Robert Finn

SAN FRANCISCO – A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, Dr. David Borenstein said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis.

Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In taking a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better–and being right most of the time,” Dr. Borenstein said.

Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography–either a plain x-ray, a CT scan, an MRI, or a bone scan–can be helpful here.

Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

Evaluation of a patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

SAN FRANCISCO – A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, Dr. David Borenstein said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis.

Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In taking a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better–and being right most of the time,” Dr. Borenstein said.

Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography–either a plain x-ray, a CT scan, an MRI, or a bone scan–can be helpful here.

Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

Evaluation of a patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

SAN FRANCISCO – A careful history and physical exam, without the need for lab tests or radiography, can help identify any red flags in patients presenting with low back pain, Dr. David Borenstein said at the annual meeting of the American College of Physicians.

The history can distinguish mechanical from systemic disorders, and the physical exam can distinguish neurologic from nonneurologic conditions, said Dr. Borenstein of George Washington University, Washington.

“Laboratory tests are notably inconsequential,” he said. “When you're taking your history and you don't think they have one of these systemic illnesses, you really don't have to do laboratory tests on these individuals.”

Laboratory tests can be useful in distinguishing inflammatory from noninflammatory disorders, and radiologic tests can confirm a diagnosis derived from other means. But testing can just as easily confuse the issue.

It's critical to quickly identify the 5% or so of patients with cauda equina compression, often associated with an expanding aneurism or a herniated disc because they require emergency surgery. Typically these patients will have urinary retention, incontinence, or saddle anesthesia. In those cases, Dr. Borenstein recommended getting an MRI on an emergent basis.

Results of one recent study showed that patients with cauda equina compression do much better if they get surgery within 48 hours of the start of acute symptoms. Patients whose surgery was delayed often experienced severe and persistent motor deficits, persistent sciatica, and sexual dysfunction (Spine 2000;25:348–51).

In taking a history of a patient with low back pain, five areas of questioning can identify many red flags. If the answers to these constitutional symptom questions are all negative, “you can treat an individual with back pain conservatively without doing an x-ray, without doing lab tests, in fact by telling them they're going to get better–and being right most of the time,” Dr. Borenstein said.

Weight loss and/or fever can signal either vertebral osteomyelitis or a vertebral neoplasm. Radiography–either a plain x-ray, a CT scan, an MRI, or a bone scan–can be helpful here.

Pain at night or with recumbency can signal either a bone tumor or a spinal-cord tumor. “If they tell you pain is worse at night, and they have any neurologic sign, that's a patient for whom I'd get an MRI,” he said.

Morning stiffness that lasts for hours can signal spondyloarthropathy or ankylosing spondylitis. Making this diagnosis is now more critical because effective therapies have recently become available. An x-ray taken with Ferguson's view of the sacroiliac joints is helpful in this diagnosis.

Evaluation of a patient who has acute, localized bone pain, equivalent in intensity to a bone fracture “is one of the few times where our laboratory tests can be helpful,” Dr. Borenstein said. He suggested getting an erythrocyte sedimentation rate, a CBC, and a chemistry profile. These tests can help differentiate the acute fracture of osteoporosis from a tumor, Paget's disease, or sickle cell disease.

Finally, if the patient has viscerogenic pain, the physician should determine whether the pain is colicky, tearing, or episodic. Colicky pain suggests a kidney or gall bladder problem; tearing pain suggests a vascular problem such as an aneurism; and pain that's episodic, coinciding with meals or with the menstrual cycle, suggests pancreatitis, peptic ulcer, or endometriosis.

Only about 10%–15% of patients presenting with lower back pain will have one of those red flags, Dr. Borenstein said. Most whose pain has a mechanical origin will get better within 4–8 weeks with conservative therapy that may consist of NSAIDs plus a muscle relaxant.

In fact, telling patients that they'll soon feel better itself has a therapeutic value. It's also good for them to be up and around as they are able, performing the normal activities of daily living. Studies have shown that patients who get 2 weeks of bed rest do no better than those performing normal activities. Patients should be counseled, however, not to go back to a vigorous exercise routine until the episode abates.

SAN FRANCISCO — Although the Department of Defense conducts a thorough medical screening of each service member returning from a theater of operations, civilian physicians must still be on the lookout for combat-related illnesses, Maj. Robert B. Wenzel, MC, USA, said at the annual meeting of the American Academy of Family Physicians.

Returning service members are so eager to finish the medical screening and be reunited with their families that they often do not focus on the examining physician's questions and concerns, said Dr. Wenzel, commander of the U.S. Army's Butzbach (Germany) Health Clinic.

The initial postdeployment screening is built around a standard DOD form, completed in part by the service member and in part by a DOD physician.

The form collects information on where the individual served and what medical symptoms he or she is experiencing now or experienced during deployment.

Several questions are intended to catch potential cases of posttraumatic stress disorder. For example, service members are asked whether they saw combat, saw people killed, or believed they were in danger of being killed.

After completing their section of the form, service members are seen by a military physician who, by regulation, must spend at least 20 minutes discussing any physical and psychological symptoms. The physician then decides whether to refer a service member to any medical specialists or for any diagnostic procedures.

Service members returning from Afghanistan will receive malaria terminal chemoprophylaxis, typically Plaquenil.

They'll also receive a tuberculin skin test, and anyone who has been deployed for at least 30 days will give a serum sample, which will be stored indefinitely.

“This lesson came out of the Persian Gulf War the first time around, with Gulf War syndrome,” Dr. Wenzel said. “We keep that on file so years from now, when there's a GWOT [Global War on Terror] syndrome, the [DOD] is going to be able to go back, do some research on all these serum samples, and see if we can figure out what's going on.”

Returning service members will also be given a medical briefing which, among other things, will provide them with information about what symptoms of infectious diseases may appear in the coming weeks and months. They are instructed, for example, that if they experience a fever, they shouldn't ignore it; rather, they should see a physician immediately. “There are diseases and bugs and critters in [Iraq and Afghanistan] that modern medicine has forgotten,” he said.

Civilian physicians should ask their patients whether they've recently returned from a combat zone; if so, physicians should consider some uncommon causes of illness (see box), even when the patient presents with seemingly typical flulike symptoms.

Within 90–180 days after returning from deployment, the service member must complete another DOD form that asks about late-appearing symptoms, both physical and psychological.

SAN FRANCISCO — Although the Department of Defense conducts a thorough medical screening of each service member returning from a theater of operations, civilian physicians must still be on the lookout for combat-related illnesses, Maj. Robert B. Wenzel, MC, USA, said at the annual meeting of the American Academy of Family Physicians.

Returning service members are so eager to finish the medical screening and be reunited with their families that they often do not focus on the examining physician's questions and concerns, said Dr. Wenzel, commander of the U.S. Army's Butzbach (Germany) Health Clinic.

The initial postdeployment screening is built around a standard DOD form, completed in part by the service member and in part by a DOD physician.

The form collects information on where the individual served and what medical symptoms he or she is experiencing now or experienced during deployment.

Several questions are intended to catch potential cases of posttraumatic stress disorder. For example, service members are asked whether they saw combat, saw people killed, or believed they were in danger of being killed.

After completing their section of the form, service members are seen by a military physician who, by regulation, must spend at least 20 minutes discussing any physical and psychological symptoms. The physician then decides whether to refer a service member to any medical specialists or for any diagnostic procedures.

Service members returning from Afghanistan will receive malaria terminal chemoprophylaxis, typically Plaquenil.

They'll also receive a tuberculin skin test, and anyone who has been deployed for at least 30 days will give a serum sample, which will be stored indefinitely.

“This lesson came out of the Persian Gulf War the first time around, with Gulf War syndrome,” Dr. Wenzel said. “We keep that on file so years from now, when there's a GWOT [Global War on Terror] syndrome, the [DOD] is going to be able to go back, do some research on all these serum samples, and see if we can figure out what's going on.”

Returning service members will also be given a medical briefing which, among other things, will provide them with information about what symptoms of infectious diseases may appear in the coming weeks and months. They are instructed, for example, that if they experience a fever, they shouldn't ignore it; rather, they should see a physician immediately. “There are diseases and bugs and critters in [Iraq and Afghanistan] that modern medicine has forgotten,” he said.

Civilian physicians should ask their patients whether they've recently returned from a combat zone; if so, physicians should consider some uncommon causes of illness (see box), even when the patient presents with seemingly typical flulike symptoms.

Within 90–180 days after returning from deployment, the service member must complete another DOD form that asks about late-appearing symptoms, both physical and psychological.

