieved with the removal of 2,434 polyps in the OC group, compared with just 561 in the primary CTC group. In addition, there were seven colonic perforations in the OC group (0.3%), four of which required surgical repair. There were no serious complications in the CTC group during either the primary examination or subsequent therapeutic OC.

“Our results suggest that primary CTC with selective OC also deserves consideration as a preferred screening strategy because it appears to achieve the same goals of detection and prevention but with the use of substantially fewer resources,” they wrote.

There is limited follow-up data for the subgroup of 158 CTC patients who chose surveillance of their 193 polyps. To date, 54 have returned for follow-up, revealing that 96% of 70 polyps have either remained stable or decreased in size. Three polyps grew at least 1 mm and were removed, but none revealed high-grade dysplasia.

“On the basis of previous experience with CTC screening, approximately 60% of polyps of 6–9 mm detected by CTC would be expected to be adenomatous, and approximately 3% of CTC-detected adenomas of 6–9 mm contain advanced histologic findings,” the authors wrote. “Therefore, we estimated that CTC surveillance would yield three to four advanced adenomas, resulting in a yield of advanced neoplasia among small lesions that was very similar to the yield associated with OC.”

Although detection rates for lesions measuring 6 mm or more were similar for both groups, there was a significant difference in overall detection rates (12.9% in the CTC group vs. 37.6% in the OC group). This is explained by the difference between the two groups in the management of diminutive lesions (measuring 5 mm or less). All such lesions were removed during OC, but were ignored in patients undergoing CTC. Recommendations released by the American Gastroenterological Association Institute Task Force on CT Colonography stipulate that:

▸ Any polyp measuring 6 mm or more at the widest diameter should be reported, and the patient should be referred for consideration of endoscopic polypectomy.

▸ Patients with three or more polyps of any size in the setting of high diagnostic confidence should be referred for consideration of endoscopic polypectomy.

▸ The appropriate clinical management of patients with one or two lesions measuring 5 mm or less is unknown; therefore, the follow-up interval should be based on individual characteristics of the patient and the procedure.