Bruce K. Dixon

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas.

She puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy,” she added.

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for.

For example, in addition to printing “Statin 20 mg #90,” the label says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The desktop labeling system also integrates with many software programs such as Outlook and Quickbooks to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added.

The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas uses the label maker to print legible, customized instructions for each patient, and puts a second copy into each chart.

'Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call.' DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas.

She puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy,” she added.

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for.

For example, in addition to printing “Statin 20 mg #90,” the label says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The desktop labeling system also integrates with many software programs such as Outlook and Quickbooks to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added.

The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas uses the label maker to print legible, customized instructions for each patient, and puts a second copy into each chart.

'Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call.' DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas.

She puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy,” she added.

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for.

For example, in addition to printing “Statin 20 mg #90,” the label says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The desktop labeling system also integrates with many software programs such as Outlook and Quickbooks to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added.

The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas uses the label maker to print legible, customized instructions for each patient, and puts a second copy into each chart.

'Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call.' DR. LUCAS

CHICAGO — CT urography is a promising technique for the detection of bladder cancer and may eliminate the need for cystoscopy in selected patients, according to a study presented at the annual meeting of the Radiological Society of North America.

The new data, which give CT urography (CTU) high marks for specificity and negative predictive value in patients at risk for bladder cancer, are a step in that direction, said Dr. Cheryl A. Sadow, who is with the department of radiology at Brigham and Women's Hospital in Boston.

“Bladder cancer is the most common malignancy of the urinary tract. Currently, cystoscopy is the gold standard for detection. CT urography offers a comprehensive evaluation of the kidneys, urinary tract, and bladder; however, its role as a primary imaging tool for the detection of bladder cancer has yet to be established,” she said.

The researchers retrospectively reviewed the results of all CTU performed at Brigham and Women's Hospital over a 5-year period. Included in the study were patients who had been referred for hematuria or for a history of urothelial cancer, and who also had a cystoscopy within 6 months of the CTU for correlation, Dr. Sadow said. A total of 838 CT urograms obtained for these indications had cystoscopic correlation.

“For CTUs, any bladder lesion that was interpreted as suspicious for malignancy was considered positive, and any other bladder abnormality or normal bladder [was] called negative. In the reading of cystoscopy reports, any lesion that was biopsied or resected was called positive, whereas if no lesion was detected, the cystoscopy was called negative,” she said.

Performance characteristics of sensitivity, specificity, and positive and negative predictive values were calculated for CTU and cystoscopy procedures using concordant negative results between the two tests or pathology.

A total of 149 cancers were found in the 838 cases assessed. There were 32 false-negative and 40 false-positive CT urograms. Overall, the sensitivity of CTU was less than that of cystoscopy (79% vs. 95%), but the exam's specificity was 94% vs. 92% for the more invasive procedure, Dr. Sadow explained. The positive predictive value was low for both, at 75% and 72%, respectively, while the negative predictive values were very high, at 95% and 99%.

When the data were subdivided by inclusion criteria, they revealed that 680 of the 838 CTU exams were performed for the indication of hematuria. In this group, 68 cancers were detected.

“Once again, sensitivity is less for CTU and the positive predictive value is low for both. However, the specificity increases to 96% in CTU, which is slightly better than for cystoscopy, and the negative predictive value for CTU increases to 98%,” Dr. Sadow said, adding that high negative predictive value allows referring physicians to feel confident that a negative CTU excludes bladder cancer in 98% of patients.

Among those referred for a history of urothelial cancer, sensitivity remained relatively low and specificity dropped significantly for CTU. The investigators suspect that bladder distortion and wall thickening from prior surgical interventions and other intravesical treatments may account in part for the decreased specificity in this cohort of patients.

Disease prevalence was 18% overall, 10% in the hematuria group, and 50% in the urothelial cancer group. As the prevalence of disease increases, the negative predictive value of the test decreases, and disease prevalence rises with age, she said.

“CT urography has such a high specificity and negative predictive value in the setting of hematuria that it may obviate the need for cystoscopy in this patient population. However, due to the relatively low sensitivity of the test, compared with cystoscopy, patients at a very high risk for bladder cancer, such as those with a history of urothelial cancer, should continue to be evaluated with cystoscopy,” Dr. Sadow concluded.

CHICAGO — CT urography is a promising technique for the detection of bladder cancer and may eliminate the need for cystoscopy in selected patients, according to a study presented at the annual meeting of the Radiological Society of North America.

The new data, which give CT urography (CTU) high marks for specificity and negative predictive value in patients at risk for bladder cancer, are a step in that direction, said Dr. Cheryl A. Sadow, who is with the department of radiology at Brigham and Women's Hospital in Boston.

“Bladder cancer is the most common malignancy of the urinary tract. Currently, cystoscopy is the gold standard for detection. CT urography offers a comprehensive evaluation of the kidneys, urinary tract, and bladder; however, its role as a primary imaging tool for the detection of bladder cancer has yet to be established,” she said.

The researchers retrospectively reviewed the results of all CTU performed at Brigham and Women's Hospital over a 5-year period. Included in the study were patients who had been referred for hematuria or for a history of urothelial cancer, and who also had a cystoscopy within 6 months of the CTU for correlation, Dr. Sadow said. A total of 838 CT urograms obtained for these indications had cystoscopic correlation.

“For CTUs, any bladder lesion that was interpreted as suspicious for malignancy was considered positive, and any other bladder abnormality or normal bladder [was] called negative. In the reading of cystoscopy reports, any lesion that was biopsied or resected was called positive, whereas if no lesion was detected, the cystoscopy was called negative,” she said.

Performance characteristics of sensitivity, specificity, and positive and negative predictive values were calculated for CTU and cystoscopy procedures using concordant negative results between the two tests or pathology.

A total of 149 cancers were found in the 838 cases assessed. There were 32 false-negative and 40 false-positive CT urograms. Overall, the sensitivity of CTU was less than that of cystoscopy (79% vs. 95%), but the exam's specificity was 94% vs. 92% for the more invasive procedure, Dr. Sadow explained. The positive predictive value was low for both, at 75% and 72%, respectively, while the negative predictive values were very high, at 95% and 99%.

When the data were subdivided by inclusion criteria, they revealed that 680 of the 838 CTU exams were performed for the indication of hematuria. In this group, 68 cancers were detected.

“Once again, sensitivity is less for CTU and the positive predictive value is low for both. However, the specificity increases to 96% in CTU, which is slightly better than for cystoscopy, and the negative predictive value for CTU increases to 98%,” Dr. Sadow said, adding that high negative predictive value allows referring physicians to feel confident that a negative CTU excludes bladder cancer in 98% of patients.

Among those referred for a history of urothelial cancer, sensitivity remained relatively low and specificity dropped significantly for CTU. The investigators suspect that bladder distortion and wall thickening from prior surgical interventions and other intravesical treatments may account in part for the decreased specificity in this cohort of patients.

Disease prevalence was 18% overall, 10% in the hematuria group, and 50% in the urothelial cancer group. As the prevalence of disease increases, the negative predictive value of the test decreases, and disease prevalence rises with age, she said.

“CT urography has such a high specificity and negative predictive value in the setting of hematuria that it may obviate the need for cystoscopy in this patient population. However, due to the relatively low sensitivity of the test, compared with cystoscopy, patients at a very high risk for bladder cancer, such as those with a history of urothelial cancer, should continue to be evaluated with cystoscopy,” Dr. Sadow concluded.

CHICAGO — CT urography is a promising technique for the detection of bladder cancer and may eliminate the need for cystoscopy in selected patients, according to a study presented at the annual meeting of the Radiological Society of North America.

The new data, which give CT urography (CTU) high marks for specificity and negative predictive value in patients at risk for bladder cancer, are a step in that direction, said Dr. Cheryl A. Sadow, who is with the department of radiology at Brigham and Women's Hospital in Boston.

“Bladder cancer is the most common malignancy of the urinary tract. Currently, cystoscopy is the gold standard for detection. CT urography offers a comprehensive evaluation of the kidneys, urinary tract, and bladder; however, its role as a primary imaging tool for the detection of bladder cancer has yet to be established,” she said.