SAN FRANCISCO — Although the Department of Defense conducts a thorough medical screening of each service member returning from a theater of operations, civilian physicians must still be on the lookout for combat-related illnesses, Maj. Robert B. Wenzel, MC, USA, said at the annual meeting of the American Academy of Family Physicians.

Returning service members are so eager to finish the medical screening and be reunited with their families that they often do not focus on the examining physician's questions and concerns, said Dr. Wenzel, commander of the U.S. Army's Butzbach (Germany) Health Clinic.

The initial postdeployment screening is built around a standard DOD form, completed in part by the service member and in part by a DOD physician.

The form collects information on where the individual served and what medical symptoms he or she is experiencing now or experienced during deployment.

Several questions are intended to catch potential cases of posttraumatic stress disorder. For example, service members are asked whether they saw combat, saw people killed, or believed they were in danger of being killed.

After completing their section of the form, service members are seen by a military physician who, by regulation, must spend at least 20 minutes discussing any physical and psychological symptoms. The physician then decides whether to refer a service member to any medical specialists or for any diagnostic procedures.

Service members returning from Afghanistan will receive malaria terminal chemoprophylaxis, typically Plaquenil.

They'll also receive a tuberculin skin test, and anyone who has been deployed for at least 30 days will give a serum sample, which will be stored indefinitely.

“This lesson came out of the Persian Gulf War the first time around, with Gulf War syndrome,” Dr. Wenzel said. “We keep that on file so years from now, when there's a GWOT [Global War on Terror] syndrome, the [DOD] is going to be able to go back, do some research on all these serum samples, and see if we can figure out what's going on.”

Returning service members will also be given a medical briefing which, among other things, will provide them with information about what symptoms of infectious diseases may appear in the coming weeks and months. They are instructed, for example, that if they experience a fever, they shouldn't ignore it; rather, they should see a physician immediately. “There are diseases and bugs and critters in [Iraq and Afghanistan] that modern medicine has forgotten,” he said.

Civilian physicians should ask their patients whether they've recently returned from a combat zone; if so, physicians should consider some uncommon causes of illness (see box), even when the patient presents with seemingly typical flulike symptoms.

Within 90–180 days after returning from deployment, the service member must complete another DOD form that asks about late-appearing symptoms, both physical and psychological.

SAN FRANCISCO — Every member of the U.S. armed services undergoes a thorough medical screening before being deployed to a combat zone, Maj. Robert B. Wenzel, M.C., USA, said at the annual meeting of the American Academy of Family Physicians.

Sometimes an active-duty or reserve service member will visit his or her personal physician soon after they receive word that they're about to be deployed, requesting a letter that will excuse them from service.

“Don't waste your time writing that letter,” Dr. Wenzel said. “I'm the Department of Defense [DOD] physician that's going to make a recommendation, and your letter saying that Sgt. Smith shouldn't report means nothing to me.”

Although predeployment screenings are always conducted by DOD medical personnel, there are several ways civilian physicians can become involved, said Dr. Wenzel, commander of the U.S. Army Butzbach (Germany) Health Clinic:

▸ Objective health summary. Civilian physicians can help by providing an objective narrative summary of the patient's condition. Often DOD medical personnel have trouble locating the patient's medical records, and when that happens, the evaluation can be a slow and painful process. An objective medical summary can save the patient—and the military—a great deal of trouble.

When a service member receives a notice of deployment, he or she first reports to a mobilization center for additional training, including a briefing on the medical threats they may encounter.

They spend a full day filling out forms, getting vaccinated, and having various medical evaluations.

“All those movies that you've seen about military-medicine cattle cars, people going from one station to another and getting shots and filling out forms—it's all true,” Dr. Wenzel said. “They walk in with their records, and they go from one station to the next to the next to the next. It is designed to be a very thorough screening before we put them on a plane to Iraq or Afghanistan or one of the other sites.”

▸ Immunizations. Service members must be up to date on the standard vaccines—MMR, polio, meningococcal; those being sent to a theater of operations will receive vaccines against smallpox, hepatitis A, tetanus-diphtheria, typhoid, and influenza (if in season). Until recently an anthrax vaccine was required as well, but in 2004 a federal judge first suspended anthrax vaccinations altogether, and then allowed them with certain restrictions, including one allowing any service member to refuse the anthrax vaccine with no penalty.

Civilian physicians can help by providing patient immunization records. A patient who recently has had a tetanus shot, for example, won't need to have it repeated.

▸ Vision screening. Each service member who needs corrective lenses must have two pairs of glasses and a set of lens inserts for a chemical protective mask. If they don't already have these, they'll receive them at the mobilization site before they're sent overseas.

▸ Hearing screening. “You would be amazed at the number of people who we decide need hearing aids when they show up for their mobilization,” Dr. Wenzel said. “They've been going through life perfectly content not listening to their spouse.”

▸ Dental screening. This is the most common reason for a delay in deployment. Often a service member will be held at the mobilization site for extensive dental work before they can be deployed.

▸ HIV. Everyone receives an HIV test. Those who test positive cannot be sent overseas.

▸ Tuberculin skin test. When they test positive and have no prior history of TB, they're started on medication. Negative tests are used as a baseline. They'll receive another test following the deployment to determine whether they seroconverted while they were gone.

▸ G6PD. Everyone receives a glucose-6-phosphate dehydrogenase test, because some personnel serving in Afghanistan have contracted malaria. Standard malaria medications, such as primaquine, can cause hemolytic anemia in people who have G6PD deficiency.

▸ DNA sampling. A blood sample is collected from every service member and stored in case its DNA is needed to identify remains.

▸ Medications. Before being sent to a theater of operations, every service member must have a 180-day supply of any medications they're taking. In some cases. substitutions may be made, depending on the current DOD formulary.

SAN FRANCISCO — Every member of the U.S. armed services undergoes a thorough medical screening before being deployed to a combat zone, Maj. Robert B. Wenzel, M.C., USA, said at the annual meeting of the American Academy of Family Physicians.

Sometimes an active-duty or reserve service member will visit his or her personal physician soon after they receive word that they're about to be deployed, requesting a letter that will excuse them from service.

“Don't waste your time writing that letter,” Dr. Wenzel said. “I'm the Department of Defense [DOD] physician that's going to make a recommendation, and your letter saying that Sgt. Smith shouldn't report means nothing to me.”

Although predeployment screenings are always conducted by DOD medical personnel, there are several ways civilian physicians can become involved, said Dr. Wenzel, commander of the U.S. Army Butzbach (Germany) Health Clinic:

▸ Objective health summary. Civilian physicians can help by providing an objective narrative summary of the patient's condition. Often DOD medical personnel have trouble locating the patient's medical records, and when that happens, the evaluation can be a slow and painful process. An objective medical summary can save the patient—and the military—a great deal of trouble.

When a service member receives a notice of deployment, he or she first reports to a mobilization center for additional training, including a briefing on the medical threats they may encounter.

They spend a full day filling out forms, getting vaccinated, and having various medical evaluations.

“All those movies that you've seen about military-medicine cattle cars, people going from one station to another and getting shots and filling out forms—it's all true,” Dr. Wenzel said. “They walk in with their records, and they go from one station to the next to the next to the next. It is designed to be a very thorough screening before we put them on a plane to Iraq or Afghanistan or one of the other sites.”

▸ Immunizations. Service members must be up to date on the standard vaccines—MMR, polio, meningococcal; those being sent to a theater of operations will receive vaccines against smallpox, hepatitis A, tetanus-diphtheria, typhoid, and influenza (if in season). Until recently an anthrax vaccine was required as well, but in 2004 a federal judge first suspended anthrax vaccinations altogether, and then allowed them with certain restrictions, including one allowing any service member to refuse the anthrax vaccine with no penalty.

Civilian physicians can help by providing patient immunization records. A patient who recently has had a tetanus shot, for example, won't need to have it repeated.

▸ Vision screening. Each service member who needs corrective lenses must have two pairs of glasses and a set of lens inserts for a chemical protective mask. If they don't already have these, they'll receive them at the mobilization site before they're sent overseas.

▸ Hearing screening. “You would be amazed at the number of people who we decide need hearing aids when they show up for their mobilization,” Dr. Wenzel said. “They've been going through life perfectly content not listening to their spouse.”

▸ Dental screening. This is the most common reason for a delay in deployment. Often a service member will be held at the mobilization site for extensive dental work before they can be deployed.

▸ HIV. Everyone receives an HIV test. Those who test positive cannot be sent overseas.

▸ Tuberculin skin test. When they test positive and have no prior history of TB, they're started on medication. Negative tests are used as a baseline. They'll receive another test following the deployment to determine whether they seroconverted while they were gone.

