Robert Finn

SAN FRANCISCO — The use of traditional Chinese medicine is nearly universal among Chinese immigrants living in San Francisco, Amy Wu and Samuel LeBaron, M.D., reported in a poster session at the annual meeting of the American Academy of Family Physicians.

In a survey of 198 patients, self-medication with herbs was the most frequent form of traditional Chinese medicine (TCM), used by 93% of the patients within the past 12 months. Overall, 68% reported self-medication with topical preparations, 33% reported using herbal medications prescribed by a TCM doctor, and 7% reported using topicals prescribed by a TCM doctor.

Also, 14% of the patients reported using acupuncture, 12% massage therapy, 11% tai chi, 7% qigong, and 5% other modalities.

In a parallel study, Ms. Wu (a third-year medical student) and family physician Dr. LeBaron of Stanford (Calif.) University found that of 17 physicians serving those patients, 24% said they asked about TCM rarely, 58% sometimes, and 18% usually.

Since conducting this study, “I find that I'm asking all my Chinese patients now about their use of TCM, which I had not done before,” Dr. LeBaron said in an interview. “More than half of them say yes. They've already been using it for whatever ailment brought them in.”

He acknowledged that he would advise some patients to be cautious in using TCM, including such those with renal or liver disease, patients on multiple medications, or those on medications with many known interactions, such as coumadin.

He described a patient being treated by an oncologist for prostate cancer, and who was also being treated by a TCM doctor with acupuncture and herbal medicine. “I actually brought the list of medications to the TCM doctor—who is well trained in Western medicine—and vice versa, I took the list of herbal preparations to the oncologist, so both of them could see what was going on and make comparisons,” he said. “I also consulted with a pharmacist. So there's a lot of double checking that we should do.”

“We have to put it in perspective too and realize that most likely with our Western medical treatments we're causing far more complications than our patients are getting from TCM. So while we should be cautious about it, we probably should be focusing the majority of our attention on the very Western drugs that we ourselves are using,” Dr. LeBaron said.

SAN FRANCISCO — The use of traditional Chinese medicine is nearly universal among Chinese immigrants living in San Francisco, Amy Wu and Samuel LeBaron, M.D., reported in a poster session at the annual meeting of the American Academy of Family Physicians.

In a survey of 198 patients, self-medication with herbs was the most frequent form of traditional Chinese medicine (TCM), used by 93% of the patients within the past 12 months. Overall, 68% reported self-medication with topical preparations, 33% reported using herbal medications prescribed by a TCM doctor, and 7% reported using topicals prescribed by a TCM doctor.

Also, 14% of the patients reported using acupuncture, 12% massage therapy, 11% tai chi, 7% qigong, and 5% other modalities.

In a parallel study, Ms. Wu (a third-year medical student) and family physician Dr. LeBaron of Stanford (Calif.) University found that of 17 physicians serving those patients, 24% said they asked about TCM rarely, 58% sometimes, and 18% usually.

Since conducting this study, “I find that I'm asking all my Chinese patients now about their use of TCM, which I had not done before,” Dr. LeBaron said in an interview. “More than half of them say yes. They've already been using it for whatever ailment brought them in.”

He acknowledged that he would advise some patients to be cautious in using TCM, including such those with renal or liver disease, patients on multiple medications, or those on medications with many known interactions, such as coumadin.

He described a patient being treated by an oncologist for prostate cancer, and who was also being treated by a TCM doctor with acupuncture and herbal medicine. “I actually brought the list of medications to the TCM doctor—who is well trained in Western medicine—and vice versa, I took the list of herbal preparations to the oncologist, so both of them could see what was going on and make comparisons,” he said. “I also consulted with a pharmacist. So there's a lot of double checking that we should do.”

“We have to put it in perspective too and realize that most likely with our Western medical treatments we're causing far more complications than our patients are getting from TCM. So while we should be cautious about it, we probably should be focusing the majority of our attention on the very Western drugs that we ourselves are using,” Dr. LeBaron said.

SAN FRANCISCO — The use of traditional Chinese medicine is nearly universal among Chinese immigrants living in San Francisco, Amy Wu and Samuel LeBaron, M.D., reported in a poster session at the annual meeting of the American Academy of Family Physicians.

In a survey of 198 patients, self-medication with herbs was the most frequent form of traditional Chinese medicine (TCM), used by 93% of the patients within the past 12 months. Overall, 68% reported self-medication with topical preparations, 33% reported using herbal medications prescribed by a TCM doctor, and 7% reported using topicals prescribed by a TCM doctor.

Also, 14% of the patients reported using acupuncture, 12% massage therapy, 11% tai chi, 7% qigong, and 5% other modalities.

In a parallel study, Ms. Wu (a third-year medical student) and family physician Dr. LeBaron of Stanford (Calif.) University found that of 17 physicians serving those patients, 24% said they asked about TCM rarely, 58% sometimes, and 18% usually.

Since conducting this study, “I find that I'm asking all my Chinese patients now about their use of TCM, which I had not done before,” Dr. LeBaron said in an interview. “More than half of them say yes. They've already been using it for whatever ailment brought them in.”

He acknowledged that he would advise some patients to be cautious in using TCM, including such those with renal or liver disease, patients on multiple medications, or those on medications with many known interactions, such as coumadin.

He described a patient being treated by an oncologist for prostate cancer, and who was also being treated by a TCM doctor with acupuncture and herbal medicine. “I actually brought the list of medications to the TCM doctor—who is well trained in Western medicine—and vice versa, I took the list of herbal preparations to the oncologist, so both of them could see what was going on and make comparisons,” he said. “I also consulted with a pharmacist. So there's a lot of double checking that we should do.”

“We have to put it in perspective too and realize that most likely with our Western medical treatments we're causing far more complications than our patients are getting from TCM. So while we should be cautious about it, we probably should be focusing the majority of our attention on the very Western drugs that we ourselves are using,” Dr. LeBaron said.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

SAN FRANCISCO — Every physician should consider how he or she would manage as the only medical professional in a mass-casualty situation, Lt. Cormac J. O'Connor, MC, USN, said at the annual meeting of the American Academy of Family Physicians.

Dr. O'Connor, a second-year resident in family medicine at Naval Hospital Camp Pendleton (Calif.), offered a mnemonic—SAGGY PRIDE—to help physicians remember the critical steps in managing mass casualties. Dr. O'Connor emphasized that his suggestions are his own and do not represent official positions of the U.S. Navy or the Department of Defense.

SAGGY PRIDE stands for Situational Awareness, Gather a Group and Yell, Plan Rapidly, Issue Directives, and Execute.

A “mass casualty” is any situation in which the number of casualties overwhelms the medical capabilities available. This can range from a single, critically ill person in a remote location to thousands of people in an urban area who are victims of a natural disaster or a terrorist attack.

“Civilian physicians are not trained to deal with mass casualty events,” said Dr. O'Connor, who has served in combat with the U.S. Marine Corps in Iraq. “[Regardless of your specialty] as a physician, you're expected to know what to do.”

Situational Awareness

In less than 1 minute, if possible, you need to get a grasp of what has happened. What is the nature of the calamity? How many people are involved? What is the location's condition and physical layout? What resources are likely to be available?