The researchers retrospectively reviewed the results of all CTU performed at Brigham and Women's Hospital over a 5-year period. Included in the study were patients who had been referred for hematuria or for a history of urothelial cancer, and who also had a cystoscopy within 6 months of the CTU for correlation, Dr. Sadow said. A total of 838 CT urograms obtained for these indications had cystoscopic correlation.

“For CTUs, any bladder lesion that was interpreted as suspicious for malignancy was considered positive, and any other bladder abnormality or normal bladder [was] called negative. In the reading of cystoscopy reports, any lesion that was biopsied or resected was called positive, whereas if no lesion was detected, the cystoscopy was called negative,” she said.

Performance characteristics of sensitivity, specificity, and positive and negative predictive values were calculated for CTU and cystoscopy procedures using concordant negative results between the two tests or pathology.

A total of 149 cancers were found in the 838 cases assessed. There were 32 false-negative and 40 false-positive CT urograms. Overall, the sensitivity of CTU was less than that of cystoscopy (79% vs. 95%), but the exam's specificity was 94% vs. 92% for the more invasive procedure, Dr. Sadow explained. The positive predictive value was low for both, at 75% and 72%, respectively, while the negative predictive values were very high, at 95% and 99%.

When the data were subdivided by inclusion criteria, they revealed that 680 of the 838 CTU exams were performed for the indication of hematuria. In this group, 68 cancers were detected.

“Once again, sensitivity is less for CTU and the positive predictive value is low for both. However, the specificity increases to 96% in CTU, which is slightly better than for cystoscopy, and the negative predictive value for CTU increases to 98%,” Dr. Sadow said, adding that high negative predictive value allows referring physicians to feel confident that a negative CTU excludes bladder cancer in 98% of patients.

Among those referred for a history of urothelial cancer, sensitivity remained relatively low and specificity dropped significantly for CTU. The investigators suspect that bladder distortion and wall thickening from prior surgical interventions and other intravesical treatments may account in part for the decreased specificity in this cohort of patients.

Disease prevalence was 18% overall, 10% in the hematuria group, and 50% in the urothelial cancer group. As the prevalence of disease increases, the negative predictive value of the test decreases, and disease prevalence rises with age, she said.

“CT urography has such a high specificity and negative predictive value in the setting of hematuria that it may obviate the need for cystoscopy in this patient population. However, due to the relatively low sensitivity of the test, compared with cystoscopy, patients at a very high risk for bladder cancer, such as those with a history of urothelial cancer, should continue to be evaluated with cystoscopy,” Dr. Sadow concluded.

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas, who puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy.”

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing “Statin 20 mg #90,” the label also says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas.

The desktop labeling system also integrates with software programs to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added. The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas also prints legible, customized instructions for each patient, and puts a second copy into each chart.

Pharmacists appreciate not having to call and ask me what I wrote for a prescription. DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas, who puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy.”

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing “Statin 20 mg #90,” the label also says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas.

The desktop labeling system also integrates with software programs to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added. The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas also prints legible, customized instructions for each patient, and puts a second copy into each chart.

Pharmacists appreciate not having to call and ask me what I wrote for a prescription. DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

“This is a very cost-effective alternative for anyone who doesn't have an EMR system,” said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

“I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine,” said Dr. Lucas, who puts one label into the patient's chart and gives a second, signed, copy to the patient to take to the pharmacy. “Or I stick the label or labels on a sheet of paper and fax it to the pharmacy.”

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing “Statin 20 mg #90,” the label also says “cholesterol med.”

“Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote,” said Dr. Lucas.

The desktop labeling system also integrates with software programs to produce individual labels. “It's nice because it has an optional mailing bar code to facilitate mailing,” she added. The label maker also prints individual postage stamps using the Web site www.stamps.com

“In addition, the data management software that comes with the machine contains our entire Rolodex file of physicians, so that patients referred to another facility get a legible copy of the name, address, and phone number on a printed label that can be affixed to the lab sheets or tickler file.”

Dr. Lucas also prints legible, customized instructions for each patient, and puts a second copy into each chart.

Pharmacists appreciate not having to call and ask me what I wrote for a prescription. DR. LUCAS

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test, and that the T.Spot-TB is more sensitive than Quantiferon-TB while Quantiferon-TB is more specific.

Both IGRAs correlate with exposure better than does the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IRGAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

“We still need to study more populations to optimize sensitivity and specificity in these IRGA tests. I'm not convinced that the cut-points currently recommended by the companies are appropriate, and we need to know how these are going to work in the immunocompromised and in young children.

“There aren't enough data to guide us in these areas, so most people are kind of holding off on using these new assays,” Dr. Daley said.

In addition, more needs to be learned about using IRGAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IRGAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

Both new tests correlate with exposure better than does the tuberculin skin test. DR. DALEY

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test, and that the T.Spot-TB is more sensitive than Quantiferon-TB while Quantiferon-TB is more specific.

Both IGRAs correlate with exposure better than does the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IRGAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

“We still need to study more populations to optimize sensitivity and specificity in these IRGA tests. I'm not convinced that the cut-points currently recommended by the companies are appropriate, and we need to know how these are going to work in the immunocompromised and in young children.

“There aren't enough data to guide us in these areas, so most people are kind of holding off on using these new assays,” Dr. Daley said.

In addition, more needs to be learned about using IRGAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IRGAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

Both new tests correlate with exposure better than does the tuberculin skin test. DR. DALEY

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test, and that the T.Spot-TB is more sensitive than Quantiferon-TB while Quantiferon-TB is more specific.

Both IGRAs correlate with exposure better than does the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IRGAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

“We still need to study more populations to optimize sensitivity and specificity in these IRGA tests. I'm not convinced that the cut-points currently recommended by the companies are appropriate, and we need to know how these are going to work in the immunocompromised and in young children.

“There aren't enough data to guide us in these areas, so most people are kind of holding off on using these new assays,” Dr. Daley said.

In addition, more needs to be learned about using IRGAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IRGAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

Both new tests correlate with exposure better than does the tuberculin skin test. DR. DALEY

SALT LAKE CITY – State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion persists among regulators and practitioners, David E. Joranson said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There are some positive aspects of policies being developed over the last several years because [states] are recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison. The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse.”

Many physicians do not have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use. This disconnect can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said.

In an interview, Mr. Joranson urged the major organizations advocating for improved pain management in palliative care to focus their members' attention on better understanding how policies can improve patient care–and then work to change those that hinder treatment.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, those who attended the meeting participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many survey participants also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies, culminating in a “report card” issued in 2006. The overall grade improved over the period in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse the addiction issue are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes that are needed, Mr. Joranson said.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Purdue Pharma L.P. and Endo Pharmaceuticals.

For more information on state policies and guidelines on pain and links to other resources, go to www.painpolicy.wisc.edu/index.htm

The Pennsylvania Uniform Control Substances Act's definition of addiction is confusing. MR. JORANSON

SALT LAKE CITY – State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion persists among regulators and practitioners, David E. Joranson said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There are some positive aspects of policies being developed over the last several years because [states] are recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison. The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse.”

Many physicians do not have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use. This disconnect can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said.

In an interview, Mr. Joranson urged the major organizations advocating for improved pain management in palliative care to focus their members' attention on better understanding how policies can improve patient care–and then work to change those that hinder treatment.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, those who attended the meeting participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many survey participants also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies, culminating in a “report card” issued in 2006. The overall grade improved over the period in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse the addiction issue are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes that are needed, Mr. Joranson said.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Purdue Pharma L.P. and Endo Pharmaceuticals.

For more information on state policies and guidelines on pain and links to other resources, go to www.painpolicy.wisc.edu/index.htm

The Pennsylvania Uniform Control Substances Act's definition of addiction is confusing. MR. JORANSON

SALT LAKE CITY – State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion persists among regulators and practitioners, David E. Joranson said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There are some positive aspects of policies being developed over the last several years because [states] are recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison. The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse.”

Many physicians do not have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use. This disconnect can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said.