▸ G6PD. Everyone receives a glucose-6-phosphate dehydrogenase test, because some personnel serving in Afghanistan have contracted malaria. Standard malaria medications, such as primaquine, can cause hemolytic anemia in people who have G6PD deficiency.

▸ DNA sampling. A blood sample is collected from every service member and stored in case its DNA is needed to identify remains.

▸ Medications. Before being sent to a theater of operations, every service member must have a 180-day supply of any medications they're taking. In some cases. substitutions may be made, depending on the current DOD formulary.

SAN FRANCISCO — Every member of the U.S. armed services undergoes a thorough medical screening before being deployed to a combat zone, Maj. Robert B. Wenzel, M.C., USA, said at the annual meeting of the American Academy of Family Physicians.

Sometimes an active-duty or reserve service member will visit his or her personal physician soon after they receive word that they're about to be deployed, requesting a letter that will excuse them from service.

“Don't waste your time writing that letter,” Dr. Wenzel said. “I'm the Department of Defense [DOD] physician that's going to make a recommendation, and your letter saying that Sgt. Smith shouldn't report means nothing to me.”

Although predeployment screenings are always conducted by DOD medical personnel, there are several ways civilian physicians can become involved, said Dr. Wenzel, commander of the U.S. Army Butzbach (Germany) Health Clinic:

▸ Objective health summary. Civilian physicians can help by providing an objective narrative summary of the patient's condition. Often DOD medical personnel have trouble locating the patient's medical records, and when that happens, the evaluation can be a slow and painful process. An objective medical summary can save the patient—and the military—a great deal of trouble.

When a service member receives a notice of deployment, he or she first reports to a mobilization center for additional training, including a briefing on the medical threats they may encounter.

They spend a full day filling out forms, getting vaccinated, and having various medical evaluations.

“All those movies that you've seen about military-medicine cattle cars, people going from one station to another and getting shots and filling out forms—it's all true,” Dr. Wenzel said. “They walk in with their records, and they go from one station to the next to the next to the next. It is designed to be a very thorough screening before we put them on a plane to Iraq or Afghanistan or one of the other sites.”

▸ Immunizations. Service members must be up to date on the standard vaccines—MMR, polio, meningococcal; those being sent to a theater of operations will receive vaccines against smallpox, hepatitis A, tetanus-diphtheria, typhoid, and influenza (if in season). Until recently an anthrax vaccine was required as well, but in 2004 a federal judge first suspended anthrax vaccinations altogether, and then allowed them with certain restrictions, including one allowing any service member to refuse the anthrax vaccine with no penalty.

Civilian physicians can help by providing patient immunization records. A patient who recently has had a tetanus shot, for example, won't need to have it repeated.

▸ Vision screening. Each service member who needs corrective lenses must have two pairs of glasses and a set of lens inserts for a chemical protective mask. If they don't already have these, they'll receive them at the mobilization site before they're sent overseas.

▸ Hearing screening. “You would be amazed at the number of people who we decide need hearing aids when they show up for their mobilization,” Dr. Wenzel said. “They've been going through life perfectly content not listening to their spouse.”

▸ Dental screening. This is the most common reason for a delay in deployment. Often a service member will be held at the mobilization site for extensive dental work before they can be deployed.

▸ HIV. Everyone receives an HIV test. Those who test positive cannot be sent overseas.

▸ Tuberculin skin test. When they test positive and have no prior history of TB, they're started on medication. Negative tests are used as a baseline. They'll receive another test following the deployment to determine whether they seroconverted while they were gone.

▸ G6PD. Everyone receives a glucose-6-phosphate dehydrogenase test, because some personnel serving in Afghanistan have contracted malaria. Standard malaria medications, such as primaquine, can cause hemolytic anemia in people who have G6PD deficiency.

▸ DNA sampling. A blood sample is collected from every service member and stored in case its DNA is needed to identify remains.

▸ Medications. Before being sent to a theater of operations, every service member must have a 180-day supply of any medications they're taking. In some cases. substitutions may be made, depending on the current DOD formulary.

Compared with placebo, β-blockers decrease the risk of stroke by only 19% when used to treat primary hypertension—about half the decrease in risk determined by some previous studies that proved highly influential in the creation of treatment guidelines, according to a metaanalysis of randomized trials involving 105,951 patients.

The metaanalysis also showed that the risk of stroke is 16% higher with β-blocker treatment than with other medications, and that β-blockers offer no advantage in preventing myocardial infarction, reported Dr. Lars Hjalmar Lindholm of Umeå (Sweden) University Hospital, and colleagues (Lancet 2005;366:1545–53).

Considering that other antihypertensives, such as thiazide diuretics and ACE inhibitors, are as effective in reducing blood pressure as are β-blockers, are as inexpensive, and provide greater decreases in the risk of stroke, the authors concluded that β-blockers should not remain the first choice in the treatment of primary hypertension.

In an editorial, Dr. D. Gareth Beevers of City Hospital, Birmingham, England, suggested that many guidelines committees will have to rethink their endorsement of β-blockers for the first-line treatment of primary hypertension. He also said that the National Heart, Lung, and Blood Institute will have to rethink proposals to use β-blockers in long-term outcome studies of the treatment of systolic hypertension (Lancet 2005;366:1510–2).

But Dr. Beevers cautioned that widespread dissemination of this new metaanalysis in the popular media may encourage patients to discontinue β-blockers abruptly. Sudden discontinuation can result in rebound angina and can precipitate myocardial infarction.

Furthermore, some patients, such as those who have an anxiety disorder in addition to hypertension, may experience some symptomatic relief from β-blockers in addition to the antihypertensive effects.

If a physician decides to discontinue a patient's β-blocker, the best strategy would be to do this by down-titration while substituting alternative antihypertensive drugs.

The authors of the metaanalysis speculated on the reasons that β-blockers are less effective than other classes of drugs in reducing the risk of strokes in spite of the fact that they are just as effective in reducing blood pressure.

They noted that although β-blocker treatment reduces brachial blood pressure, it does not reduce central systolic blood pressure as much as ACE inhibitors, diuretics, and calcium antagonists. Regression of left ventricular hypertrophy is more closely associated with patients' central blood pressure than with their brachial blood pressure, the authors asserted.

Compared with placebo, β-blockers decrease the risk of stroke by only 19% when used to treat primary hypertension—about half the decrease in risk determined by some previous studies that proved highly influential in the creation of treatment guidelines, according to a metaanalysis of randomized trials involving 105,951 patients.

The metaanalysis also showed that the risk of stroke is 16% higher with β-blocker treatment than with other medications, and that β-blockers offer no advantage in preventing myocardial infarction, reported Dr. Lars Hjalmar Lindholm of Umeå (Sweden) University Hospital, and colleagues (Lancet 2005;366:1545–53).

Considering that other antihypertensives, such as thiazide diuretics and ACE inhibitors, are as effective in reducing blood pressure as are β-blockers, are as inexpensive, and provide greater decreases in the risk of stroke, the authors concluded that β-blockers should not remain the first choice in the treatment of primary hypertension.

In an editorial, Dr. D. Gareth Beevers of City Hospital, Birmingham, England, suggested that many guidelines committees will have to rethink their endorsement of β-blockers for the first-line treatment of primary hypertension. He also said that the National Heart, Lung, and Blood Institute will have to rethink proposals to use β-blockers in long-term outcome studies of the treatment of systolic hypertension (Lancet 2005;366:1510–2).

But Dr. Beevers cautioned that widespread dissemination of this new metaanalysis in the popular media may encourage patients to discontinue β-blockers abruptly. Sudden discontinuation can result in rebound angina and can precipitate myocardial infarction.

Furthermore, some patients, such as those who have an anxiety disorder in addition to hypertension, may experience some symptomatic relief from β-blockers in addition to the antihypertensive effects.

If a physician decides to discontinue a patient's β-blocker, the best strategy would be to do this by down-titration while substituting alternative antihypertensive drugs.

The authors of the metaanalysis speculated on the reasons that β-blockers are less effective than other classes of drugs in reducing the risk of strokes in spite of the fact that they are just as effective in reducing blood pressure.

They noted that although β-blocker treatment reduces brachial blood pressure, it does not reduce central systolic blood pressure as much as ACE inhibitors, diuretics, and calcium antagonists. Regression of left ventricular hypertrophy is more closely associated with patients' central blood pressure than with their brachial blood pressure, the authors asserted.

Compared with placebo, β-blockers decrease the risk of stroke by only 19% when used to treat primary hypertension—about half the decrease in risk determined by some previous studies that proved highly influential in the creation of treatment guidelines, according to a metaanalysis of randomized trials involving 105,951 patients.