Gather a Group and Yell

Using a loud voice, identify yourself as a physician and bring all the able-bodied people together. You will not be able to handle the situation alone and will need as much help as you can muster. “You need to be the puppeteer,” Dr. O'Connor said.

Identify any other medically trained personnel available to assist you. You need everybody's help, but you must have control and confidence, something that physicians who practice emergency medicine gain with experience but which may not come as easily to other physicians.

Plan Rapidly

Divide the work. The short game is to do the best for the people who are going to die or suffer a serious injury if you don't act immediately. The long game is to consider how you're going to evacuate all of the injured to a higher level of care.

Triage is the first step in the short game. Don't waste time with people who are not seriously injured; conversely, don't focus your resources on those who are likely to die given the resources you have available.

Extremity exsanguination and pneumothorax are the two major causes of preventable death in mass casualty situations as in combat, Dr. O'Connor said. Since a physician who happens on a mass casualty is unlikely to have the equipment needed to help a patient with pneumothorax, the best thing he or she can do is to keep patients from bleeding to death from a hemorrhage of the extremity.

The best way to do this is to apply direct pressure, but even if you had a group large enough to apply direct pressure to every injured person, consider whether that is the best use of your resources.

The other alternative is to use tourniquets. Dr. O'Connor disagrees that tourniquets use can lead to the loss of a limb. He described one combat casualty he treated who had a leg wound so severe he could see the man's sciatic nerve. He applied a tourniquet that stayed on for a full 8 hours. The man lived and has full use of his leg. Peripheral muscle can stand to be deprived of oxygen for extended periods.

For the long game, think first about communicating to emergency services. These days almost everyone carries a mobile phone, but what are you going to do if cell service is down? Perhaps someone has a working BlackBerry, a CB radio, or maybe there's even a working land line.

Think about how emergency services are going to get to the site and how they're going to leave. Plan a route that gives one way for emergency vehicles (possibly including helicopters) to get in, and another way to get out. Put the people in need of evacuation at sensible collection points, and move less seriously injured people, the dead, and the dying out of the way.

Issue Directives

Be very specific and speak directly to individuals. Don't say, “Somebody, please phone for help,” Dr. O'Connor recommended. Instead say, “Ma'am, I see you have a cell phone. Call 911 right now!”

Have able-bodied people move the dead out of the way, and preferably out of sight. Designate an assistant to move the walking wounded to another location.

If possible, assign someone to stay with those who are likely to die within a short time. Get them to a quiet area. Find somebody who is mature, but who may not be physically very strong, to stay with these folks and comfort them during their last minutes or hours.

Execute

Have a group of worker bees search for heavy extremity bleeding and apply pressure dressings or tourniquets. Instruct them to use any available materials, including belts, shirts, and bras.

Finally, don't forget to continually reevaluate the situation. This may include retriaging the injured as their situations change.

SAN FRANCISCO — Every physician should consider how he or she would manage as the only medical professional in a mass-casualty situation, Lt. Cormac J. O'Connor, MC, USN, said at the annual meeting of the American Academy of Family Physicians.

Dr. O'Connor, a second-year resident in family medicine at Naval Hospital Camp Pendleton (Calif.), offered a mnemonic—SAGGY PRIDE—to help physicians remember the critical steps in managing mass casualties. Dr. O'Connor emphasized that his suggestions are his own and do not represent official positions of the U.S. Navy or the Department of Defense.

SAGGY PRIDE stands for Situational Awareness, Gather a Group and Yell, Plan Rapidly, Issue Directives, and Execute.

A “mass casualty” is any situation in which the number of casualties overwhelms the medical capabilities available. This can range from a single, critically ill person in a remote location to thousands of people in an urban area who are victims of a natural disaster or a terrorist attack.

“Civilian physicians are not trained to deal with mass casualty events,” said Dr. O'Connor, who has served in combat with the U.S. Marine Corps in Iraq. “[Regardless of your specialty] as a physician, you're expected to know what to do.”

Situational Awareness

In less than 1 minute, if possible, you need to get a grasp of what has happened. What is the nature of the calamity? How many people are involved? What is the location's condition and physical layout? What resources are likely to be available?

Gather a Group and Yell

Using a loud voice, identify yourself as a physician and bring all the able-bodied people together. You will not be able to handle the situation alone and will need as much help as you can muster. “You need to be the puppeteer,” Dr. O'Connor said.

Identify any other medically trained personnel available to assist you. You need everybody's help, but you must have control and confidence, something that physicians who practice emergency medicine gain with experience but which may not come as easily to other physicians.

Plan Rapidly

Divide the work. The short game is to do the best for the people who are going to die or suffer a serious injury if you don't act immediately. The long game is to consider how you're going to evacuate all of the injured to a higher level of care.

Triage is the first step in the short game. Don't waste time with people who are not seriously injured; conversely, don't focus your resources on those who are likely to die given the resources you have available.

Extremity exsanguination and pneumothorax are the two major causes of preventable death in mass casualty situations as in combat, Dr. O'Connor said. Since a physician who happens on a mass casualty is unlikely to have the equipment needed to help a patient with pneumothorax, the best thing he or she can do is to keep patients from bleeding to death from a hemorrhage of the extremity.

The best way to do this is to apply direct pressure, but even if you had a group large enough to apply direct pressure to every injured person, consider whether that is the best use of your resources.

The other alternative is to use tourniquets. Dr. O'Connor disagrees that tourniquets use can lead to the loss of a limb. He described one combat casualty he treated who had a leg wound so severe he could see the man's sciatic nerve. He applied a tourniquet that stayed on for a full 8 hours. The man lived and has full use of his leg. Peripheral muscle can stand to be deprived of oxygen for extended periods.

For the long game, think first about communicating to emergency services. These days almost everyone carries a mobile phone, but what are you going to do if cell service is down? Perhaps someone has a working BlackBerry, a CB radio, or maybe there's even a working land line.

Think about how emergency services are going to get to the site and how they're going to leave. Plan a route that gives one way for emergency vehicles (possibly including helicopters) to get in, and another way to get out. Put the people in need of evacuation at sensible collection points, and move less seriously injured people, the dead, and the dying out of the way.

Issue Directives

Be very specific and speak directly to individuals. Don't say, “Somebody, please phone for help,” Dr. O'Connor recommended. Instead say, “Ma'am, I see you have a cell phone. Call 911 right now!”

Have able-bodied people move the dead out of the way, and preferably out of sight. Designate an assistant to move the walking wounded to another location.

If possible, assign someone to stay with those who are likely to die within a short time. Get them to a quiet area. Find somebody who is mature, but who may not be physically very strong, to stay with these folks and comfort them during their last minutes or hours.

Execute

Have a group of worker bees search for heavy extremity bleeding and apply pressure dressings or tourniquets. Instruct them to use any available materials, including belts, shirts, and bras.

Finally, don't forget to continually reevaluate the situation. This may include retriaging the injured as their situations change.

SAN FRANCISCO — Every physician should consider how he or she would manage as the only medical professional in a mass-casualty situation, Lt. Cormac J. O'Connor, MC, USN, said at the annual meeting of the American Academy of Family Physicians.

Dr. O'Connor, a second-year resident in family medicine at Naval Hospital Camp Pendleton (Calif.), offered a mnemonic—SAGGY PRIDE—to help physicians remember the critical steps in managing mass casualties. Dr. O'Connor emphasized that his suggestions are his own and do not represent official positions of the U.S. Navy or the Department of Defense.