In an interview, Mr. Joranson urged the major organizations advocating for improved pain management in palliative care to focus their members' attention on better understanding how policies can improve patient care–and then work to change those that hinder treatment.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, those who attended the meeting participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many survey participants also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies, culminating in a “report card” issued in 2006. The overall grade improved over the period in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse the addiction issue are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes that are needed, Mr. Joranson said.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Purdue Pharma L.P. and Endo Pharmaceuticals.

For more information on state policies and guidelines on pain and links to other resources, go to www.painpolicy.wisc.edu/index.htm

The Pennsylvania Uniform Control Substances Act's definition of addiction is confusing. MR. JORANSON

SALT LAKE CITY – Collaboration between palliative care and the psychiatric inpatient unit can greatly improve mental health care for nursing home residents with behavioral and psychological symptoms of dementia, according to presenters at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. “Dementia is the most frequent reason for nursing home admissions, and nationally 80% of nursing home residents who are in need of psychiatric services fail to receive them,” said Dr. Janet Bull, vice president of medical services for Four Seasons Hospice and Palliative Care in Flat Rock, N.C.

Four Seasons has a contractual relationship with every nursing home in Henderson County.

Nationwide, half of nursing homes do not have access to adequate psychiatric consultation, said Dr. Bull, who is board certified in both hospice and palliative care and ob.gyn.

In addition, mental health funding is being cut and the Deficit Reduction Omnibus Reconciliation Act guidelines limit pharmacologic treatment for psychotic conditions, she explained.

Untreated psychiatric disorders result in decreased functioning, poor quality of life, and increased mortality, and this leads to high use of psychiatric units by nursing homes. “Very often, we don't see these patients until they end up in the ICU in a state of crisis,” Dr. Bull said.

So she and her colleagues forged a collaboration with the medical psychiatric unit of Park Ridge Hospital, in nearby Hendersonville, N.C., to create an interdisciplinary team consisting of the psychiatrist, a psychiatric nurse practitioner, a nurse, a social worker, a music therapist, an activities therapist, and the hospital chaplain.

Four Seasons team members included a palliative care physician (Dr. Bull), a palliative care nurse practitioner, and administrative support.

Last year, there were 308 admissions to the hospital medical psychiatric unit, of which two-thirds were related to behavioral and psychological symptoms of dementia (BPSD), Dr. Bull explained. “On the palliative care end, we received 242 referrals in 2006 and about two-thirds of those were related to BPSD.”

Symptoms of BPSD–seen in 83% of dementia patients and undoubtedly the most common cause of nursing home placement–include aggression, screaming, restlessness, agitation, wandering, sexual disinhibition, hoarding, cursing, and shadowing, she said.

Unfortunately, there are several barriers to quality end-of-life care in the typical psychiatric setting, said Judith A. Adams, the palliative care nurse at Four Seasons.

“Psychiatrists often don't recognize end-of-life symptoms because they're focused on psychological symptoms, and there's a lack of knowledge of pain medications,” Ms. Adams explained, adding that psychiatric patients face many stressors, such as physical restraints and noisy, busy environments.

Although the psychiatry profession is taking strides to improve end-of-life care, the psychiatry-palliative care partnership approach offers an excellent alternative, she said.

“However, roles have to be clearly defined. In the psychiatry department, the psychiatrist is the attending physician. Our role is strictly one of consultation, and this is a crucial point. We are assessing and treating pain and nonpain symptoms, and we're not going to treat unless the psychiatrist asks us to,” Ms. Adams cautioned.

A second pitfall is not having clear communications on the expectations of the palliative care consult.

The partnership has resulted in improved patient quality of care; avoidance of suffering and futile care in future medical admissions related to clear goals; and overall enhancement of the hospital's palliative care service, Ms. Adams said.

Two-thirds of the referrals to palliative care received in 2006 were related to BPSD. DR. BULL

SALT LAKE CITY – Collaboration between palliative care and the psychiatric inpatient unit can greatly improve mental health care for nursing home residents with behavioral and psychological symptoms of dementia, according to presenters at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. “Dementia is the most frequent reason for nursing home admissions, and nationally 80% of nursing home residents who are in need of psychiatric services fail to receive them,” said Dr. Janet Bull, vice president of medical services for Four Seasons Hospice and Palliative Care in Flat Rock, N.C.

Four Seasons has a contractual relationship with every nursing home in Henderson County.

Nationwide, half of nursing homes do not have access to adequate psychiatric consultation, said Dr. Bull, who is board certified in both hospice and palliative care and ob.gyn.

In addition, mental health funding is being cut and the Deficit Reduction Omnibus Reconciliation Act guidelines limit pharmacologic treatment for psychotic conditions, she explained.

Untreated psychiatric disorders result in decreased functioning, poor quality of life, and increased mortality, and this leads to high use of psychiatric units by nursing homes. “Very often, we don't see these patients until they end up in the ICU in a state of crisis,” Dr. Bull said.

So she and her colleagues forged a collaboration with the medical psychiatric unit of Park Ridge Hospital, in nearby Hendersonville, N.C., to create an interdisciplinary team consisting of the psychiatrist, a psychiatric nurse practitioner, a nurse, a social worker, a music therapist, an activities therapist, and the hospital chaplain.

Four Seasons team members included a palliative care physician (Dr. Bull), a palliative care nurse practitioner, and administrative support.

Last year, there were 308 admissions to the hospital medical psychiatric unit, of which two-thirds were related to behavioral and psychological symptoms of dementia (BPSD), Dr. Bull explained. “On the palliative care end, we received 242 referrals in 2006 and about two-thirds of those were related to BPSD.”

Symptoms of BPSD–seen in 83% of dementia patients and undoubtedly the most common cause of nursing home placement–include aggression, screaming, restlessness, agitation, wandering, sexual disinhibition, hoarding, cursing, and shadowing, she said.

Unfortunately, there are several barriers to quality end-of-life care in the typical psychiatric setting, said Judith A. Adams, the palliative care nurse at Four Seasons.

“Psychiatrists often don't recognize end-of-life symptoms because they're focused on psychological symptoms, and there's a lack of knowledge of pain medications,” Ms. Adams explained, adding that psychiatric patients face many stressors, such as physical restraints and noisy, busy environments.

Although the psychiatry profession is taking strides to improve end-of-life care, the psychiatry-palliative care partnership approach offers an excellent alternative, she said.

“However, roles have to be clearly defined. In the psychiatry department, the psychiatrist is the attending physician. Our role is strictly one of consultation, and this is a crucial point. We are assessing and treating pain and nonpain symptoms, and we're not going to treat unless the psychiatrist asks us to,” Ms. Adams cautioned.

A second pitfall is not having clear communications on the expectations of the palliative care consult.

The partnership has resulted in improved patient quality of care; avoidance of suffering and futile care in future medical admissions related to clear goals; and overall enhancement of the hospital's palliative care service, Ms. Adams said.

Two-thirds of the referrals to palliative care received in 2006 were related to BPSD. DR. BULL

SALT LAKE CITY – Collaboration between palliative care and the psychiatric inpatient unit can greatly improve mental health care for nursing home residents with behavioral and psychological symptoms of dementia, according to presenters at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association. “Dementia is the most frequent reason for nursing home admissions, and nationally 80% of nursing home residents who are in need of psychiatric services fail to receive them,” said Dr. Janet Bull, vice president of medical services for Four Seasons Hospice and Palliative Care in Flat Rock, N.C.

Four Seasons has a contractual relationship with every nursing home in Henderson County.

Nationwide, half of nursing homes do not have access to adequate psychiatric consultation, said Dr. Bull, who is board certified in both hospice and palliative care and ob.gyn.

In addition, mental health funding is being cut and the Deficit Reduction Omnibus Reconciliation Act guidelines limit pharmacologic treatment for psychotic conditions, she explained.

Untreated psychiatric disorders result in decreased functioning, poor quality of life, and increased mortality, and this leads to high use of psychiatric units by nursing homes. “Very often, we don't see these patients until they end up in the ICU in a state of crisis,” Dr. Bull said.