The metaanalysis also showed that the risk of stroke is 16% higher with β-blocker treatment than with other medications, and that β-blockers offer no advantage in preventing myocardial infarction, reported Dr. Lars Hjalmar Lindholm of Umeå (Sweden) University Hospital, and colleagues (Lancet 2005;366:1545–53).

Considering that other antihypertensives, such as thiazide diuretics and ACE inhibitors, are as effective in reducing blood pressure as are β-blockers, are as inexpensive, and provide greater decreases in the risk of stroke, the authors concluded that β-blockers should not remain the first choice in the treatment of primary hypertension.

In an editorial, Dr. D. Gareth Beevers of City Hospital, Birmingham, England, suggested that many guidelines committees will have to rethink their endorsement of β-blockers for the first-line treatment of primary hypertension. He also said that the National Heart, Lung, and Blood Institute will have to rethink proposals to use β-blockers in long-term outcome studies of the treatment of systolic hypertension (Lancet 2005;366:1510–2).

But Dr. Beevers cautioned that widespread dissemination of this new metaanalysis in the popular media may encourage patients to discontinue β-blockers abruptly. Sudden discontinuation can result in rebound angina and can precipitate myocardial infarction.

Furthermore, some patients, such as those who have an anxiety disorder in addition to hypertension, may experience some symptomatic relief from β-blockers in addition to the antihypertensive effects.

If a physician decides to discontinue a patient's β-blocker, the best strategy would be to do this by down-titration while substituting alternative antihypertensive drugs.

The authors of the metaanalysis speculated on the reasons that β-blockers are less effective than other classes of drugs in reducing the risk of strokes in spite of the fact that they are just as effective in reducing blood pressure.

They noted that although β-blocker treatment reduces brachial blood pressure, it does not reduce central systolic blood pressure as much as ACE inhibitors, diuretics, and calcium antagonists. Regression of left ventricular hypertrophy is more closely associated with patients' central blood pressure than with their brachial blood pressure, the authors asserted.

SAN FRANCISCO — The rise in the diagnosis of type 2 diabetes among children is calling attention to certain differences in disease characteristics between children and adults, Dr. Francine Ratner Kaufman, reported at the Third World Congress on Insulin Resistance Syndrome.

In fact, some children seem to have a form of diabetes that's a hybrid between type 1 and type 2, said Dr. Kaufman of the University of Southern California, Los Angeles. Workers in the field have used a variety of designations for this, including “hybrid diabetes,” “double diabetes,” “type 1.5,” and “type 3.”

The typical child with type 1 diabetes will have a positive antibody test and low fasting C-peptide values. The situation is reversed in the typical child with type 2 diabetes-negative antibodies and high fasting C-peptide. But some children have a positive antibody test along with high fasting C-peptide levels. It's those children who have the hybrid form.

“A fair number of these children who come looking as if they have type 2 diabetes also have evidence of islet-cell autoimmunity,” Dr. Kaufman said. “Whether that represents that they have type 1 or type 2 diabetes or that this evidence of antibody is a different phenomenon than it is in the adult population, we don't know.”

Before insulin pumps and refined glucose control, children with type 1 diabetes were typically underweight. Better control means that more of these children are of normal weight, and about 20% may even be obese. That means that obesity alone cannot be used to distinguish type 1 from type 2 disease, even though at least 85% of children with type 2 diabetes are overweight or obese.

Type 2 diabetes seems to take a somewhat different course in children than in adults. In adults the disease is often indolent, preceded by a long asymptomatic period. Screening reveals many adults who have undiagnosed type 2 diabetes. In contrast, at least five studies of overweight children, who would be expected to be at high risk of type 2 diabetes, have found very low rates—6% or less—of undiagnosed type 2 diabetes. This may indicate that children progress more rapidly than do adults through progressive B-cell failure to type 2 diabetes.

A recent study found few parameters that can help distinguish children who have impaired glucose tolerance and will go on to develop type 2 diabetes from those who will revert to normal glucose tolerance (Diabetes Care 2005;28:902–9). The two groups were similar in fasting and postprandial glucose, insulin, and C-peptide levels, for example. The best predictor turned out to be rapid increases in weight and body mass index.

Similarities between the two types, along with the presence of a hybrid form, argue for the “accelerator hypothesis,” which views type 1 and type 2 diabetes as the same disorder of insulin resistance, set against different genetic backgrounds, Dr. Kaufman said.

SAN FRANCISCO — The rise in the diagnosis of type 2 diabetes among children is calling attention to certain differences in disease characteristics between children and adults, Dr. Francine Ratner Kaufman, reported at the Third World Congress on Insulin Resistance Syndrome.

In fact, some children seem to have a form of diabetes that's a hybrid between type 1 and type 2, said Dr. Kaufman of the University of Southern California, Los Angeles. Workers in the field have used a variety of designations for this, including “hybrid diabetes,” “double diabetes,” “type 1.5,” and “type 3.”

The typical child with type 1 diabetes will have a positive antibody test and low fasting C-peptide values. The situation is reversed in the typical child with type 2 diabetes-negative antibodies and high fasting C-peptide. But some children have a positive antibody test along with high fasting C-peptide levels. It's those children who have the hybrid form.

“A fair number of these children who come looking as if they have type 2 diabetes also have evidence of islet-cell autoimmunity,” Dr. Kaufman said. “Whether that represents that they have type 1 or type 2 diabetes or that this evidence of antibody is a different phenomenon than it is in the adult population, we don't know.”

Before insulin pumps and refined glucose control, children with type 1 diabetes were typically underweight. Better control means that more of these children are of normal weight, and about 20% may even be obese. That means that obesity alone cannot be used to distinguish type 1 from type 2 disease, even though at least 85% of children with type 2 diabetes are overweight or obese.

Type 2 diabetes seems to take a somewhat different course in children than in adults. In adults the disease is often indolent, preceded by a long asymptomatic period. Screening reveals many adults who have undiagnosed type 2 diabetes. In contrast, at least five studies of overweight children, who would be expected to be at high risk of type 2 diabetes, have found very low rates—6% or less—of undiagnosed type 2 diabetes. This may indicate that children progress more rapidly than do adults through progressive B-cell failure to type 2 diabetes.

A recent study found few parameters that can help distinguish children who have impaired glucose tolerance and will go on to develop type 2 diabetes from those who will revert to normal glucose tolerance (Diabetes Care 2005;28:902–9). The two groups were similar in fasting and postprandial glucose, insulin, and C-peptide levels, for example. The best predictor turned out to be rapid increases in weight and body mass index.

Similarities between the two types, along with the presence of a hybrid form, argue for the “accelerator hypothesis,” which views type 1 and type 2 diabetes as the same disorder of insulin resistance, set against different genetic backgrounds, Dr. Kaufman said.

SAN FRANCISCO — The rise in the diagnosis of type 2 diabetes among children is calling attention to certain differences in disease characteristics between children and adults, Dr. Francine Ratner Kaufman, reported at the Third World Congress on Insulin Resistance Syndrome.

In fact, some children seem to have a form of diabetes that's a hybrid between type 1 and type 2, said Dr. Kaufman of the University of Southern California, Los Angeles. Workers in the field have used a variety of designations for this, including “hybrid diabetes,” “double diabetes,” “type 1.5,” and “type 3.”

The typical child with type 1 diabetes will have a positive antibody test and low fasting C-peptide values. The situation is reversed in the typical child with type 2 diabetes-negative antibodies and high fasting C-peptide. But some children have a positive antibody test along with high fasting C-peptide levels. It's those children who have the hybrid form.

“A fair number of these children who come looking as if they have type 2 diabetes also have evidence of islet-cell autoimmunity,” Dr. Kaufman said. “Whether that represents that they have type 1 or type 2 diabetes or that this evidence of antibody is a different phenomenon than it is in the adult population, we don't know.”

Before insulin pumps and refined glucose control, children with type 1 diabetes were typically underweight. Better control means that more of these children are of normal weight, and about 20% may even be obese. That means that obesity alone cannot be used to distinguish type 1 from type 2 disease, even though at least 85% of children with type 2 diabetes are overweight or obese.

Type 2 diabetes seems to take a somewhat different course in children than in adults. In adults the disease is often indolent, preceded by a long asymptomatic period. Screening reveals many adults who have undiagnosed type 2 diabetes. In contrast, at least five studies of overweight children, who would be expected to be at high risk of type 2 diabetes, have found very low rates—6% or less—of undiagnosed type 2 diabetes. This may indicate that children progress more rapidly than do adults through progressive B-cell failure to type 2 diabetes.