SAGGY PRIDE stands for Situational Awareness, Gather a Group and Yell, Plan Rapidly, Issue Directives, and Execute.

A “mass casualty” is any situation in which the number of casualties overwhelms the medical capabilities available. This can range from a single, critically ill person in a remote location to thousands of people in an urban area who are victims of a natural disaster or a terrorist attack.

“Civilian physicians are not trained to deal with mass casualty events,” said Dr. O'Connor, who has served in combat with the U.S. Marine Corps in Iraq. “[Regardless of your specialty] as a physician, you're expected to know what to do.”

Situational Awareness

In less than 1 minute, if possible, you need to get a grasp of what has happened. What is the nature of the calamity? How many people are involved? What is the location's condition and physical layout? What resources are likely to be available?

Gather a Group and Yell

Using a loud voice, identify yourself as a physician and bring all the able-bodied people together. You will not be able to handle the situation alone and will need as much help as you can muster. “You need to be the puppeteer,” Dr. O'Connor said.

Identify any other medically trained personnel available to assist you. You need everybody's help, but you must have control and confidence, something that physicians who practice emergency medicine gain with experience but which may not come as easily to other physicians.

Plan Rapidly

Divide the work. The short game is to do the best for the people who are going to die or suffer a serious injury if you don't act immediately. The long game is to consider how you're going to evacuate all of the injured to a higher level of care.

Triage is the first step in the short game. Don't waste time with people who are not seriously injured; conversely, don't focus your resources on those who are likely to die given the resources you have available.

Extremity exsanguination and pneumothorax are the two major causes of preventable death in mass casualty situations as in combat, Dr. O'Connor said. Since a physician who happens on a mass casualty is unlikely to have the equipment needed to help a patient with pneumothorax, the best thing he or she can do is to keep patients from bleeding to death from a hemorrhage of the extremity.

The best way to do this is to apply direct pressure, but even if you had a group large enough to apply direct pressure to every injured person, consider whether that is the best use of your resources.

The other alternative is to use tourniquets. Dr. O'Connor disagrees that tourniquets use can lead to the loss of a limb. He described one combat casualty he treated who had a leg wound so severe he could see the man's sciatic nerve. He applied a tourniquet that stayed on for a full 8 hours. The man lived and has full use of his leg. Peripheral muscle can stand to be deprived of oxygen for extended periods.

For the long game, think first about communicating to emergency services. These days almost everyone carries a mobile phone, but what are you going to do if cell service is down? Perhaps someone has a working BlackBerry, a CB radio, or maybe there's even a working land line.

Think about how emergency services are going to get to the site and how they're going to leave. Plan a route that gives one way for emergency vehicles (possibly including helicopters) to get in, and another way to get out. Put the people in need of evacuation at sensible collection points, and move less seriously injured people, the dead, and the dying out of the way.

Issue Directives

Be very specific and speak directly to individuals. Don't say, “Somebody, please phone for help,” Dr. O'Connor recommended. Instead say, “Ma'am, I see you have a cell phone. Call 911 right now!”

Have able-bodied people move the dead out of the way, and preferably out of sight. Designate an assistant to move the walking wounded to another location.

If possible, assign someone to stay with those who are likely to die within a short time. Get them to a quiet area. Find somebody who is mature, but who may not be physically very strong, to stay with these folks and comfort them during their last minutes or hours.

Execute

Have a group of worker bees search for heavy extremity bleeding and apply pressure dressings or tourniquets. Instruct them to use any available materials, including belts, shirts, and bras.

Finally, don't forget to continually reevaluate the situation. This may include retriaging the injured as their situations change.

Repeated cycles of a combination of cyclophosphamide and rituximab proved effective in treating severe, recalcitrant systemic lupus erythematosus, according to a study by Kristine P. Ng, M.D., and colleagues at University College London (England).

The study involved seven refractory patients with SLE who underwent a total of 18 cycles of B-cell depletion, with 2 or 3 cycles per patient (Ann. Rheum. Dis. 2005 Nov. 3 [Epub doi.10.1136/ard.2005.044487]).

The regimen for each cycle involved two infusions of rituximab and intravenous cyclophosphamide given 2 weeks apart. One patient did not receive cyclophosphamide because of a previous allergy.

Routine immunosuppressives were stopped prior to the first cycle, but each cycle was accompanied by steroid cover. Mycophenolate was added in three patients after the third cycle, and in a fourth patient after the second cycle. One patient received methotrexate after the first cycle.

Four of seven patients improved clinically 4–6 months following the second cycle. Mean British Isles Lupus Assessment Group (BILAG) global scores dropped from 15 to 6 for all patients. The mean duration of response after the second cycle was 13 months, whereas the mean duration of B-cell depletion was 6 months.

Two of the four responsive patients improved clinically after the third cycle, with global BILAG scores dropping from 10 to 2 in one patient and from 27 to 6 in the other at 7 months. One of the patients relapsed 1 year later, and the other remained healthy without any immunosuppressives 13 months following the third cycle.

The study “gives us an extra leg up on the therapy of recalcitrant lupus, not only lupus nephritis but lupus everything,” Robert Lahita, M.D., noted in an interview.

Dr. Lahita, a rheumatologist and vice president and chairman of medicine at Jersey City (N.J.) Medical Center, was not involved with the study. However, after hearing about the combination therapy at a recent meeting, he treated two recalcitrant SLE patients with rituximab and cyclophosphamide with good results.

“It has worked very nicely,” he said. “The patients feel well, and the only drawback to the Rituxan [rituximab] therapy is maybe an allergic response on occasion. Cytoxan [cyclophosphamide] by itself is what we were using previously. We'd give Cytoxan every month for 6 months. And that gave you results, but it wasn't the same. [Rituxan] gives you a little bit of extra zip. It's like the perfect icing on the cake.”

The downside is that some patients develop leukopenia, which necessitates discontinuing treatment until white cell counts rise back up to around 6,000–7,000 per mcL, he said.

“These are patients who don't respond to anything else and are near death as it is,” Dr. Lahita said. “In most cases, these patients—the recalcitrant ones—would wind up getting bone marrow transplants. And that is really devastating because of the high mortality.”

Dr. Lahita expects B-cell depletion to move beyond patients with highly recalcitrant SLE. “It's a safe treatment, and anything that's safe will be carried forward to other forms of the disease,” he said.

Repeated cycles of a combination of cyclophosphamide and rituximab proved effective in treating severe, recalcitrant systemic lupus erythematosus, according to a study by Kristine P. Ng, M.D., and colleagues at University College London (England).

The study involved seven refractory patients with SLE who underwent a total of 18 cycles of B-cell depletion, with 2 or 3 cycles per patient (Ann. Rheum. Dis. 2005 Nov. 3 [Epub doi.10.1136/ard.2005.044487]).

The regimen for each cycle involved two infusions of rituximab and intravenous cyclophosphamide given 2 weeks apart. One patient did not receive cyclophosphamide because of a previous allergy.

Routine immunosuppressives were stopped prior to the first cycle, but each cycle was accompanied by steroid cover. Mycophenolate was added in three patients after the third cycle, and in a fourth patient after the second cycle. One patient received methotrexate after the first cycle.