So she and her colleagues forged a collaboration with the medical psychiatric unit of Park Ridge Hospital, in nearby Hendersonville, N.C., to create an interdisciplinary team consisting of the psychiatrist, a psychiatric nurse practitioner, a nurse, a social worker, a music therapist, an activities therapist, and the hospital chaplain.

Four Seasons team members included a palliative care physician (Dr. Bull), a palliative care nurse practitioner, and administrative support.

Last year, there were 308 admissions to the hospital medical psychiatric unit, of which two-thirds were related to behavioral and psychological symptoms of dementia (BPSD), Dr. Bull explained. “On the palliative care end, we received 242 referrals in 2006 and about two-thirds of those were related to BPSD.”

Symptoms of BPSD–seen in 83% of dementia patients and undoubtedly the most common cause of nursing home placement–include aggression, screaming, restlessness, agitation, wandering, sexual disinhibition, hoarding, cursing, and shadowing, she said.

Unfortunately, there are several barriers to quality end-of-life care in the typical psychiatric setting, said Judith A. Adams, the palliative care nurse at Four Seasons.

“Psychiatrists often don't recognize end-of-life symptoms because they're focused on psychological symptoms, and there's a lack of knowledge of pain medications,” Ms. Adams explained, adding that psychiatric patients face many stressors, such as physical restraints and noisy, busy environments.

Although the psychiatry profession is taking strides to improve end-of-life care, the psychiatry-palliative care partnership approach offers an excellent alternative, she said.

“However, roles have to be clearly defined. In the psychiatry department, the psychiatrist is the attending physician. Our role is strictly one of consultation, and this is a crucial point. We are assessing and treating pain and nonpain symptoms, and we're not going to treat unless the psychiatrist asks us to,” Ms. Adams cautioned.

A second pitfall is not having clear communications on the expectations of the palliative care consult.

The partnership has resulted in improved patient quality of care; avoidance of suffering and futile care in future medical admissions related to clear goals; and overall enhancement of the hospital's palliative care service, Ms. Adams said.

Two-thirds of the referrals to palliative care received in 2006 were related to BPSD. DR. BULL

ST. LOUIS – A short course of therapy lasting less than a week may significantly reduce posttraumatic stress disorder symptoms for youths in short-stay facilities, Adrianna R. Wechsler reported at the annual meeting of the Anxiety Disorders Association of America.

Ms. Wechsler and her colleagues at the University of Nevada, Las Vegas, said the study results indicate that Brief Therapy for Traumatized Children (BTTC) may provide an easy, effective therapy that could be used by schools, church youth groups, or other community outreach programs. The therapy was developed by Lisa M. Linning, Ph.D., a psychologist at the university.

Traumatized children are highly distressed, and their functioning and development are threatened by their trauma symptoms, said Ms. Wechsler, who led the research effort.

“The two key concerns within the field of child clinical psychology are, first, the safety of these children, and second, the reestablishment of optimal childhood development,” she said.

After experiencing or witnessing an event with actual or threatened death or serious injury, a child may experience intense fear and develop such symptoms as reexperiencing the event; avoidance or numbing behavior; and increased arousal. Clinically significant symptoms lasting longer than 1 month indicate posttraumatic stress disorder (PTSD). Shorter periods warrant a diagnosis of acute stress disorder (ASD), Wechsler explained.

Dr. Linning developed BTTC with the goal of reducing PTSD symptoms in a rapidly moving, high-turnover setting. BTTC involved a maximum of six group therapy sessions of 90 minutes each among a group of 147 young volunteers at a Nevada crisis center.

“Our hope was that replacing the use of pretreatment avoidance coping that many of these adolescents use with more active coping strategies would yield the greatest symptom reduction,” Ms. Wechsler said.

By the end of the study, data on 58 ethnically diverse youths aged 12–17 years were available for study, and the mean number of sessions attended was four. Only 19 youths were able to attend all six sessions.

All 58 met the criteria for ASD or PTSD; almost half said they lived in a single-parent environment; four-fifths indicated that at least one family member had served time in prison; and almost half said there was regular drug or alcohol use in the home, she said.

The intervention was preceded by structured diagnostic interviews and three self-report questionnaires. The therapy sessions were administered by Dr. Linning with the assistance of two research assistants to help protect data integrity. The intervention was followed by follow-up interviews, and two self-report measures were collected.

Treatment components included psychoeducation; anxiety management techniques; mindfulness for self-monitoring; restructuring of cognitive distortions; boundary setting; positive coping strategies; narrative and emotional expression; brief exposure therapy; and journaling.

Measurements were derived using the Anxiety Disorders Interview Schedule (child version), the Childhood PTSD Interview, the Coping Skills Inventory, the “When Bad Things Happen” scale, and the Youth Self-Report.

“In our satisfaction survey, 40 of the 58 youths described their therapy as helpful, and 51 felt that nothing about the therapy should be changed,” Ms. Wechsler said. “These are good results, considering that these children are perceived to be somewhat resistant to therapy.”

Structural equation modeling revealed that PTSD symptoms were significantly reduced. Also, regression equation modeling revealed that dissociation was a predictor of PTSD change.

Future studies should include longitudinal data and a control group for comparison, she said.

Brief Therapy for Traumatized Children can be used by schools and community groups. MS. WECHSLER

ST. LOUIS – A short course of therapy lasting less than a week may significantly reduce posttraumatic stress disorder symptoms for youths in short-stay facilities, Adrianna R. Wechsler reported at the annual meeting of the Anxiety Disorders Association of America.

Ms. Wechsler and her colleagues at the University of Nevada, Las Vegas, said the study results indicate that Brief Therapy for Traumatized Children (BTTC) may provide an easy, effective therapy that could be used by schools, church youth groups, or other community outreach programs. The therapy was developed by Lisa M. Linning, Ph.D., a psychologist at the university.

Traumatized children are highly distressed, and their functioning and development are threatened by their trauma symptoms, said Ms. Wechsler, who led the research effort.

“The two key concerns within the field of child clinical psychology are, first, the safety of these children, and second, the reestablishment of optimal childhood development,” she said.

After experiencing or witnessing an event with actual or threatened death or serious injury, a child may experience intense fear and develop such symptoms as reexperiencing the event; avoidance or numbing behavior; and increased arousal. Clinically significant symptoms lasting longer than 1 month indicate posttraumatic stress disorder (PTSD). Shorter periods warrant a diagnosis of acute stress disorder (ASD), Wechsler explained.

Dr. Linning developed BTTC with the goal of reducing PTSD symptoms in a rapidly moving, high-turnover setting. BTTC involved a maximum of six group therapy sessions of 90 minutes each among a group of 147 young volunteers at a Nevada crisis center.

“Our hope was that replacing the use of pretreatment avoidance coping that many of these adolescents use with more active coping strategies would yield the greatest symptom reduction,” Ms. Wechsler said.

By the end of the study, data on 58 ethnically diverse youths aged 12–17 years were available for study, and the mean number of sessions attended was four. Only 19 youths were able to attend all six sessions.

All 58 met the criteria for ASD or PTSD; almost half said they lived in a single-parent environment; four-fifths indicated that at least one family member had served time in prison; and almost half said there was regular drug or alcohol use in the home, she said.

The intervention was preceded by structured diagnostic interviews and three self-report questionnaires. The therapy sessions were administered by Dr. Linning with the assistance of two research assistants to help protect data integrity. The intervention was followed by follow-up interviews, and two self-report measures were collected.

Treatment components included psychoeducation; anxiety management techniques; mindfulness for self-monitoring; restructuring of cognitive distortions; boundary setting; positive coping strategies; narrative and emotional expression; brief exposure therapy; and journaling.

Measurements were derived using the Anxiety Disorders Interview Schedule (child version), the Childhood PTSD Interview, the Coping Skills Inventory, the “When Bad Things Happen” scale, and the Youth Self-Report.

“In our satisfaction survey, 40 of the 58 youths described their therapy as helpful, and 51 felt that nothing about the therapy should be changed,” Ms. Wechsler said. “These are good results, considering that these children are perceived to be somewhat resistant to therapy.”

Structural equation modeling revealed that PTSD symptoms were significantly reduced. Also, regression equation modeling revealed that dissociation was a predictor of PTSD change.