A recent study found few parameters that can help distinguish children who have impaired glucose tolerance and will go on to develop type 2 diabetes from those who will revert to normal glucose tolerance (Diabetes Care 2005;28:902–9). The two groups were similar in fasting and postprandial glucose, insulin, and C-peptide levels, for example. The best predictor turned out to be rapid increases in weight and body mass index.

Similarities between the two types, along with the presence of a hybrid form, argue for the “accelerator hypothesis,” which views type 1 and type 2 diabetes as the same disorder of insulin resistance, set against different genetic backgrounds, Dr. Kaufman said.

SAN FRANCISCO — Pediatric brain-death guidelines were followed to the letter in only 1 case of 142 that resulted in organ donation during a 5-year period in Southern California, Dr. Mudit Mathur reported at the annual congress of the Society of Critical Care Medicine.

“There is an urgent need for the update and revision of these criteria. … What we need are clear, consistent, uniform, and reliable guidelines in terms of brain-death diagnosis, declaration, documentation, and reporting,” said Dr. Mathur, a pediatric critical care specialist at Loma Linda (Calif.) University Children's Hospital.

The guidelines, issued in 1987 by the American Academy of Pediatrics Task Force on Brain Death in Children, call for the evaluation of 14 clinical elements in determining that a child is brain dead (Arch. Neurol. 1987;44:587–8). (See sidebar.)

A review showed that the charts of the 142 children declared to be brain dead contained documentation of a median of 6 of the 14 elements considered crucial to establishing brain death. Involvement of a pediatric intensivist in the diagnosis did not result in more elements being recorded.

The AAP guidelines call for the diagnosis of brain death to be based on findings from two exams to be conducted at separate times; the physician conducting each exam should evaluate the patient on the 14 clinical elements. The review's findings showed that on the first exam, charts from only 8 of the 142 cases included documentation of more than 10 elements. On the second exam, charts from only three cases included notes on more than 10 elements. In only one case were all 14 elements recorded at both exams.

Also, among the cases studied, the correct age-specific interval was followed only 12% of the time.

Dr. Mathur and his colleagues reviewed the charts of all children referred to OneLegacy, Southern California's organ procurement organization, from January 2000 to December 2004. OneLegacy serves seven Southern California counties that together have a population of 18 million people, 220 hospitals, and 14 transplant centers. Of 277 patients referred during the 5-year period, 142 had organ donation. A majority of those children (80%) were 1 year of age or older.

About a third of the patients were seen in children's hospitals, another third in community hospitals, and the rest in county hospitals, university-affiliated hospitals, and combined adult and children's hospitals. Two-thirds of the patients received their care in a pediatric ICU.

Neurosurgeons and pediatric intensivists were each involved in about 29% of the exams, with internists, neurologists, and/or other physicians involved in the remainder.

Measurement of cerebral blood flow was used to confirm brain death in 73% of 106 cases. Brain death was confirmed by electroencephalogram in 22% of cases. Patients had both exams in only six cases.

“It's not surprising why we have a preference for relying on cerebral blood flow,” Dr. Mathur said. “It's a lot easier to explain this [scan] to a parent than anything else that we do.”

“I must say I find this utterly shocking,” said a member of the audience, who identified himself as a physician from Southampton in the United Kingdom. “We've had a [brain-death] checklist for years.” He said that he was particularly surprised in light of the American reputation for litigiousness.

“I agree that these are shocking data,” Dr. Mathur replied. “However, California law requires in a situation of organ donation that two physicians document that the patient is brain dead. [The law does not] lay out any medical testing or any guidelines or documentation. So if two physicians licensed in the state of California can say a patient is brain dead, that's sufficient. They don't have to specify how they determined it.”

Elements for Brain Death Declaration

In his study, Dr. Mathur and his colleagues examined charts of pediatric organ donors for documentation of the following 14 elements that should be considered before declaring a child to be brain dead, according to 1987 guidelines (Arch. Neurol. 1987;44:587–8):

▸ Documented etiology of coma

▸ Coexistence of coma and apnea

▸ Flaccid tone, no movements

▸ Absence of pupillary reflex

▸ Absence of corneal reflex

▸ Absence of gag reflex

▸ Absence of cough reflex

▸ Absence of eye movement with doll's eye maneuver

▸ Absence of respiratory effort

▸ Absence of hypothermia

▸ Absence of hypotension

▸ Irreversibility of changes

▸ No history of drug or metabolic intoxication

▸ Absence of respiratory effort on apnea test.

Source: Dr. Mathur

SAN FRANCISCO — Pediatric brain-death guidelines were followed to the letter in only 1 case of 142 that resulted in organ donation during a 5-year period in Southern California, Dr. Mudit Mathur reported at the annual congress of the Society of Critical Care Medicine.

“There is an urgent need for the update and revision of these criteria. … What we need are clear, consistent, uniform, and reliable guidelines in terms of brain-death diagnosis, declaration, documentation, and reporting,” said Dr. Mathur, a pediatric critical care specialist at Loma Linda (Calif.) University Children's Hospital.

The guidelines, issued in 1987 by the American Academy of Pediatrics Task Force on Brain Death in Children, call for the evaluation of 14 clinical elements in determining that a child is brain dead (Arch. Neurol. 1987;44:587–8). (See sidebar.)

A review showed that the charts of the 142 children declared to be brain dead contained documentation of a median of 6 of the 14 elements considered crucial to establishing brain death. Involvement of a pediatric intensivist in the diagnosis did not result in more elements being recorded.

The AAP guidelines call for the diagnosis of brain death to be based on findings from two exams to be conducted at separate times; the physician conducting each exam should evaluate the patient on the 14 clinical elements. The review's findings showed that on the first exam, charts from only 8 of the 142 cases included documentation of more than 10 elements. On the second exam, charts from only three cases included notes on more than 10 elements. In only one case were all 14 elements recorded at both exams.

Also, among the cases studied, the correct age-specific interval was followed only 12% of the time.

Dr. Mathur and his colleagues reviewed the charts of all children referred to OneLegacy, Southern California's organ procurement organization, from January 2000 to December 2004. OneLegacy serves seven Southern California counties that together have a population of 18 million people, 220 hospitals, and 14 transplant centers. Of 277 patients referred during the 5-year period, 142 had organ donation. A majority of those children (80%) were 1 year of age or older.

About a third of the patients were seen in children's hospitals, another third in community hospitals, and the rest in county hospitals, university-affiliated hospitals, and combined adult and children's hospitals. Two-thirds of the patients received their care in a pediatric ICU.

Neurosurgeons and pediatric intensivists were each involved in about 29% of the exams, with internists, neurologists, and/or other physicians involved in the remainder.

Measurement of cerebral blood flow was used to confirm brain death in 73% of 106 cases. Brain death was confirmed by electroencephalogram in 22% of cases. Patients had both exams in only six cases.

“It's not surprising why we have a preference for relying on cerebral blood flow,” Dr. Mathur said. “It's a lot easier to explain this [scan] to a parent than anything else that we do.”

“I must say I find this utterly shocking,” said a member of the audience, who identified himself as a physician from Southampton in the United Kingdom. “We've had a [brain-death] checklist for years.” He said that he was particularly surprised in light of the American reputation for litigiousness.

“I agree that these are shocking data,” Dr. Mathur replied. “However, California law requires in a situation of organ donation that two physicians document that the patient is brain dead. [The law does not] lay out any medical testing or any guidelines or documentation. So if two physicians licensed in the state of California can say a patient is brain dead, that's sufficient. They don't have to specify how they determined it.”

Elements for Brain Death Declaration

In his study, Dr. Mathur and his colleagues examined charts of pediatric organ donors for documentation of the following 14 elements that should be considered before declaring a child to be brain dead, according to 1987 guidelines (Arch. Neurol. 1987;44:587–8):

▸ Documented etiology of coma

▸ Coexistence of coma and apnea

▸ Flaccid tone, no movements

▸ Absence of pupillary reflex

▸ Absence of corneal reflex

▸ Absence of gag reflex

▸ Absence of cough reflex

▸ Absence of eye movement with doll's eye maneuver

▸ Absence of respiratory effort

▸ Absence of hypothermia

▸ Absence of hypotension

▸ Irreversibility of changes

▸ No history of drug or metabolic intoxication

▸ Absence of respiratory effort on apnea test.

Source: Dr. Mathur

SAN FRANCISCO — Pediatric brain-death guidelines were followed to the letter in only 1 case of 142 that resulted in organ donation during a 5-year period in Southern California, Dr. Mudit Mathur reported at the annual congress of the Society of Critical Care Medicine.