Four of seven patients improved clinically 4–6 months following the second cycle. Mean British Isles Lupus Assessment Group (BILAG) global scores dropped from 15 to 6 for all patients. The mean duration of response after the second cycle was 13 months, whereas the mean duration of B-cell depletion was 6 months.

Two of the four responsive patients improved clinically after the third cycle, with global BILAG scores dropping from 10 to 2 in one patient and from 27 to 6 in the other at 7 months. One of the patients relapsed 1 year later, and the other remained healthy without any immunosuppressives 13 months following the third cycle.

The study “gives us an extra leg up on the therapy of recalcitrant lupus, not only lupus nephritis but lupus everything,” Robert Lahita, M.D., noted in an interview.

Dr. Lahita, a rheumatologist and vice president and chairman of medicine at Jersey City (N.J.) Medical Center, was not involved with the study. However, after hearing about the combination therapy at a recent meeting, he treated two recalcitrant SLE patients with rituximab and cyclophosphamide with good results.

“It has worked very nicely,” he said. “The patients feel well, and the only drawback to the Rituxan [rituximab] therapy is maybe an allergic response on occasion. Cytoxan [cyclophosphamide] by itself is what we were using previously. We'd give Cytoxan every month for 6 months. And that gave you results, but it wasn't the same. [Rituxan] gives you a little bit of extra zip. It's like the perfect icing on the cake.”

The downside is that some patients develop leukopenia, which necessitates discontinuing treatment until white cell counts rise back up to around 6,000–7,000 per mcL, he said.

“These are patients who don't respond to anything else and are near death as it is,” Dr. Lahita said. “In most cases, these patients—the recalcitrant ones—would wind up getting bone marrow transplants. And that is really devastating because of the high mortality.”

Dr. Lahita expects B-cell depletion to move beyond patients with highly recalcitrant SLE. “It's a safe treatment, and anything that's safe will be carried forward to other forms of the disease,” he said.

Repeated cycles of a combination of cyclophosphamide and rituximab proved effective in treating severe, recalcitrant systemic lupus erythematosus, according to a study by Kristine P. Ng, M.D., and colleagues at University College London (England).

The study involved seven refractory patients with SLE who underwent a total of 18 cycles of B-cell depletion, with 2 or 3 cycles per patient (Ann. Rheum. Dis. 2005 Nov. 3 [Epub doi.10.1136/ard.2005.044487]).

The regimen for each cycle involved two infusions of rituximab and intravenous cyclophosphamide given 2 weeks apart. One patient did not receive cyclophosphamide because of a previous allergy.

Routine immunosuppressives were stopped prior to the first cycle, but each cycle was accompanied by steroid cover. Mycophenolate was added in three patients after the third cycle, and in a fourth patient after the second cycle. One patient received methotrexate after the first cycle.

Four of seven patients improved clinically 4–6 months following the second cycle. Mean British Isles Lupus Assessment Group (BILAG) global scores dropped from 15 to 6 for all patients. The mean duration of response after the second cycle was 13 months, whereas the mean duration of B-cell depletion was 6 months.

Two of the four responsive patients improved clinically after the third cycle, with global BILAG scores dropping from 10 to 2 in one patient and from 27 to 6 in the other at 7 months. One of the patients relapsed 1 year later, and the other remained healthy without any immunosuppressives 13 months following the third cycle.

The study “gives us an extra leg up on the therapy of recalcitrant lupus, not only lupus nephritis but lupus everything,” Robert Lahita, M.D., noted in an interview.

Dr. Lahita, a rheumatologist and vice president and chairman of medicine at Jersey City (N.J.) Medical Center, was not involved with the study. However, after hearing about the combination therapy at a recent meeting, he treated two recalcitrant SLE patients with rituximab and cyclophosphamide with good results.

“It has worked very nicely,” he said. “The patients feel well, and the only drawback to the Rituxan [rituximab] therapy is maybe an allergic response on occasion. Cytoxan [cyclophosphamide] by itself is what we were using previously. We'd give Cytoxan every month for 6 months. And that gave you results, but it wasn't the same. [Rituxan] gives you a little bit of extra zip. It's like the perfect icing on the cake.”

The downside is that some patients develop leukopenia, which necessitates discontinuing treatment until white cell counts rise back up to around 6,000–7,000 per mcL, he said.

“These are patients who don't respond to anything else and are near death as it is,” Dr. Lahita said. “In most cases, these patients—the recalcitrant ones—would wind up getting bone marrow transplants. And that is really devastating because of the high mortality.”

Dr. Lahita expects B-cell depletion to move beyond patients with highly recalcitrant SLE. “It's a safe treatment, and anything that's safe will be carried forward to other forms of the disease,” he said.

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 should be tested if they have any risk factors. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to that of a healthy young adult. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of −2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of −2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road. “If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown.”

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 should be tested if they have any risk factors. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to that of a healthy young adult. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of −2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of −2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road. “If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown.”

SANTA BARBARA, CALIF. — While it's well known that bone mineral density testing should be routine for women over the age of 65, it can be difficult to decide whether to test other patients and difficult to know what to do with the results, Barbara P. Lukert, M.D., said at a symposium sponsored by the American College of Rheumatology.

The International Society for Clinical Densitometry and the National Osteoporosis Foundation list similar indications for testing bone mineral density (BMD), said Dr. Lukert of the University of Kansas Medical Center, Kansas City. While these guidelines appear straightforward, there are complexities.

The guidelines say that in addition to all women over 65, postmenopausal women under 65 should be tested if they have any risk factors. But studies have not succeeded in identifying all of those risk factors, so in Dr. Lukert's view it's probably prudent to measure BMD in all postmenopausal women.

Premenopausal women, on the other hand, should not have their BMD measured routinely.

The guidelines also call for BMD testing in men over 70. “We know very little about the development of osteoporosis in men, except that we do know that it's much more common than we had previously thought,” Dr. Lukert said. “We aren't measuring bone density in men frequently enough.”

Similarly, the guidelines call for BMD testing in any adult who has had a fragility fracture, but in practice this is done only about 15% of the time, an oversight that Dr. Lukert described as “appalling.”

BMD testing should also be done in adults with any disease or condition associated with bone loss or low bone mass. The conditions include Cushing's disease, hyperthyroidism, hyperparathyroidism, and rheumatoid arthritis.

Some medications are associated with bone loss, most notably the glucocorticoids, and the guidelines say that any adult taking one of these medications should have BMD testing.

Any adult who's being considered for pharmacologic therapy for bone loss should have his or her BMD assessed, and anyone receiving that therapy should have BMD testing to monitor the treatment effect.

“If we follow these indications, we would greatly increase the number of patients who are having their bone density measured,” Dr. Lukert said.

One complexity comes in interpreting the BMD results in some of these groups. For postmenopausal women one typically uses the T score, which compares the individual's BMD to that of a healthy young adult. The T score is expressed in terms of the number of standard deviations the individual's BMD falls above or below this norm. The World Health Organization defines osteoporosis as a T score of −2.5 or below, and osteopenia as a T score between −1 and −2.5.