Future studies should include longitudinal data and a control group for comparison, she said.

Brief Therapy for Traumatized Children can be used by schools and community groups. MS. WECHSLER

ST. LOUIS – A short course of therapy lasting less than a week may significantly reduce posttraumatic stress disorder symptoms for youths in short-stay facilities, Adrianna R. Wechsler reported at the annual meeting of the Anxiety Disorders Association of America.

Ms. Wechsler and her colleagues at the University of Nevada, Las Vegas, said the study results indicate that Brief Therapy for Traumatized Children (BTTC) may provide an easy, effective therapy that could be used by schools, church youth groups, or other community outreach programs. The therapy was developed by Lisa M. Linning, Ph.D., a psychologist at the university.

Traumatized children are highly distressed, and their functioning and development are threatened by their trauma symptoms, said Ms. Wechsler, who led the research effort.

“The two key concerns within the field of child clinical psychology are, first, the safety of these children, and second, the reestablishment of optimal childhood development,” she said.

After experiencing or witnessing an event with actual or threatened death or serious injury, a child may experience intense fear and develop such symptoms as reexperiencing the event; avoidance or numbing behavior; and increased arousal. Clinically significant symptoms lasting longer than 1 month indicate posttraumatic stress disorder (PTSD). Shorter periods warrant a diagnosis of acute stress disorder (ASD), Wechsler explained.

Dr. Linning developed BTTC with the goal of reducing PTSD symptoms in a rapidly moving, high-turnover setting. BTTC involved a maximum of six group therapy sessions of 90 minutes each among a group of 147 young volunteers at a Nevada crisis center.

“Our hope was that replacing the use of pretreatment avoidance coping that many of these adolescents use with more active coping strategies would yield the greatest symptom reduction,” Ms. Wechsler said.

By the end of the study, data on 58 ethnically diverse youths aged 12–17 years were available for study, and the mean number of sessions attended was four. Only 19 youths were able to attend all six sessions.

All 58 met the criteria for ASD or PTSD; almost half said they lived in a single-parent environment; four-fifths indicated that at least one family member had served time in prison; and almost half said there was regular drug or alcohol use in the home, she said.

The intervention was preceded by structured diagnostic interviews and three self-report questionnaires. The therapy sessions were administered by Dr. Linning with the assistance of two research assistants to help protect data integrity. The intervention was followed by follow-up interviews, and two self-report measures were collected.

Treatment components included psychoeducation; anxiety management techniques; mindfulness for self-monitoring; restructuring of cognitive distortions; boundary setting; positive coping strategies; narrative and emotional expression; brief exposure therapy; and journaling.

Measurements were derived using the Anxiety Disorders Interview Schedule (child version), the Childhood PTSD Interview, the Coping Skills Inventory, the “When Bad Things Happen” scale, and the Youth Self-Report.

“In our satisfaction survey, 40 of the 58 youths described their therapy as helpful, and 51 felt that nothing about the therapy should be changed,” Ms. Wechsler said. “These are good results, considering that these children are perceived to be somewhat resistant to therapy.”

Structural equation modeling revealed that PTSD symptoms were significantly reduced. Also, regression equation modeling revealed that dissociation was a predictor of PTSD change.

Future studies should include longitudinal data and a control group for comparison, she said.

Brief Therapy for Traumatized Children can be used by schools and community groups. MS. WECHSLER

SALT LAKE CITY — A nurse-practitioner model can overcome regulatory and reimbursement barriers to the delivery of palliative care to patients in nursing homes, according to Dr. Jeanne Elnadry, medical director of the Hospice of Yuma (Ariz.).

“These chronically ill and terminal patients are among the most vulnerable in our society, and they have lots of needs that are not adequately addressed,” Dr. Elnadry said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“Nurse practitioners can help to fill some of that void if they have adequate training and desire,” she added.

In 2004, Dr. Elnadry—along with Peggy Edwards, a nurse practitioner certified in geriatrics and palliative care management—began developing a modest palliative care service that provides consultations to Yuma's four nursing homes, which have a total of 450 beds.

Their goals were to decrease utilization of the local hospital's emergency department, to reduce hospitalizations, and to provide better and more comprehensive care to nursing home residents, said Dr. Elnadry, who also provides palliative care consultations at the Yuma Regional Medical Center.

“Palliative care in nursing homes is for patients who, for some reason, cannot receive hospice care even though they have a prognosis of under 6 months,” Dr. Elnadry said in an interview. It's also for patients who will most likely live longer than 6 months but have a life-limiting or highly symptomatic condition, or for patients who have a condition such as Alzheimer's disease who may require palliative care for an extended period of time until they are eligible for hospice care, she said.

Many nursing home patients have terminal diagnoses with prognoses of much less than 6 months, and would benefit from the types of services available in hospice, such as social work services, the assessment and management of complex symptoms by registered nurses, and bereavement support, she said.

The role of the palliative care nurse practitioner is to provide consultations (on a physician's order), to communicate directly with the primary physician, to conduct family meetings as necessary, to write symptom management orders, and to perform follow-up for symptom management and decision making, Dr. Elnadry explained.

She noted that among the challenges to the provision of palliative care in nursing homes are several myths: that such care is strictly for the end of life; that Medicare will not pay for skilled and palliative care simultaneously; that Medicare skilled beds are only for patients who are able to participate in rehabilitative care and are going to “get better”; and that palliative care services by physicians, nurse practitioners, and physician assistants is not reimbursable.

One obstacle is that Medicare will not pay for hospice care and skilled nursing care in a nursing home at the same time, and there is no payer source for palliative care interdisciplinary teams in nursing homes. Dr. Elnadry—who bills her visits under Medicare Part B, which doesn't cover all expenses—said that the Centers for Medicare and Medicaid Services needs to address the needs of these very ill nursing home patients.

“Because there is no adequate system for reimbursement for the time required for complex consultations and family meetings, some programs rely on grants, but you can't run a health care system on grants. We didn't obtain a grant and [thus] have to cover our costs through billing. That's important because a nurse practitioner costs less than a physician, so if the nurse sees enough patients, then the billing may cover her costs,” Dr. Elnadry said in an interview.

Ms. Edwards noted that “ours is a heavily regulated industry with an unbelievable burden of rules and regulations that weigh against palliative care in nursing homes.” There is no incentive to accept a patient into a nursing home if he or she is considered “terminal,” she added.

The first step in implementing a palliative care service in the nursing home is to identify those with the authority to help you succeed, Ms. Edwards explained. “Develop your champions, including the administrator, the head of finance, the minimum data set coordinator, the director of nursing, and perhaps your director of social services. These are key people with clout.”

Ms. Edwards recommended targeting appropriate patients for palliative care, such as patients with aggressive advanced disease and a poor prognosis or those who have functional decline despite receiving physical therapy rehabilitation; patients who make frequent trips to the hospital; and patients with acute, chronic, or uncontrolled pain.

“Include advance care planning with advance directives, and address psychosocial and spiritual concerns with patients and their families, and with caregivers and staff,” she said.

Dying patients in skilled Medicare beds benefit from the kind of intensive symptom management that hospice would provide but cannot give in that setting. “That's where palliative care can help until the patient is through his skilled term and is appropriate for hospice,” Dr. Elnadry suggested.

As their consultation service developed, several benefits became apparent to Ms. Edwards and Dr. Elnadry. Hospice care in the nursing homes increased, and more patients have made the transition to the Medicare hospice benefit.

In addition, the nursing staff enjoyed heightened confidence in their assessment and symptom management skills, and felt more empowered to approach primary care physicians about symptom management for their patients, Dr. Elnadry said. She added that the nurses also have developed a higher regard for the input of their nursing assistants.

Before starting a service, be sure to plan for growth, Dr. Elnadry advised. “We had so much growth that we could not keep up, and it's not that easy to recruit people when you have a sudden growth spurt in the number of nursing home patients.”

Contracts have to be carefully worked out. Medicare Plus Choice plans often have specific hospice eligibility requirements, and sometimes will not allow hospice care if the Medicare Plus Choice program is paying for the nursing home bed, she added.