“There is an urgent need for the update and revision of these criteria. … What we need are clear, consistent, uniform, and reliable guidelines in terms of brain-death diagnosis, declaration, documentation, and reporting,” said Dr. Mathur, a pediatric critical care specialist at Loma Linda (Calif.) University Children's Hospital.

The guidelines, issued in 1987 by the American Academy of Pediatrics Task Force on Brain Death in Children, call for the evaluation of 14 clinical elements in determining that a child is brain dead (Arch. Neurol. 1987;44:587–8). (See sidebar.)

A review showed that the charts of the 142 children declared to be brain dead contained documentation of a median of 6 of the 14 elements considered crucial to establishing brain death. Involvement of a pediatric intensivist in the diagnosis did not result in more elements being recorded.

The AAP guidelines call for the diagnosis of brain death to be based on findings from two exams to be conducted at separate times; the physician conducting each exam should evaluate the patient on the 14 clinical elements. The review's findings showed that on the first exam, charts from only 8 of the 142 cases included documentation of more than 10 elements. On the second exam, charts from only three cases included notes on more than 10 elements. In only one case were all 14 elements recorded at both exams.

Also, among the cases studied, the correct age-specific interval was followed only 12% of the time.

Dr. Mathur and his colleagues reviewed the charts of all children referred to OneLegacy, Southern California's organ procurement organization, from January 2000 to December 2004. OneLegacy serves seven Southern California counties that together have a population of 18 million people, 220 hospitals, and 14 transplant centers. Of 277 patients referred during the 5-year period, 142 had organ donation. A majority of those children (80%) were 1 year of age or older.

About a third of the patients were seen in children's hospitals, another third in community hospitals, and the rest in county hospitals, university-affiliated hospitals, and combined adult and children's hospitals. Two-thirds of the patients received their care in a pediatric ICU.

Neurosurgeons and pediatric intensivists were each involved in about 29% of the exams, with internists, neurologists, and/or other physicians involved in the remainder.

Measurement of cerebral blood flow was used to confirm brain death in 73% of 106 cases. Brain death was confirmed by electroencephalogram in 22% of cases. Patients had both exams in only six cases.

“It's not surprising why we have a preference for relying on cerebral blood flow,” Dr. Mathur said. “It's a lot easier to explain this [scan] to a parent than anything else that we do.”

“I must say I find this utterly shocking,” said a member of the audience, who identified himself as a physician from Southampton in the United Kingdom. “We've had a [brain-death] checklist for years.” He said that he was particularly surprised in light of the American reputation for litigiousness.

“I agree that these are shocking data,” Dr. Mathur replied. “However, California law requires in a situation of organ donation that two physicians document that the patient is brain dead. [The law does not] lay out any medical testing or any guidelines or documentation. So if two physicians licensed in the state of California can say a patient is brain dead, that's sufficient. They don't have to specify how they determined it.”

Elements for Brain Death Declaration

In his study, Dr. Mathur and his colleagues examined charts of pediatric organ donors for documentation of the following 14 elements that should be considered before declaring a child to be brain dead, according to 1987 guidelines (Arch. Neurol. 1987;44:587–8):

▸ Documented etiology of coma

▸ Coexistence of coma and apnea

▸ Flaccid tone, no movements

▸ Absence of pupillary reflex

▸ Absence of corneal reflex

▸ Absence of gag reflex

▸ Absence of cough reflex

▸ Absence of eye movement with doll's eye maneuver

▸ Absence of respiratory effort

▸ Absence of hypothermia

▸ Absence of hypotension

▸ Irreversibility of changes

▸ No history of drug or metabolic intoxication

▸ Absence of respiratory effort on apnea test.

Source: Dr. Mathur

A new study indicates that adolescent anterior knee pain may be a predisposing factor to patellofemoral osteoarthritis many years later.

Physicians have traditionally told patients that adolescent anterior knee pain is usually self-limiting and benign. But the stud and by Dr. Matthew R. Utting his colleagues from Southmead Hospital in Westbury-on-Trym, England, showed that 22% of patients with patellofemoral arthritis who had undergone arthroplasty recalled having anterior knee pain as an adolescent.

In contrast, only 6% of patients who had undergone medial unicompartmental arthroplasty recalled adolescent anterior knee pain, a significant difference (Knee 2005;12:362–5).

The investigators sent questionnaires to 150 patients who had undergone patellofemoral arthroplasty and to another 150 patients who had undergone medial unicompartmental arthroplasty. The response rate was an impressive 77% from the medial unicompartmental arthroplasty group and 79% from the patellofemoral arthroplasty group.

The mean patient age was 67 years in the patellofemoral group and 68 years in the medial unicompartmental arthroplasty group, a difference that was not statistically significant.

Patients in the patellofemoral group experienced a mean of 16 years of pain before the arthroplasty, compared with 9 years for the medial unicompartmental arthroplasty group. Among the patellofemoral group, 16% recalled previous trauma of the patella, compared with 6% of the medial unicompartmental arthroplasty group.

There was no difference in the number of patellar fractures, with two individuals in each group reporting this. Many of the individuals with patellofemoral osteoarthritis reported having symptoms for at least 20 years prior to their arthroplasty, suggesting that the problem had been more or less continuous throughout their lives and that it may have arisen directly from anterior adolescent knee pain.

The investigators noted several limitations of their study. It was retrospective and relied on patients' memories from 40–50 years prior. Furthermore, it's impossible from this study to determine how many people with adolescent anterior knee pain go on to develop patellofemoral osteoarthritis.

A new study indicates that adolescent anterior knee pain may be a predisposing factor to patellofemoral osteoarthritis many years later.

Physicians have traditionally told patients that adolescent anterior knee pain is usually self-limiting and benign. But the stud and by Dr. Matthew R. Utting his colleagues from Southmead Hospital in Westbury-on-Trym, England, showed that 22% of patients with patellofemoral arthritis who had undergone arthroplasty recalled having anterior knee pain as an adolescent.

In contrast, only 6% of patients who had undergone medial unicompartmental arthroplasty recalled adolescent anterior knee pain, a significant difference (Knee 2005;12:362–5).

The investigators sent questionnaires to 150 patients who had undergone patellofemoral arthroplasty and to another 150 patients who had undergone medial unicompartmental arthroplasty. The response rate was an impressive 77% from the medial unicompartmental arthroplasty group and 79% from the patellofemoral arthroplasty group.

The mean patient age was 67 years in the patellofemoral group and 68 years in the medial unicompartmental arthroplasty group, a difference that was not statistically significant.

Patients in the patellofemoral group experienced a mean of 16 years of pain before the arthroplasty, compared with 9 years for the medial unicompartmental arthroplasty group. Among the patellofemoral group, 16% recalled previous trauma of the patella, compared with 6% of the medial unicompartmental arthroplasty group.

There was no difference in the number of patellar fractures, with two individuals in each group reporting this. Many of the individuals with patellofemoral osteoarthritis reported having symptoms for at least 20 years prior to their arthroplasty, suggesting that the problem had been more or less continuous throughout their lives and that it may have arisen directly from anterior adolescent knee pain.

The investigators noted several limitations of their study. It was retrospective and relied on patients' memories from 40–50 years prior. Furthermore, it's impossible from this study to determine how many people with adolescent anterior knee pain go on to develop patellofemoral osteoarthritis.

A new study indicates that adolescent anterior knee pain may be a predisposing factor to patellofemoral osteoarthritis many years later.

Physicians have traditionally told patients that adolescent anterior knee pain is usually self-limiting and benign. But the stud and by Dr. Matthew R. Utting his colleagues from Southmead Hospital in Westbury-on-Trym, England, showed that 22% of patients with patellofemoral arthritis who had undergone arthroplasty recalled having anterior knee pain as an adolescent.

In contrast, only 6% of patients who had undergone medial unicompartmental arthroplasty recalled adolescent anterior knee pain, a significant difference (Knee 2005;12:362–5).

The investigators sent questionnaires to 150 patients who had undergone patellofemoral arthroplasty and to another 150 patients who had undergone medial unicompartmental arthroplasty. The response rate was an impressive 77% from the medial unicompartmental arthroplasty group and 79% from the patellofemoral arthroplasty group.

The mean patient age was 67 years in the patellofemoral group and 68 years in the medial unicompartmental arthroplasty group, a difference that was not statistically significant.

Patients in the patellofemoral group experienced a mean of 16 years of pain before the arthroplasty, compared with 9 years for the medial unicompartmental arthroplasty group. Among the patellofemoral group, 16% recalled previous trauma of the patella, compared with 6% of the medial unicompartmental arthroplasty group.