But in premenopausal women, men aged 50–64 with no risk factors, and men aged 20–50 with risk factors, the use of T scores can be misleading. Instead, one should use the z score, which compares an individual's BMD with that of an age-matched sample. The use of T scores would imply a relationship with fracture risk that may not exist or may differ from group to group. A postmenopausal woman with a certain BMD would have many times the fracture risk of a premenopausal woman with the same BMD.

Once one has a T score or z score, the question becomes whether to treat the patient's osteoporosis or osteopenia. The National Osteoporosis Foundation recommends treating all women with a T score of −2 or below, and women with at least one additional risk factor and a T score of −1.5 or below.

On the other hand, a recent study determined that it was not cost effective to treat osteopenic women because treatment does not significantly reduce their fracture risk over a 5-year period (Ann. Intern. Med. 2005;142:734–41).

But Dr. Lukert pointed out that it's unknown whether pharmacotherapy would improve fracture risk more than 5 years down the road. “If we start treating the patient with a T score of −2 when she is 50 years old, maybe we won't change her fracture rate in the next 5 years, but at 65 will she have a reduced risk for fracture? That is a big unknown.”

SAN FRANCISCO – Opioids are the mainstay of pain treatment at the end of life, but using them in this population presents some challenges, Janet L. Abrahm, M.D., said at the annual meeting of the American College of Physicians.

Dr. Abrahm, codirector of the pain and palliative care program at the Dana-Farber Cancer Institute, Boston, offered a series of pearls on the topic.

▸ Chronic pain doesn't look like acute pain. A person in chronic, severe pain may not have any objective, observable signs. You have to believe the patient, and be alert for behavioral signs. For example, people in pain often guard the painful part of their bodies. They don't eat, sleep, or interact normally.

▸ Don't forget nonpharmacologic therapies. Heat, cold, and massage can all be helpful. Cold seems to work especially well with neuropathic pain. Have a family member fill a foam cup with water, freeze it, and give the patient an ice massage. Heat works well if there's a muscle spasm. Positioning is also important. Help patients take their limbs off their pressure points. Acupuncture has been clearly shown to help with pain, and cognitive-behavioral therapy also is quite effective.

▸ Pharmacokinetic studies have shown that the peak methadone level will not occur for 3–4 days after initiation. The patient will complain of incomplete pain relief for the first few days, and the physician will be tempted to start the medication at too high a dose. But starting at 10 mg three times a day will result in the patient being very sleepy by day 3.

▸ “Don't do what I did and make somebody seize from Demerol,” Dr. Abrahm said. “Demerol [meperidine] is a useless drug for chronic, severe pain.” That's due to its short half-life. A patient who uses it for a couple of days will start to show signs of opioid toxicity.

▸ Myoclonus is one of the early signs of opioid neurotoxicity. Patients may exhibit spontaneous jerking, or they may pull their hand away when touched. “At the end of life that's particularly poignant,” Dr. Abrahm commented. “You might have a family member think that her mother was pulling her hand away, and that she had done something terrible [so] that her mother wouldn't even hold her hand.” Assure the family member that it was just a reflex. Other early signs of opioid neurotoxicity are hypervigilance and hyperalgesia.

▸ If a patient experiences myoclonic jerks from opioid toxicity, it's useful to administer a liter or two of fluids to flush out some of the drug and its metabolites. Then switch the patient to an equal analgesic dose of a different opioid.

▸ Bad dreams also can signal opioid neurotoxicity. Make a practice of asking patients whether they're having nightmares or hallucinations; many will be reluctant to bring up this symptom on their own.

▸ Preventive laxatives are a must when you institute any opioid, even at the level of oxycodone. People in pain don't think about whether they've had a bowel movement. At the end of life, people can even become delirious because they're impacted. “I actually have recommended within the last 3 days of life an enema for someone who was impacted and delirious, and she quieted down and was much more comfortable after that,” Dr. Abrahm said. “The nurses took back all the bad things they said about me.”

Fiber-based laxatives don't work well in these patients because “fiber turns to cement in your gut when you're on opioids,” she said. She prefers using senna; sometimes an osmotic agent will be required. Polyethylene glycol is better than lactulose or sorbitol because it doesn't cause gas or bloating.

▸ For quick pain relief, transmucosal fentanyl can be as fast as intravenous administration. The patient puts this lollipop-like “Oralet” against the inside of his or her gums, where it's dissolved by saliva. It works within 5 or 10 minutes. Manufacturers are working on a more effervescent form of transmucosal fentanyl for patients with inadequate saliva. Patients should be cautioned not to swallow the Oralet because the liver would metabolize most of the drug in that case.

▸ Fentanyl patches also function well, but they need a subcutaneous fat reservoir to work. Elderly patients are often malnourished, and in these patients the fentanyl will simply be absorbed into the bloodstream and quickly metabolized by the liver. That makes the fentanyl patch “a very expensive Band-Aid,” in Dr. Abrahm's words.

Dr. Abrahm acknowledged serving as a consultant to or on the speakers' bureau of a number of pharmaceutical companies that market pain medications.

Dosage Calculations and Conversions

Dr. Abrams offered these suggestions for dealing with dosages:

▸ In switching a patient from one opioid to another, rely on published equivalence charts but lower the calculated dose by one-third to be safe. Different opioids bind slightly differently to receptors, and incomplete cross-tolerance is common, she noted.

▸ The conversion from morphine to methadone depends on whether the patient is on a low dose or a high dose. At low doses of morphine–30 mg per day or so–4 mg of morphine is equivalent to 1 mg of methadone. But at over 1,000 mg of morphine per day, 20 mg of morphine is equivalent to 1 mg of methadone.

▸ When switching a patient from intravenous to oral Dilaudid (hydromorphone hydrochloride), increase the dose by a factor of five. This seems high, but the fact is that the liver metabolizes four-fifths of the oral Dilaudid on its first pass. “Anybody who has been getting 2 mg of intravenous Dilaudid and then gets 4 mg by mouth, you have convinced him that only the shots work,” Dr. Abrahm said.

▸ In converting a patient from oral to intravenous morphine–such as when the patient is coming into the hospital with nothing by mouth–don't forget to include rescue doses in the calculation. If the patient is taking 150 mg of sustained-release morphine every 12 hours, and his or her rescue oral opioid totals 150 mg/day, the total 24-hour morphine dose is 450 mg. That's equivalent to 150 mg IV or 6.25 mg/hr. “It doesn't hurt to put this [calculation] on the chart,” she said, because 6.25 mg/hr seems like a lot to hospital staff.

If this isn't done, patients will normally be started at 1 mg/hr, and Dr. Abrahm said that she has experienced patients going into withdrawal before she could write the higher dose on the chart. The rescue dose should be 10% of the total daily dose every 4 hours. For this patient, that's 15 mg every 4 hours, or more commonly, 5–10 mg every 2 hours.

SAN FRANCISCO – Opioids are the mainstay of pain treatment at the end of life, but using them in this population presents some challenges, Janet L. Abrahm, M.D., said at the annual meeting of the American College of Physicians.

Dr. Abrahm, codirector of the pain and palliative care program at the Dana-Farber Cancer Institute, Boston, offered a series of pearls on the topic.

▸ Chronic pain doesn't look like acute pain. A person in chronic, severe pain may not have any objective, observable signs. You have to believe the patient, and be alert for behavioral signs. For example, people in pain often guard the painful part of their bodies. They don't eat, sleep, or interact normally.