Finally, data collection is difficult when multiple institutions are involved. “If there is not adequate staff to collect data prospectively, access to data may be lost if the nursing home doesn't open its charts for review and data collection,” Dr. Elnadry said.

Meeting the Need for Palliative Care

Over the past 5 years, the nurse-practitioner model has helped Home & Hospice Care of Rhode Island, Providence, provide 350 consults and more than 1,200 nursing home visits, said Dr. Joan Teno, who is the collaborating physician with the hospice's nurse-practitioner palliative care consult service.

“This has been a very successful model for reaching a variety of nursing homes throughout the state, and our two nurse practitioners make it economically feasible to do on Medicare billing,” said Dr. Teno, professor of community health at Brown University, Providence.

“The nurse practitioners are wonderful because they shuffle very easily between the world of nursing and the world of physicians, and they're very successful at providing consults to nursing home residents who either need a pain and palliative care consult service or [would] come onto hospice services except for the financial disincentives under the skilled Medicare hospice benefit,” Dr. Teno said in an interview.

Dr. Teno added her voice to those who would like to see the Centers for Medicare and Medicaid Services improve benefits for interdisciplinary team care in nursing homes.

“And I would suggest that CMS [allow] an overlap program whereby people can access those skilled services and hospice at the same time,” she said.

The need to provide quality end-of-life care in nursing homes is mushrooming as the population of the country ages. A survey conducted in 2000 suggested that more than 40% of the chronically ill and dying spend at least some portion of their last month of life in a nursing home, according to Dr. Teno.

“We've found that [adding a] pain and palliative contract service is one means of addressing these concerns by providing very skilled nurse practitioners to provide consultations, teach and train the nursing staff, help mobilize the existing team in the nursing home, and then address questions around advance care planning and good pain management,” she said.

SALT LAKE CITY — A nurse-practitioner model can overcome regulatory and reimbursement barriers to the delivery of palliative care to patients in nursing homes, according to Dr. Jeanne Elnadry, medical director of the Hospice of Yuma (Ariz.).

“These chronically ill and terminal patients are among the most vulnerable in our society, and they have lots of needs that are not adequately addressed,” Dr. Elnadry said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“Nurse practitioners can help to fill some of that void if they have adequate training and desire,” she added.

In 2004, Dr. Elnadry—along with Peggy Edwards, a nurse practitioner certified in geriatrics and palliative care management—began developing a modest palliative care service that provides consultations to Yuma's four nursing homes, which have a total of 450 beds.

Their goals were to decrease utilization of the local hospital's emergency department, to reduce hospitalizations, and to provide better and more comprehensive care to nursing home residents, said Dr. Elnadry, who also provides palliative care consultations at the Yuma Regional Medical Center.

“Palliative care in nursing homes is for patients who, for some reason, cannot receive hospice care even though they have a prognosis of under 6 months,” Dr. Elnadry said in an interview. It's also for patients who will most likely live longer than 6 months but have a life-limiting or highly symptomatic condition, or for patients who have a condition such as Alzheimer's disease who may require palliative care for an extended period of time until they are eligible for hospice care, she said.

Many nursing home patients have terminal diagnoses with prognoses of much less than 6 months, and would benefit from the types of services available in hospice, such as social work services, the assessment and management of complex symptoms by registered nurses, and bereavement support, she said.

The role of the palliative care nurse practitioner is to provide consultations (on a physician's order), to communicate directly with the primary physician, to conduct family meetings as necessary, to write symptom management orders, and to perform follow-up for symptom management and decision making, Dr. Elnadry explained.

She noted that among the challenges to the provision of palliative care in nursing homes are several myths: that such care is strictly for the end of life; that Medicare will not pay for skilled and palliative care simultaneously; that Medicare skilled beds are only for patients who are able to participate in rehabilitative care and are going to “get better”; and that palliative care services by physicians, nurse practitioners, and physician assistants is not reimbursable.

One obstacle is that Medicare will not pay for hospice care and skilled nursing care in a nursing home at the same time, and there is no payer source for palliative care interdisciplinary teams in nursing homes. Dr. Elnadry—who bills her visits under Medicare Part B, which doesn't cover all expenses—said that the Centers for Medicare and Medicaid Services needs to address the needs of these very ill nursing home patients.

“Because there is no adequate system for reimbursement for the time required for complex consultations and family meetings, some programs rely on grants, but you can't run a health care system on grants. We didn't obtain a grant and [thus] have to cover our costs through billing. That's important because a nurse practitioner costs less than a physician, so if the nurse sees enough patients, then the billing may cover her costs,” Dr. Elnadry said in an interview.

Ms. Edwards noted that “ours is a heavily regulated industry with an unbelievable burden of rules and regulations that weigh against palliative care in nursing homes.” There is no incentive to accept a patient into a nursing home if he or she is considered “terminal,” she added.

The first step in implementing a palliative care service in the nursing home is to identify those with the authority to help you succeed, Ms. Edwards explained. “Develop your champions, including the administrator, the head of finance, the minimum data set coordinator, the director of nursing, and perhaps your director of social services. These are key people with clout.”

Ms. Edwards recommended targeting appropriate patients for palliative care, such as patients with aggressive advanced disease and a poor prognosis or those who have functional decline despite receiving physical therapy rehabilitation; patients who make frequent trips to the hospital; and patients with acute, chronic, or uncontrolled pain.

“Include advance care planning with advance directives, and address psychosocial and spiritual concerns with patients and their families, and with caregivers and staff,” she said.

Dying patients in skilled Medicare beds benefit from the kind of intensive symptom management that hospice would provide but cannot give in that setting. “That's where palliative care can help until the patient is through his skilled term and is appropriate for hospice,” Dr. Elnadry suggested.

As their consultation service developed, several benefits became apparent to Ms. Edwards and Dr. Elnadry. Hospice care in the nursing homes increased, and more patients have made the transition to the Medicare hospice benefit.

In addition, the nursing staff enjoyed heightened confidence in their assessment and symptom management skills, and felt more empowered to approach primary care physicians about symptom management for their patients, Dr. Elnadry said. She added that the nurses also have developed a higher regard for the input of their nursing assistants.

Before starting a service, be sure to plan for growth, Dr. Elnadry advised. “We had so much growth that we could not keep up, and it's not that easy to recruit people when you have a sudden growth spurt in the number of nursing home patients.”

Contracts have to be carefully worked out. Medicare Plus Choice plans often have specific hospice eligibility requirements, and sometimes will not allow hospice care if the Medicare Plus Choice program is paying for the nursing home bed, she added.

Finally, data collection is difficult when multiple institutions are involved. “If there is not adequate staff to collect data prospectively, access to data may be lost if the nursing home doesn't open its charts for review and data collection,” Dr. Elnadry said.

Meeting the Need for Palliative Care

Over the past 5 years, the nurse-practitioner model has helped Home & Hospice Care of Rhode Island, Providence, provide 350 consults and more than 1,200 nursing home visits, said Dr. Joan Teno, who is the collaborating physician with the hospice's nurse-practitioner palliative care consult service.

“This has been a very successful model for reaching a variety of nursing homes throughout the state, and our two nurse practitioners make it economically feasible to do on Medicare billing,” said Dr. Teno, professor of community health at Brown University, Providence.

“The nurse practitioners are wonderful because they shuffle very easily between the world of nursing and the world of physicians, and they're very successful at providing consults to nursing home residents who either need a pain and palliative care consult service or [would] come onto hospice services except for the financial disincentives under the skilled Medicare hospice benefit,” Dr. Teno said in an interview.

Dr. Teno added her voice to those who would like to see the Centers for Medicare and Medicaid Services improve benefits for interdisciplinary team care in nursing homes.

“And I would suggest that CMS [allow] an overlap program whereby people can access those skilled services and hospice at the same time,” she said.

The need to provide quality end-of-life care in nursing homes is mushrooming as the population of the country ages. A survey conducted in 2000 suggested that more than 40% of the chronically ill and dying spend at least some portion of their last month of life in a nursing home, according to Dr. Teno.