There was no difference in the number of patellar fractures, with two individuals in each group reporting this. Many of the individuals with patellofemoral osteoarthritis reported having symptoms for at least 20 years prior to their arthroplasty, suggesting that the problem had been more or less continuous throughout their lives and that it may have arisen directly from anterior adolescent knee pain.

The investigators noted several limitations of their study. It was retrospective and relied on patients' memories from 40–50 years prior. Furthermore, it's impossible from this study to determine how many people with adolescent anterior knee pain go on to develop patellofemoral osteoarthritis.

SAN FRANCISCO — Looks can be deceiving when evaluating stenoses for treatment with stenting, Dr. John M. Hodgson said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Not all stenoses detected on angiography are accompanied by ischemia, said Dr. Hodgson of St. Joseph's Hospital, Phoenix. “Two-thirds of the time, when a patient comes to the cath lab we do not have any functional imaging,” he said. “We do not know for sure that the patient has ischemia. And then we're left to interpret these fuzzy, two-dimensional angiograms.”

But the relatively new technology of measuring fractional flow reserve (FFR) during catheterization could help physicians make better informed decisions about revascularization and stenting.

In FFR, a pressure transducer is sent into the coronary artery, past the anatomic lesion. FFR is the transstenotic pressure gradient across a stenosis, measured at peak blood flow after the administration of a vasodilator (such as adenosine) and indexed for aortic driving pressure.

The result is a direct measurement of the influence of a specific lesion on blood flow. Only when the FFR is 0.75 or less, indicating a functional blockage of at least 25%, is stenting helpful.

The value of FFR was shown in a prospective randomized trial that indicated that not only is it safe to not revascularize stable lesions that don't limit blood flow more than 25%, but also that it provides better 24-month outcomes than does angiography (Circulation 2001;103:2928–34).

SAN FRANCISCO — Looks can be deceiving when evaluating stenoses for treatment with stenting, Dr. John M. Hodgson said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Not all stenoses detected on angiography are accompanied by ischemia, said Dr. Hodgson of St. Joseph's Hospital, Phoenix. “Two-thirds of the time, when a patient comes to the cath lab we do not have any functional imaging,” he said. “We do not know for sure that the patient has ischemia. And then we're left to interpret these fuzzy, two-dimensional angiograms.”

But the relatively new technology of measuring fractional flow reserve (FFR) during catheterization could help physicians make better informed decisions about revascularization and stenting.

In FFR, a pressure transducer is sent into the coronary artery, past the anatomic lesion. FFR is the transstenotic pressure gradient across a stenosis, measured at peak blood flow after the administration of a vasodilator (such as adenosine) and indexed for aortic driving pressure.

The result is a direct measurement of the influence of a specific lesion on blood flow. Only when the FFR is 0.75 or less, indicating a functional blockage of at least 25%, is stenting helpful.

The value of FFR was shown in a prospective randomized trial that indicated that not only is it safe to not revascularize stable lesions that don't limit blood flow more than 25%, but also that it provides better 24-month outcomes than does angiography (Circulation 2001;103:2928–34).

SAN FRANCISCO — Looks can be deceiving when evaluating stenoses for treatment with stenting, Dr. John M. Hodgson said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Not all stenoses detected on angiography are accompanied by ischemia, said Dr. Hodgson of St. Joseph's Hospital, Phoenix. “Two-thirds of the time, when a patient comes to the cath lab we do not have any functional imaging,” he said. “We do not know for sure that the patient has ischemia. And then we're left to interpret these fuzzy, two-dimensional angiograms.”

But the relatively new technology of measuring fractional flow reserve (FFR) during catheterization could help physicians make better informed decisions about revascularization and stenting.

In FFR, a pressure transducer is sent into the coronary artery, past the anatomic lesion. FFR is the transstenotic pressure gradient across a stenosis, measured at peak blood flow after the administration of a vasodilator (such as adenosine) and indexed for aortic driving pressure.

The result is a direct measurement of the influence of a specific lesion on blood flow. Only when the FFR is 0.75 or less, indicating a functional blockage of at least 25%, is stenting helpful.

The value of FFR was shown in a prospective randomized trial that indicated that not only is it safe to not revascularize stable lesions that don't limit blood flow more than 25%, but also that it provides better 24-month outcomes than does angiography (Circulation 2001;103:2928–34).

SAN FRANCISCO — Echocardiography provides a great deal of information to help determine a patient's risk following a myocardial infarction, Dr. Thomas Ryan said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Echo and stress echo are not the only ways to risk stratify patients, acknowledged Dr. Ryan of Duke University, Durham, N.C.

“There are a lot of ways we can do it, but I think our goals should be to do it in the most efficient, the most effective, and the most cost-responsible fashion possible,” he said.

Echocardiography provides a variety of perspectives on left ventricular function. It allows for a calculation of ejection fraction. Doppler plus the principle of continuity of flow allows for the measurement of stroke volume across both valves, which in turn allows for the calculation of cardiac output. The contour of the mitral regurgitation depth can be used to measure the rate of change in left ventricular pressure (dP/dt). And finally, one can generate a wall-motion score.

“All of these different approaches to left ventricular systolic function have been shown to be prognostically important … to identify patients at risk and to manage them accordingly,” Dr. Ryan said.

Together, the degree of left ventricular dysfunction and the presence and severity of mitral regurgitation are the most powerful predictors of early risk after acute MI.

The results of a study of more than 3,000 patients in the Duke database show that an echo score derived from these two factors neatly stratifies patients into three categories.

Patients get no points for a good ejection fraction or good mitral regurgitation. They get 2 points each for poor ejection fraction and poor mitral regurgitation, and they get 1 point each for intermediate values. The echo score is the sum of the ejection fraction and mitral regurgitation scores.

Patients with an echo score of 0 have better than 90% 2-year survival. Those with an echo score of 3 or 4 have about a 50% 2-year survival, and those with a score of 1 or 2 have about a 75% 2-year survival.

Diastolic function has prognostic implications as well. If the deceleration time of the mitral P wave is 115 milliseconds or more, then the 30-month survival is 100%. Those with mitral deceleration times of less than 115 milliseconds have a 30-month survival rate of about 40%.

The combination of these measures means that the physician will get a great deal of information even before resorting to stress echocardiography.

Dr. Ryan said that he favors an algorithm based on echocardiography for the predischarge evaluation of patients following an MI. Those with ejection fractions of less than 40% should go to the catheterization laboratory.

If left ventricular function is preserved after an MI, then the management decision can often be made on the basis of the presence or absence of inducible ischemia.

Stress testing allows physicians to distinguish between those patients who should be sent to the catheterization laboratory for consideration for revascularization and those who can be treated medically.

SAN FRANCISCO — Echocardiography provides a great deal of information to help determine a patient's risk following a myocardial infarction, Dr. Thomas Ryan said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Echo and stress echo are not the only ways to risk stratify patients, acknowledged Dr. Ryan of Duke University, Durham, N.C.

“There are a lot of ways we can do it, but I think our goals should be to do it in the most efficient, the most effective, and the most cost-responsible fashion possible,” he said.

Echocardiography provides a variety of perspectives on left ventricular function. It allows for a calculation of ejection fraction. Doppler plus the principle of continuity of flow allows for the measurement of stroke volume across both valves, which in turn allows for the calculation of cardiac output. The contour of the mitral regurgitation depth can be used to measure the rate of change in left ventricular pressure (dP/dt). And finally, one can generate a wall-motion score.

“All of these different approaches to left ventricular systolic function have been shown to be prognostically important … to identify patients at risk and to manage them accordingly,” Dr. Ryan said.

Together, the degree of left ventricular dysfunction and the presence and severity of mitral regurgitation are the most powerful predictors of early risk after acute MI.

The results of a study of more than 3,000 patients in the Duke database show that an echo score derived from these two factors neatly stratifies patients into three categories.

Patients get no points for a good ejection fraction or good mitral regurgitation. They get 2 points each for poor ejection fraction and poor mitral regurgitation, and they get 1 point each for intermediate values. The echo score is the sum of the ejection fraction and mitral regurgitation scores.

Patients with an echo score of 0 have better than 90% 2-year survival. Those with an echo score of 3 or 4 have about a 50% 2-year survival, and those with a score of 1 or 2 have about a 75% 2-year survival.

Diastolic function has prognostic implications as well. If the deceleration time of the mitral P wave is 115 milliseconds or more, then the 30-month survival is 100%. Those with mitral deceleration times of less than 115 milliseconds have a 30-month survival rate of about 40%.

The combination of these measures means that the physician will get a great deal of information even before resorting to stress echocardiography.