▸ Don't forget nonpharmacologic therapies. Heat, cold, and massage can all be helpful. Cold seems to work especially well with neuropathic pain. Have a family member fill a foam cup with water, freeze it, and give the patient an ice massage. Heat works well if there's a muscle spasm. Positioning is also important. Help patients take their limbs off their pressure points. Acupuncture has been clearly shown to help with pain, and cognitive-behavioral therapy also is quite effective.

▸ Pharmacokinetic studies have shown that the peak methadone level will not occur for 3–4 days after initiation. The patient will complain of incomplete pain relief for the first few days, and the physician will be tempted to start the medication at too high a dose. But starting at 10 mg three times a day will result in the patient being very sleepy by day 3.

▸ “Don't do what I did and make somebody seize from Demerol,” Dr. Abrahm said. “Demerol [meperidine] is a useless drug for chronic, severe pain.” That's due to its short half-life. A patient who uses it for a couple of days will start to show signs of opioid toxicity.

▸ Myoclonus is one of the early signs of opioid neurotoxicity. Patients may exhibit spontaneous jerking, or they may pull their hand away when touched. “At the end of life that's particularly poignant,” Dr. Abrahm commented. “You might have a family member think that her mother was pulling her hand away, and that she had done something terrible [so] that her mother wouldn't even hold her hand.” Assure the family member that it was just a reflex. Other early signs of opioid neurotoxicity are hypervigilance and hyperalgesia.

▸ If a patient experiences myoclonic jerks from opioid toxicity, it's useful to administer a liter or two of fluids to flush out some of the drug and its metabolites. Then switch the patient to an equal analgesic dose of a different opioid.

▸ Bad dreams also can signal opioid neurotoxicity. Make a practice of asking patients whether they're having nightmares or hallucinations; many will be reluctant to bring up this symptom on their own.

▸ Preventive laxatives are a must when you institute any opioid, even at the level of oxycodone. People in pain don't think about whether they've had a bowel movement. At the end of life, people can even become delirious because they're impacted. “I actually have recommended within the last 3 days of life an enema for someone who was impacted and delirious, and she quieted down and was much more comfortable after that,” Dr. Abrahm said. “The nurses took back all the bad things they said about me.”

Fiber-based laxatives don't work well in these patients because “fiber turns to cement in your gut when you're on opioids,” she said. She prefers using senna; sometimes an osmotic agent will be required. Polyethylene glycol is better than lactulose or sorbitol because it doesn't cause gas or bloating.

▸ For quick pain relief, transmucosal fentanyl can be as fast as intravenous administration. The patient puts this lollipop-like “Oralet” against the inside of his or her gums, where it's dissolved by saliva. It works within 5 or 10 minutes. Manufacturers are working on a more effervescent form of transmucosal fentanyl for patients with inadequate saliva. Patients should be cautioned not to swallow the Oralet because the liver would metabolize most of the drug in that case.

▸ Fentanyl patches also function well, but they need a subcutaneous fat reservoir to work. Elderly patients are often malnourished, and in these patients the fentanyl will simply be absorbed into the bloodstream and quickly metabolized by the liver. That makes the fentanyl patch “a very expensive Band-Aid,” in Dr. Abrahm's words.

Dr. Abrahm acknowledged serving as a consultant to or on the speakers' bureau of a number of pharmaceutical companies that market pain medications.

Dosage Calculations and Conversions

Dr. Abrams offered these suggestions for dealing with dosages:

▸ In switching a patient from one opioid to another, rely on published equivalence charts but lower the calculated dose by one-third to be safe. Different opioids bind slightly differently to receptors, and incomplete cross-tolerance is common, she noted.

▸ The conversion from morphine to methadone depends on whether the patient is on a low dose or a high dose. At low doses of morphine–30 mg per day or so–4 mg of morphine is equivalent to 1 mg of methadone. But at over 1,000 mg of morphine per day, 20 mg of morphine is equivalent to 1 mg of methadone.

▸ When switching a patient from intravenous to oral Dilaudid (hydromorphone hydrochloride), increase the dose by a factor of five. This seems high, but the fact is that the liver metabolizes four-fifths of the oral Dilaudid on its first pass. “Anybody who has been getting 2 mg of intravenous Dilaudid and then gets 4 mg by mouth, you have convinced him that only the shots work,” Dr. Abrahm said.

▸ In converting a patient from oral to intravenous morphine–such as when the patient is coming into the hospital with nothing by mouth–don't forget to include rescue doses in the calculation. If the patient is taking 150 mg of sustained-release morphine every 12 hours, and his or her rescue oral opioid totals 150 mg/day, the total 24-hour morphine dose is 450 mg. That's equivalent to 150 mg IV or 6.25 mg/hr. “It doesn't hurt to put this [calculation] on the chart,” she said, because 6.25 mg/hr seems like a lot to hospital staff.

If this isn't done, patients will normally be started at 1 mg/hr, and Dr. Abrahm said that she has experienced patients going into withdrawal before she could write the higher dose on the chart. The rescue dose should be 10% of the total daily dose every 4 hours. For this patient, that's 15 mg every 4 hours, or more commonly, 5–10 mg every 2 hours.

SAN FRANCISCO – Opioids are the mainstay of pain treatment at the end of life, but using them in this population presents some challenges, Janet L. Abrahm, M.D., said at the annual meeting of the American College of Physicians.

Dr. Abrahm, codirector of the pain and palliative care program at the Dana-Farber Cancer Institute, Boston, offered a series of pearls on the topic.

▸ Chronic pain doesn't look like acute pain. A person in chronic, severe pain may not have any objective, observable signs. You have to believe the patient, and be alert for behavioral signs. For example, people in pain often guard the painful part of their bodies. They don't eat, sleep, or interact normally.

▸ Don't forget nonpharmacologic therapies. Heat, cold, and massage can all be helpful. Cold seems to work especially well with neuropathic pain. Have a family member fill a foam cup with water, freeze it, and give the patient an ice massage. Heat works well if there's a muscle spasm. Positioning is also important. Help patients take their limbs off their pressure points. Acupuncture has been clearly shown to help with pain, and cognitive-behavioral therapy also is quite effective.

▸ Pharmacokinetic studies have shown that the peak methadone level will not occur for 3–4 days after initiation. The patient will complain of incomplete pain relief for the first few days, and the physician will be tempted to start the medication at too high a dose. But starting at 10 mg three times a day will result in the patient being very sleepy by day 3.

▸ “Don't do what I did and make somebody seize from Demerol,” Dr. Abrahm said. “Demerol [meperidine] is a useless drug for chronic, severe pain.” That's due to its short half-life. A patient who uses it for a couple of days will start to show signs of opioid toxicity.

▸ Myoclonus is one of the early signs of opioid neurotoxicity. Patients may exhibit spontaneous jerking, or they may pull their hand away when touched. “At the end of life that's particularly poignant,” Dr. Abrahm commented. “You might have a family member think that her mother was pulling her hand away, and that she had done something terrible [so] that her mother wouldn't even hold her hand.” Assure the family member that it was just a reflex. Other early signs of opioid neurotoxicity are hypervigilance and hyperalgesia.

▸ If a patient experiences myoclonic jerks from opioid toxicity, it's useful to administer a liter or two of fluids to flush out some of the drug and its metabolites. Then switch the patient to an equal analgesic dose of a different opioid.