“We've found that [adding a] pain and palliative contract service is one means of addressing these concerns by providing very skilled nurse practitioners to provide consultations, teach and train the nursing staff, help mobilize the existing team in the nursing home, and then address questions around advance care planning and good pain management,” she said.

SALT LAKE CITY — A nurse-practitioner model can overcome regulatory and reimbursement barriers to the delivery of palliative care to patients in nursing homes, according to Dr. Jeanne Elnadry, medical director of the Hospice of Yuma (Ariz.).

“These chronically ill and terminal patients are among the most vulnerable in our society, and they have lots of needs that are not adequately addressed,” Dr. Elnadry said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“Nurse practitioners can help to fill some of that void if they have adequate training and desire,” she added.

In 2004, Dr. Elnadry—along with Peggy Edwards, a nurse practitioner certified in geriatrics and palliative care management—began developing a modest palliative care service that provides consultations to Yuma's four nursing homes, which have a total of 450 beds.

Their goals were to decrease utilization of the local hospital's emergency department, to reduce hospitalizations, and to provide better and more comprehensive care to nursing home residents, said Dr. Elnadry, who also provides palliative care consultations at the Yuma Regional Medical Center.

“Palliative care in nursing homes is for patients who, for some reason, cannot receive hospice care even though they have a prognosis of under 6 months,” Dr. Elnadry said in an interview. It's also for patients who will most likely live longer than 6 months but have a life-limiting or highly symptomatic condition, or for patients who have a condition such as Alzheimer's disease who may require palliative care for an extended period of time until they are eligible for hospice care, she said.

Many nursing home patients have terminal diagnoses with prognoses of much less than 6 months, and would benefit from the types of services available in hospice, such as social work services, the assessment and management of complex symptoms by registered nurses, and bereavement support, she said.

The role of the palliative care nurse practitioner is to provide consultations (on a physician's order), to communicate directly with the primary physician, to conduct family meetings as necessary, to write symptom management orders, and to perform follow-up for symptom management and decision making, Dr. Elnadry explained.

She noted that among the challenges to the provision of palliative care in nursing homes are several myths: that such care is strictly for the end of life; that Medicare will not pay for skilled and palliative care simultaneously; that Medicare skilled beds are only for patients who are able to participate in rehabilitative care and are going to “get better”; and that palliative care services by physicians, nurse practitioners, and physician assistants is not reimbursable.

One obstacle is that Medicare will not pay for hospice care and skilled nursing care in a nursing home at the same time, and there is no payer source for palliative care interdisciplinary teams in nursing homes. Dr. Elnadry—who bills her visits under Medicare Part B, which doesn't cover all expenses—said that the Centers for Medicare and Medicaid Services needs to address the needs of these very ill nursing home patients.

“Because there is no adequate system for reimbursement for the time required for complex consultations and family meetings, some programs rely on grants, but you can't run a health care system on grants. We didn't obtain a grant and [thus] have to cover our costs through billing. That's important because a nurse practitioner costs less than a physician, so if the nurse sees enough patients, then the billing may cover her costs,” Dr. Elnadry said in an interview.

Ms. Edwards noted that “ours is a heavily regulated industry with an unbelievable burden of rules and regulations that weigh against palliative care in nursing homes.” There is no incentive to accept a patient into a nursing home if he or she is considered “terminal,” she added.

The first step in implementing a palliative care service in the nursing home is to identify those with the authority to help you succeed, Ms. Edwards explained. “Develop your champions, including the administrator, the head of finance, the minimum data set coordinator, the director of nursing, and perhaps your director of social services. These are key people with clout.”

Ms. Edwards recommended targeting appropriate patients for palliative care, such as patients with aggressive advanced disease and a poor prognosis or those who have functional decline despite receiving physical therapy rehabilitation; patients who make frequent trips to the hospital; and patients with acute, chronic, or uncontrolled pain.

“Include advance care planning with advance directives, and address psychosocial and spiritual concerns with patients and their families, and with caregivers and staff,” she said.

Dying patients in skilled Medicare beds benefit from the kind of intensive symptom management that hospice would provide but cannot give in that setting. “That's where palliative care can help until the patient is through his skilled term and is appropriate for hospice,” Dr. Elnadry suggested.

As their consultation service developed, several benefits became apparent to Ms. Edwards and Dr. Elnadry. Hospice care in the nursing homes increased, and more patients have made the transition to the Medicare hospice benefit.

In addition, the nursing staff enjoyed heightened confidence in their assessment and symptom management skills, and felt more empowered to approach primary care physicians about symptom management for their patients, Dr. Elnadry said. She added that the nurses also have developed a higher regard for the input of their nursing assistants.

Before starting a service, be sure to plan for growth, Dr. Elnadry advised. “We had so much growth that we could not keep up, and it's not that easy to recruit people when you have a sudden growth spurt in the number of nursing home patients.”

Contracts have to be carefully worked out. Medicare Plus Choice plans often have specific hospice eligibility requirements, and sometimes will not allow hospice care if the Medicare Plus Choice program is paying for the nursing home bed, she added.

Finally, data collection is difficult when multiple institutions are involved. “If there is not adequate staff to collect data prospectively, access to data may be lost if the nursing home doesn't open its charts for review and data collection,” Dr. Elnadry said.

Meeting the Need for Palliative Care

Over the past 5 years, the nurse-practitioner model has helped Home & Hospice Care of Rhode Island, Providence, provide 350 consults and more than 1,200 nursing home visits, said Dr. Joan Teno, who is the collaborating physician with the hospice's nurse-practitioner palliative care consult service.

“This has been a very successful model for reaching a variety of nursing homes throughout the state, and our two nurse practitioners make it economically feasible to do on Medicare billing,” said Dr. Teno, professor of community health at Brown University, Providence.

“The nurse practitioners are wonderful because they shuffle very easily between the world of nursing and the world of physicians, and they're very successful at providing consults to nursing home residents who either need a pain and palliative care consult service or [would] come onto hospice services except for the financial disincentives under the skilled Medicare hospice benefit,” Dr. Teno said in an interview.

Dr. Teno added her voice to those who would like to see the Centers for Medicare and Medicaid Services improve benefits for interdisciplinary team care in nursing homes.

“And I would suggest that CMS [allow] an overlap program whereby people can access those skilled services and hospice at the same time,” she said.

The need to provide quality end-of-life care in nursing homes is mushrooming as the population of the country ages. A survey conducted in 2000 suggested that more than 40% of the chronically ill and dying spend at least some portion of their last month of life in a nursing home, according to Dr. Teno.

“We've found that [adding a] pain and palliative contract service is one means of addressing these concerns by providing very skilled nurse practitioners to provide consultations, teach and train the nursing staff, help mobilize the existing team in the nursing home, and then address questions around advance care planning and good pain management,” she said.

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross-reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test. Both of the IGRAs correlate with exposure better than the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IGRAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

More needs to be learned about using IGRAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IGRAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

A new class of tuberculosis tests, in vitro T-cell-based interferon-γ release assays, may become available soon, Dr. Charles Daley said. Marcia Ward

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross-reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test. Both of the IGRAs correlate with exposure better than the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IGRAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

More needs to be learned about using IGRAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IGRAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

A new class of tuberculosis tests, in vitro T-cell-based interferon-γ release assays, may become available soon, Dr. Charles Daley said. Marcia Ward

KEYSTONE, COLO. — New tests that detect latent tuberculosis infection by quantifying interferon-γ released from sensitized lymphocytes in whole blood may be a big step toward the elimination of TB, Dr. Charles Daley said at a meeting on allergy/clinical immunology, asthma, and pulmonary medicine.

This class of tests, called in vitro T-cell-based interferon-γ release assays (IGRAs), is the first replacement for the flawed tuberculin skin test, which has been in use in one form or another for a century.

“We absolutely can and must replace the tuberculin skin test, and the reason we can is because of these specific mycobacterium tuberculosis antigens, ESAT-6 and CFP-10,” Dr. Daley said at the meeting, sponsored by the National Jewish Medical and Research Center.

The first replacement for the tuberculin skin test in a century, Quantiferon-TB (Cellestis), was approved by the Food and Drug Administration in 2001.