Dr. Ryan said that he favors an algorithm based on echocardiography for the predischarge evaluation of patients following an MI. Those with ejection fractions of less than 40% should go to the catheterization laboratory.

If left ventricular function is preserved after an MI, then the management decision can often be made on the basis of the presence or absence of inducible ischemia.

Stress testing allows physicians to distinguish between those patients who should be sent to the catheterization laboratory for consideration for revascularization and those who can be treated medically.

SAN FRANCISCO — Echocardiography provides a great deal of information to help determine a patient's risk following a myocardial infarction, Dr. Thomas Ryan said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

Echo and stress echo are not the only ways to risk stratify patients, acknowledged Dr. Ryan of Duke University, Durham, N.C.

“There are a lot of ways we can do it, but I think our goals should be to do it in the most efficient, the most effective, and the most cost-responsible fashion possible,” he said.

Echocardiography provides a variety of perspectives on left ventricular function. It allows for a calculation of ejection fraction. Doppler plus the principle of continuity of flow allows for the measurement of stroke volume across both valves, which in turn allows for the calculation of cardiac output. The contour of the mitral regurgitation depth can be used to measure the rate of change in left ventricular pressure (dP/dt). And finally, one can generate a wall-motion score.

“All of these different approaches to left ventricular systolic function have been shown to be prognostically important … to identify patients at risk and to manage them accordingly,” Dr. Ryan said.

Together, the degree of left ventricular dysfunction and the presence and severity of mitral regurgitation are the most powerful predictors of early risk after acute MI.

The results of a study of more than 3,000 patients in the Duke database show that an echo score derived from these two factors neatly stratifies patients into three categories.

Patients get no points for a good ejection fraction or good mitral regurgitation. They get 2 points each for poor ejection fraction and poor mitral regurgitation, and they get 1 point each for intermediate values. The echo score is the sum of the ejection fraction and mitral regurgitation scores.

Patients with an echo score of 0 have better than 90% 2-year survival. Those with an echo score of 3 or 4 have about a 50% 2-year survival, and those with a score of 1 or 2 have about a 75% 2-year survival.

Diastolic function has prognostic implications as well. If the deceleration time of the mitral P wave is 115 milliseconds or more, then the 30-month survival is 100%. Those with mitral deceleration times of less than 115 milliseconds have a 30-month survival rate of about 40%.

The combination of these measures means that the physician will get a great deal of information even before resorting to stress echocardiography.

Dr. Ryan said that he favors an algorithm based on echocardiography for the predischarge evaluation of patients following an MI. Those with ejection fractions of less than 40% should go to the catheterization laboratory.

If left ventricular function is preserved after an MI, then the management decision can often be made on the basis of the presence or absence of inducible ischemia.

Stress testing allows physicians to distinguish between those patients who should be sent to the catheterization laboratory for consideration for revascularization and those who can be treated medically.

Although physicians have long recommended bed rest or restricted activity for pregnant women with hypertension, a systematic review of available studies found only weak evidence that this practice benefits women or their children.

In the review, published by the Cochrane Collaboration, Dr. Shireen Meher of the University of Liverpool (UK), and colleagues were able to identify only four studies involving a total of 449 women that directly addressed this issue (Cochrane Database of Systematic Reviews 2005, Issue 4, Art. No. CD003514.pub2. DOI: 10.1002/14651858.CD003514.pub2).

Two of the studies enrolled women hospitalized for preeclampsia (proteinuric hypertension) and compared some rest with strict bed rest. These two trials failed to find any significant differences between the groups on any measure.

The other two trials, one of which the authors described as having “uncertain” quality, compared some bed rest in the hospital with routine activity at home for nonproteinuric hypertension. One of those studies found the risk of severe hypertension reduced by 42% and the risk of preterm birth reduced by 47% in women getting some bed rest in the hospital.

Although those results reached statistical significance, the clinical significance remains unclear, concluded the authors. The results had very wide confidence intervals: 11%–62% reduced risk of severe hypertension and 1%–71% reduced risk of preterm birth.

There were no statistically significant differences between the groups on many other potential outcomes, including miscarriage, perinatal death, severe preeclampsia, placental abruption, elective delivery, endotracheal intubation, and infants who were small for their gestational age.

None of the studies reported any adverse events associated with bed rest. Potential adverse events include thrombosis, muscle atrophy, and bone demineralization.

In addition to these negative medical consequences, bed rest may have other types of negative effects. None of the included studies examined the financial implications of bed rest for women, their families, and the health care system.

The authors concluded that the published studies provide insufficient evidence to provide clear guidance for clinical practice. Thus, they wrote, the evidence base does not support the routine recommendation of bed rest for hypertension in pregnancy.

Bed rest, a time-honored treatment for hypertension during pregnancy is of little benefit, a study review concludes. Stanford W. Carpenter

Although physicians have long recommended bed rest or restricted activity for pregnant women with hypertension, a systematic review of available studies found only weak evidence that this practice benefits women or their children.

In the review, published by the Cochrane Collaboration, Dr. Shireen Meher of the University of Liverpool (UK), and colleagues were able to identify only four studies involving a total of 449 women that directly addressed this issue (Cochrane Database of Systematic Reviews 2005, Issue 4, Art. No. CD003514.pub2. DOI: 10.1002/14651858.CD003514.pub2).

Two of the studies enrolled women hospitalized for preeclampsia (proteinuric hypertension) and compared some rest with strict bed rest. These two trials failed to find any significant differences between the groups on any measure.

The other two trials, one of which the authors described as having “uncertain” quality, compared some bed rest in the hospital with routine activity at home for nonproteinuric hypertension. One of those studies found the risk of severe hypertension reduced by 42% and the risk of preterm birth reduced by 47% in women getting some bed rest in the hospital.

Although those results reached statistical significance, the clinical significance remains unclear, concluded the authors. The results had very wide confidence intervals: 11%–62% reduced risk of severe hypertension and 1%–71% reduced risk of preterm birth.

There were no statistically significant differences between the groups on many other potential outcomes, including miscarriage, perinatal death, severe preeclampsia, placental abruption, elective delivery, endotracheal intubation, and infants who were small for their gestational age.

None of the studies reported any adverse events associated with bed rest. Potential adverse events include thrombosis, muscle atrophy, and bone demineralization.

In addition to these negative medical consequences, bed rest may have other types of negative effects. None of the included studies examined the financial implications of bed rest for women, their families, and the health care system.

The authors concluded that the published studies provide insufficient evidence to provide clear guidance for clinical practice. Thus, they wrote, the evidence base does not support the routine recommendation of bed rest for hypertension in pregnancy.

Bed rest, a time-honored treatment for hypertension during pregnancy is of little benefit, a study review concludes. Stanford W. Carpenter

Although physicians have long recommended bed rest or restricted activity for pregnant women with hypertension, a systematic review of available studies found only weak evidence that this practice benefits women or their children.

In the review, published by the Cochrane Collaboration, Dr. Shireen Meher of the University of Liverpool (UK), and colleagues were able to identify only four studies involving a total of 449 women that directly addressed this issue (Cochrane Database of Systematic Reviews 2005, Issue 4, Art. No. CD003514.pub2. DOI: 10.1002/14651858.CD003514.pub2).

Two of the studies enrolled women hospitalized for preeclampsia (proteinuric hypertension) and compared some rest with strict bed rest. These two trials failed to find any significant differences between the groups on any measure.

The other two trials, one of which the authors described as having “uncertain” quality, compared some bed rest in the hospital with routine activity at home for nonproteinuric hypertension. One of those studies found the risk of severe hypertension reduced by 42% and the risk of preterm birth reduced by 47% in women getting some bed rest in the hospital.

Although those results reached statistical significance, the clinical significance remains unclear, concluded the authors. The results had very wide confidence intervals: 11%–62% reduced risk of severe hypertension and 1%–71% reduced risk of preterm birth.

There were no statistically significant differences between the groups on many other potential outcomes, including miscarriage, perinatal death, severe preeclampsia, placental abruption, elective delivery, endotracheal intubation, and infants who were small for their gestational age.

None of the studies reported any adverse events associated with bed rest. Potential adverse events include thrombosis, muscle atrophy, and bone demineralization.

In addition to these negative medical consequences, bed rest may have other types of negative effects. None of the included studies examined the financial implications of bed rest for women, their families, and the health care system.

The authors concluded that the published studies provide insufficient evidence to provide clear guidance for clinical practice. Thus, they wrote, the evidence base does not support the routine recommendation of bed rest for hypertension in pregnancy.

Bed rest, a time-honored treatment for hypertension during pregnancy is of little benefit, a study review concludes. Stanford W. Carpenter