▸ Bad dreams also can signal opioid neurotoxicity. Make a practice of asking patients whether they're having nightmares or hallucinations; many will be reluctant to bring up this symptom on their own.

▸ Preventive laxatives are a must when you institute any opioid, even at the level of oxycodone. People in pain don't think about whether they've had a bowel movement. At the end of life, people can even become delirious because they're impacted. “I actually have recommended within the last 3 days of life an enema for someone who was impacted and delirious, and she quieted down and was much more comfortable after that,” Dr. Abrahm said. “The nurses took back all the bad things they said about me.”

Fiber-based laxatives don't work well in these patients because “fiber turns to cement in your gut when you're on opioids,” she said. She prefers using senna; sometimes an osmotic agent will be required. Polyethylene glycol is better than lactulose or sorbitol because it doesn't cause gas or bloating.

▸ For quick pain relief, transmucosal fentanyl can be as fast as intravenous administration. The patient puts this lollipop-like “Oralet” against the inside of his or her gums, where it's dissolved by saliva. It works within 5 or 10 minutes. Manufacturers are working on a more effervescent form of transmucosal fentanyl for patients with inadequate saliva. Patients should be cautioned not to swallow the Oralet because the liver would metabolize most of the drug in that case.

▸ Fentanyl patches also function well, but they need a subcutaneous fat reservoir to work. Elderly patients are often malnourished, and in these patients the fentanyl will simply be absorbed into the bloodstream and quickly metabolized by the liver. That makes the fentanyl patch “a very expensive Band-Aid,” in Dr. Abrahm's words.

Dr. Abrahm acknowledged serving as a consultant to or on the speakers' bureau of a number of pharmaceutical companies that market pain medications.

Dosage Calculations and Conversions

Dr. Abrams offered these suggestions for dealing with dosages:

▸ In switching a patient from one opioid to another, rely on published equivalence charts but lower the calculated dose by one-third to be safe. Different opioids bind slightly differently to receptors, and incomplete cross-tolerance is common, she noted.

▸ The conversion from morphine to methadone depends on whether the patient is on a low dose or a high dose. At low doses of morphine–30 mg per day or so–4 mg of morphine is equivalent to 1 mg of methadone. But at over 1,000 mg of morphine per day, 20 mg of morphine is equivalent to 1 mg of methadone.

▸ When switching a patient from intravenous to oral Dilaudid (hydromorphone hydrochloride), increase the dose by a factor of five. This seems high, but the fact is that the liver metabolizes four-fifths of the oral Dilaudid on its first pass. “Anybody who has been getting 2 mg of intravenous Dilaudid and then gets 4 mg by mouth, you have convinced him that only the shots work,” Dr. Abrahm said.

▸ In converting a patient from oral to intravenous morphine–such as when the patient is coming into the hospital with nothing by mouth–don't forget to include rescue doses in the calculation. If the patient is taking 150 mg of sustained-release morphine every 12 hours, and his or her rescue oral opioid totals 150 mg/day, the total 24-hour morphine dose is 450 mg. That's equivalent to 150 mg IV or 6.25 mg/hr. “It doesn't hurt to put this [calculation] on the chart,” she said, because 6.25 mg/hr seems like a lot to hospital staff.

If this isn't done, patients will normally be started at 1 mg/hr, and Dr. Abrahm said that she has experienced patients going into withdrawal before she could write the higher dose on the chart. The rescue dose should be 10% of the total daily dose every 4 hours. For this patient, that's 15 mg every 4 hours, or more commonly, 5–10 mg every 2 hours.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000. An injected inactivated polio vaccine (IPV) is used instead in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio.

The safety of the biologic etanercept (Enbrel) doesn't appear to vary depending on the age of the patient taking it for a rheumatic disease, according to the findings from a review of 22 clinical trials.

The investigation, by Roy Fleischmann, M.D., of the University of Texas Southwestern Medical Center at Dallas, and his colleagues, examined data on 3,893 subjects with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.

Most of the clinical trials were controlled, with control patients taking either placebo or methotrexate (Ann. Rheum. Dis. [online] Sept. 21, 2005; http://ard.bmjjournals.com/onlinefirst.shtml

Significantly more subjects aged 65 years and older reported adverse events and serious adverse events whether they were treated with etanercept or not. The rate of medically important adverse events was higher in elderly users and nonusers of the biologic (10% and 7%, respectively), compared with younger users and nonusers (4% and 1%).

But when the data were analyzed to take into account event rates associated with etanercept among control subjects, the only statistically significant difference was a higher proportion of infectious events in younger subjects.

The study was funded by Immunex Corp. and by Wyeth, the manufacturers of etanercept.

The safety of the biologic etanercept (Enbrel) doesn't appear to vary depending on the age of the patient taking it for a rheumatic disease, according to the findings from a review of 22 clinical trials.

The investigation, by Roy Fleischmann, M.D., of the University of Texas Southwestern Medical Center at Dallas, and his colleagues, examined data on 3,893 subjects with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.

Most of the clinical trials were controlled, with control patients taking either placebo or methotrexate (Ann. Rheum. Dis. [online] Sept. 21, 2005; http://ard.bmjjournals.com/onlinefirst.shtml

Significantly more subjects aged 65 years and older reported adverse events and serious adverse events whether they were treated with etanercept or not. The rate of medically important adverse events was higher in elderly users and nonusers of the biologic (10% and 7%, respectively), compared with younger users and nonusers (4% and 1%).

But when the data were analyzed to take into account event rates associated with etanercept among control subjects, the only statistically significant difference was a higher proportion of infectious events in younger subjects.

The study was funded by Immunex Corp. and by Wyeth, the manufacturers of etanercept.

The safety of the biologic etanercept (Enbrel) doesn't appear to vary depending on the age of the patient taking it for a rheumatic disease, according to the findings from a review of 22 clinical trials.

The investigation, by Roy Fleischmann, M.D., of the University of Texas Southwestern Medical Center at Dallas, and his colleagues, examined data on 3,893 subjects with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.

Most of the clinical trials were controlled, with control patients taking either placebo or methotrexate (Ann. Rheum. Dis. [online] Sept. 21, 2005; http://ard.bmjjournals.com/onlinefirst.shtml

Significantly more subjects aged 65 years and older reported adverse events and serious adverse events whether they were treated with etanercept or not. The rate of medically important adverse events was higher in elderly users and nonusers of the biologic (10% and 7%, respectively), compared with younger users and nonusers (4% and 1%).

But when the data were analyzed to take into account event rates associated with etanercept among control subjects, the only statistically significant difference was a higher proportion of infectious events in younger subjects.

The study was funded by Immunex Corp. and by Wyeth, the manufacturers of etanercept.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000.

An injected inactivated polio vaccine (IPV) is used instead, in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000.

An injected inactivated polio vaccine (IPV) is used instead, in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

A small outbreak of poliovirus infection has been reported among unvaccinated children living in rural Minnesota. All cases to date have been linked to the live attentuated virus used in the oral polio vaccine, according to the Minnesota Department of Health and the Centers for Disease Control and Prevention.

Because oral polio vaccine (OPV) is known to cause paralysis in about 1 in every 13 million doses, its use was discontinued in Canada in 1997 and in the United States in 2000.