A version called Quantiferon-TB Gold In-Tube, which should be available this summer, will allow the drawing of blood directly into tubes containing the antigens, said Dr. Daley, who is head of mycobacterial and respiratory infections at National Jewish, Denver.

Another impending test is T-Spot.TB (Oxford Immunotec Ltd.), which detects or spots individual T cells, and can be used for the diagnosis of latent disease simply by detecting the presence of an effector T-cell response.

A major advantage of these new tests is that they avoid false-positive results caused by previous inoculation with the BCG vaccine, which is widely used outside the United States and is a critical factor in the screening of foreign-born individuals.

“Over time, this cross-reactivity has led to a distrust of the skin test in vaccinated people, many of whom can't remember when or even if they received BCG,” Dr. Daley explained.

Dr. Daley, who consults for both companies, said that IGRAs are more sensitive and specific than the tuberculin skin test. Both of the IGRAs correlate with exposure better than the tuberculin skin test, and may be more cost effective as well, he explained.

In addition, IGRAs require only one patient visit, assess responses to multiple antigens simultaneously, do not boost anamnestic immune responses, provide results within a day, and greatly reduce interreader variability.

A prospective study of 393 consecutively enrolled patients with latent tuberculosis infection or suspected TB looked at agreement between the tuberculin skin test and both interferon-γ release assays, and found that indeterminate results were more common with Quantiferon-TB than with T-Spot.TB, particularly in young children and those who were immunocompromised (Lancet 2006;367:1328–34).

More needs to be learned about using IGRAs for serial testing. To that end, Dr. Daley and others are launching a four-center U.S. study of 3,000 health care workers who will be tested every 6 months with skin tests and both IGRAs.

Meanwhile, Dr. Daley and his colleagues at National Jewish are using Quantiferon-TB Gold and will begin using T-Spot.TB this summer.

A new class of tuberculosis tests, in vitro T-cell-based interferon-γ release assays, may become available soon, Dr. Charles Daley said. Marcia Ward

SALT LAKE CITY — State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion and misunderstanding persist among regulators and practitioners, according to David E. Joranson.

“There are some positive aspects of policies being developed over the last several years because [states] are more affirmatively recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison.

The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse,” he said.

A large number of physicians don't have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use, a lapse that can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“The major organizations advocating for improved pain management in palliative care should focus the attention of their members on better understanding how policies can improve patient care, and then work to bring change to those policies that are hindering treatment,” Mr. Joranson said in an interview.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, attendees participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many of the participants in the survey also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies.

The group's efforts culminated in a “report card,” which was issued in 2006. The overall grade improved over the period of the study in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse physical dependence with addiction are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

States that have no statutes relating to pain management and no regulations or guidelines from the state medical or pharmacy boards are Alaska, Delaware, Illinois, and Indiana, Mr. Joranson said.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

“Obviously, some of the laws that have the potential to confuse patients and practitioners need to be changed,” Mr. Joranson said.

“This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes,” he added.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Endo Pharmaceuticals and Purdue Pharma L.P.

For more information and links to other resources, go to www.painpolicy.wisc.edu/index.htm

'If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain.' MR. JORANSON

SALT LAKE CITY — State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion and misunderstanding persist among regulators and practitioners, according to David E. Joranson.

“There are some positive aspects of policies being developed over the last several years because [states] are more affirmatively recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison.

The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse,” he said.

A large number of physicians don't have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use, a lapse that can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“The major organizations advocating for improved pain management in palliative care should focus the attention of their members on better understanding how policies can improve patient care, and then work to bring change to those policies that are hindering treatment,” Mr. Joranson said in an interview.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, attendees participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many of the participants in the survey also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies.

The group's efforts culminated in a “report card,” which was issued in 2006. The overall grade improved over the period of the study in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse physical dependence with addiction are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

States that have no statutes relating to pain management and no regulations or guidelines from the state medical or pharmacy boards are Alaska, Delaware, Illinois, and Indiana, Mr. Joranson said.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

“Obviously, some of the laws that have the potential to confuse patients and practitioners need to be changed,” Mr. Joranson said.

“This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes,” he added.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Endo Pharmaceuticals and Purdue Pharma L.P.

For more information and links to other resources, go to www.painpolicy.wisc.edu/index.htm

'If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain.' MR. JORANSON

SALT LAKE CITY — State laws governing the availability and use of opioid analgesics are becoming less onerous, but confusion and misunderstanding persist among regulators and practitioners, according to David E. Joranson.

“There are some positive aspects of policies being developed over the last several years because [states] are more affirmatively recognizing how valuable opioids are in medical practice,” said Mr. Joranson, director of the University of Wisconsin Pain and Policy Studies Group in Madison.

The group's mission is to “achieve more balanced international, national, and state policies so that patients' access to pain medications is not compromised by efforts to prevent diversion and drug abuse,” he said.

A large number of physicians don't have a clear understanding of federal and state regulations governing pain management and overestimate state and federal restrictions on opioid use, a lapse that can contribute to unreasonable fear of regulatory scrutiny and unnecessary conservatism in prescribing, he said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“The major organizations advocating for improved pain management in palliative care should focus the attention of their members on better understanding how policies can improve patient care, and then work to bring change to those policies that are hindering treatment,” Mr. Joranson said in an interview.

“If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain. If he doesn't know the law, he might be concerned,” he added.

During a luncheon presentation, attendees participated in an electronic survey that showed significant gaps in knowledge.

For example, more than half of the 300 survey participants, which included physicians and nurses, said that the Drug Enforcement Administration limits prescriptions for schedule II controlled substances such as morphine to a 30-day supply, when in fact the DEA permits an unlimited supply (though the agency is currently finalizing a 90-day supply limit).

Many of the participants in the survey also were unaware that several states recently adopted pain policies and eliminated restrictions on drug quantity, Mr. Joranson said. This same survey drew similar results at the recent annual meeting of the American Academy of Pain Medicine in New Orleans, he added.

The Wisconsin Pain and Policy Studies Group conducted a 6-year evaluation and analysis of each state's policies.

The group's efforts culminated in a “report card,” which was issued in 2006. The overall grade improved over the period of the study in 19 states.

Mr. Joranson said that, unfortunately, 16 states confuse physical dependence and addiction, and at least one state contradicts itself. The Pennsylvania Uniform Controlled Substances Act defines a drug-dependent person as someone “who is using a drug, controlled substance, or alcohol, and who is in a state of psychic or physical dependence, or both. … This definition shall include those persons commonly known as 'drug addicts.'”

Yet the Pennsylvania State Board of Medicine guideline says physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.

“So if you have a physically dependent pain patient in Pennsylvania, depending on which definition you look at, that person either is an addict or is definitively not an addict,” Mr. Joranson said.

Other states that confuse physical dependence with addiction are Arizona, Colorado, Georgia, Hawaii, Idaho, Indiana, Louisiana, Maryland, Missouri, Nevada, New Jersey, North Carolina, Oklahoma, Tennessee, and Wyoming.

States that have no statutes relating to pain management and no regulations or guidelines from the state medical or pharmacy boards are Alaska, Delaware, Illinois, and Indiana, Mr. Joranson said.

A model policy is available from the Federation of State Medical Boards, summarized as follows:

▸ Controlled substances are necessary for public health.

▸ People should have access to appropriate and effective pain relief.

▸ Pain management is part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness.

▸ Physicians should not fear regulatory sanctions.

▸ Physical dependence is not synonymous with addiction.

“Obviously, some of the laws that have the potential to confuse patients and practitioners need to be changed,” Mr. Joranson said.

“This is an opportunity for physicians to come forward and explain to policy makers the importance of making those changes,” he added.

Mr. Joranson has received honoraria from A.L. Pharma Inc. and Abbott Laboratories, and he has received grant support from Endo Pharmaceuticals and Purdue Pharma L.P.

For more information and links to other resources, go to www.painpolicy.wisc.edu/index.htm

'If a physician knows the laws, he should be perfectly comfortable prescribing opioids for chronic pain.' MR. JORANSON