An injected inactivated polio vaccine (IPV) is used instead, in accordance with recommendations by the CDC's Advisory Committee on Immunization Practices and the American Academy of Pediatrics Committee on Infectious Diseases. But other countries around the world continue to use OPV. Health workers presume that a person vaccinated with OPV in another country was the original source of the outbreak, according to the CDC report.

The five Minnesota children reported to have poliovirus infection are members of a remote Amish community in central Minnesota. The Amish often decline to vaccinate their children. None of the children exhibited the flaccid paralysis that accompanies poliovirus infection in 1 of every 200 cases. The first four cases are described by the CDC (MMWR 2005;54:1053–5) and the fifth case was reported at press time.

The polio outbreak was discovered by chance on Sept. 29, 2005, during testing of a stool sample from a 7-month-old infant with severe combined immunodeficiency disease. Subsequent testing of other community members uncovered infections from the same viral strain in three unvaccinated siblings from an unrelated family, and a fifth unvaccinated child from a third family. All three families are members of the same small Amish community, which includes about 200 members in 24 families.

Partial sequencing of the viral capsid identified it as a type 1 poliovirus derived from one of the three strains in the Sabin oral poliovirus vaccine (OPV). The viral sequence differed from the original vaccine strain by 2.3%. This vaccine is known to mutate at a rate of about 1% per year, suggesting that it's been circulating for 2–3 years.

Although the source of the infection likely was someone who received OPV abroad, none of the infected children or their family members had a recent history of international travel or contact with foreigners, and the central Minnesota Amish community in which the infections occurred has little association with outsiders.

Public health officials have been going door to door in the affected community offering vaccinations. IPV offers protection against the OPV-derived vaccine strain of polio. As of Oct. 14, 2005, fewer than 20 children in the affected community have been vaccinated against polio since this outbreak of disease.

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single proton emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles.

A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of a number of important parameters of cardiac function. (See box.) And numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months.

This low rate of cardiac events is especially impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise.

Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR.

Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk.

SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures the percentage of myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia. This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy.

Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

For any degree of ischemia, the absolute benefit of revascularization compared with medical therapy will vary with several factors, including left ventricular ejection fraction, the extent of viable myocardium, and underlying patient risk. The absolute benefit of revascularization is better for women than for men, better for diabetics than for nondiabetics, and better for elderly patients than for those who are middle aged, for example.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

▸ Percent hypoperfusion

▸ Percent reversibility

▸ Lung-to-heart ratio

▸ Transient ischemic dilatation

▸ Left ventricular mass

▸ Left ventricular ejection fraction

▸ End diastolic volume

▸ End systolic volume

▸ Wall motion

▸ Wall thickening

▸ Peak filling rate

Source: Dr. Berman

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single proton emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles.

A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of a number of important parameters of cardiac function. (See box.) And numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months.

This low rate of cardiac events is especially impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise.

Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR.

Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk.

SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures the percentage of myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia. This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy.

Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

For any degree of ischemia, the absolute benefit of revascularization compared with medical therapy will vary with several factors, including left ventricular ejection fraction, the extent of viable myocardium, and underlying patient risk. The absolute benefit of revascularization is better for women than for men, better for diabetics than for nondiabetics, and better for elderly patients than for those who are middle aged, for example.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

▸ Percent hypoperfusion

▸ Percent reversibility

▸ Lung-to-heart ratio

▸ Transient ischemic dilatation

▸ Left ventricular mass

▸ Left ventricular ejection fraction

▸ End diastolic volume

▸ End systolic volume

▸ Wall motion

▸ Wall thickening

▸ Peak filling rate

Source: Dr. Berman

SAN FRANCISCO — Quantitative nuclear cardiology allows for highly sensitive, specific, and reproducible estimates of a patient's risk, and assists in the decision of who should be sent for revascularization, Daniel S. Berman, M.D., said at a cardiovascular imaging conference sponsored by the American College of Cardiology.

When quantitative techniques are used with single proton emission computed tomography (SPECT), the results are operator independent, said Dr. Berman of Cedars-Sinai Medical Center, Los Angeles.

A quantitative SPECT assessment of myocardial perfusion and function reduces the reliance on expert observers, standardizes results from center to center, facilitates serial assessments, and ultimately improves patient outcomes.

The technology produces reliable assessments of a number of important parameters of cardiac function. (See box.) And numerous studies have shown how these parameters relate to cardiac risk.

For example, pooled data from more than 17,000 patients show that those with a normal stress myocardial perfusion SPECT had only a 0.6% chance of suffering cardiac death or a nonfatal MI over a mean follow-up of 27 months.

This low rate of cardiac events is especially impressive because these were patients with known or suspected coronary artery disease.

This study included patients who were under either exercise or pharmacologic stress. According to another study, a normal stress myocardial perfusion SPECT has less prognostic value if the patient fails to reach at least 70% of the predicted maximal heart rate (PMHR) during exercise.

Among more than 5,000 patients, the cardiac event rate for patients who failed to reach 70% PMHR was more than three times that of those who reached 70%–100% PMHR.

Patients who are unable to reach 70% PMHR during exercise need to undergo myocardial perfusion SPECT with pharmacologic stress, Dr. Berman said.

The presence of diabetes is another factor that modifies a patient's risk after myocardial perfusion SPECT. For any given summed stress score (SSS)—an estimate of the overall size and severity of a perfusion defect during stress—nondiabetics have the lowest level of risk, insulin-dependent diabetics have the highest level of risk, and non-insulin-dependent diabetics have an intermediate risk.

SSS alone isn't enough, however. The summed difference score, which subtracts the summed rest score from the SSS, is a more reliable measure.

Better still is to normalize these scores based on the maximum possible score. This yields measures the percentage of myocardium perfused that are independent of the specific SPECT system employed. When applied to the summed difference score, the percent myocardium perfused is a measure of ischemia. This measure of ischemia is important in deciding whether to refer patients to revascularization or to treat them with medical therapy.

Studies have shown that patients with extensive ischemia have a much lower risk of cardiac death with revascularization than with medical therapy. On the other hand, patients with less than about 10% ischemia have a lower risk of cardiac death with medical therapy.

For any degree of ischemia, the absolute benefit of revascularization compared with medical therapy will vary with several factors, including left ventricular ejection fraction, the extent of viable myocardium, and underlying patient risk. The absolute benefit of revascularization is better for women than for men, better for diabetics than for nondiabetics, and better for elderly patients than for those who are middle aged, for example.

Despite its value, cardiac perfusion SPECT does have a number of limitations, Dr. Berman said. Because the test detects only hydrodynamically significant lesions, it won't pick up early atherosclerosis. It also won't pick up some of the patients at the very highest risk, those with a balanced reduction in perfusion. And it may underestimate the extent of ischemia and cardiovascular disease as well as the amount of viable myocardium.

Measurements Possible With Quantitative Cardiac Perfusion SPECT

▸ Percent hypoperfusion

▸ Percent reversibility

▸ Lung-to-heart ratio

▸ Transient ischemic dilatation

▸ Left ventricular mass

▸ Left ventricular ejection fraction

▸ End diastolic volume

▸ End systolic volume

▸ Wall motion

▸ Wall thickening

▸ Peak filling rate

Source: Dr. Berman