Heidi Splete

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Measles Outbreak in Boarding School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses.

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

The most severe cases occurred in the two unvaccinated students—13-year-old twins who were hospitalized for dehydration. Overall, the six vaccinated patients had significantly fewer days of rash (5 vs. 10) and fewer missed days of school or work (5 vs. 8), compared with the unvaccinated patients, the investigators said.

Hepatitis A Vaccine Cuts Outbreaks

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health in Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a communitywide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

In contrast to the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers.

FluMist School Program Shows Benefit

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls.

Overall, both adults and children in the test school households reported significantly fewer fever- and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Chlamydia Follow-Up Needs Work

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Significantly fewer boys than girls received either safe sex counseling (62% vs. 83%) or partner management advice (31% vs. 57%). The lack of counseling illustrates a missed opportunity to moderate high-risk behavior, the researchers noted.

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

Vaccine Contains Measles in School

The largest reported school-based measles outbreak in the United States since 1998 was limited to nine cases—eight students and one adult staff member—in a boarding school of more than 600 students, said Dr. Lorraine F. Yeung of the Centers for Disease Control and Prevention, Atlanta, and her associates.

A total of 629 (95%) of the 663 students aged 13–26 years had received at least two doses of measles-containing vaccine (MCV); two of those students had accidentally received a third dose. Eight students had not received any vaccination; four of these had not been vaccinated for philosophical or religious reasons (Pediatrics 2005;116:1287–91). The vaccine effectiveness rate was 97% among the 627 students who received two doses, but it was higher among those who had received both doses in the United States than among those who received both doses outside the United States (99% vs. 94%).

Six of the eight student cases had received two doses of vaccine, and two were unvaccinated. Of the six vaccinated patients, three had received their doses outside of the United States, including the source patient, a 17-year-old boy who had traveled to Beirut, Lebanon, and became ill upon his return.

Lack of Follow-Up for Chlamydia

The majority of adolescents received appropriate antibiotics for chlamydia an average of 6 days after testing positive, but few received other types of follow-up care, based on a study of 122 patients, said Dr. Loris Y. Hwang and colleagues at the University of California, San Francisco.

The 96 girls and 26 boys aged 14–19 years had tested positive for Chlamydia trachomatis infection during the study period, and 118 cases were treated. Although 97% of the adolescents received appropriate antibiotics, only 79% received safe sex counseling and 52% received partner management advice (Arch. Pediatr. Adolesc. Med. 2005;159:1162–6).

Hepatitis in Child Care Settings

Routine implementation of the hepatitis A vaccine contributed to historically low levels of infection—6/100,000 people—in Maricopa County, Ariz., said Hesha Jani Duggirala, Ph.D., of Tulane University, New Orleans, and the Maricopa County Department of Public Health, Phoenix.

Maricopa County traditionally averaged 38 hepatitis cases per 100,000 people—more than three times the national average. In a community-wide outbreak in 1997, hepatitis patients were more than six times as likely to have a history of attending or working in a child care center, compared with healthy people, and approximately 40% of cases in 1997 were linked to direct or indirect child care contact. This finding prompted the requirement of hepatitis A vaccination for all children aged 2–5 years who attended child care centers (Pediatr. Infect. Dis. J. 2005;24:974–8).

According to data from the Arizona State Immunization Information System, 23,817 children aged 2–5 years living in Maricopa County received one dose of the hepatitis A vaccine between February 1999 and June 2000; this number represented approximately 12% of children aged 2–5 years living in the county.

During 1998–2001, the age-specific incidence declined for all age groups; the steepest declines occurred among children aged 0–4 years (−91%) and aged 5–9 years (−94%).

Unlike the 1997 outbreak, few cases reported during 1998–2001 were associated with child care centers. The researchers conducted a case-control study of 72 cases and 144 age-matched controls, and found that neither direct nor indirect child care center contact was significantly associated with illness in a logistic regression analysis, although direct contact with an infected person remained a significant risk factor.

FluMist Program Cuts Illness Rates

Use of live, attentuated flu vaccine significantly reduced the rates of fever and respiratory illness in a pilot study of 185 school-aged children, said Dr. James C. King Jr. of the University of Maryland, Baltimore, and his associates.

Children at a designated test school received the live, attenuated vaccine (FluMist) prior to the 2003–2004 flu season, while children from two other schools in the community served as controls (Pediatrics 2005;116:868–73).

Overall, adults and children in the test school households reported significantly fewer fever and respiratory illness-related ambulatory physician visits, compared with controls, during a 7-day recall period near the peak influenza week in December 2003. The most significant differences between the test and control groups included the mean number of child medical visits per 100 children (5.6 in the test school group, compared with 15.3 and 18.3 in the two control groups) and the number of over-the-counter medicines purchased per 100 households (25.9 in the test group vs. 51.2 and 44.5 for the two control groups).

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.

ST. LOUIS — A medical practice intervention reduced the incidence of Candida species from 36% among 45 control neonates admitted between Jan. 1, 1995, and June 30, 1996, to 6% among 69 neonates admitted between July 1, 1996, and December 31, 1998, said Dr. Maliha J. Shareef in a poster presented at the annual meeting of the Midwest Society for Pediatric Research.

The intervention included administration of oral nystatin every 6 hours for the first week of life, and as an accompaniment to each antibiotic course during the first 4 weeks, wrote Dr. Shareef of St. Francis Medical Center, Peoria, Ill. Modification of parameters for early extubation, early discontinuation of central lines, and use of parenteral nutrition and antibiotics also were part of the intervention.

The study included neonates weighing 750 g or less at birth, who were admitted to a neonatal ICU within the first week of life.

A retrospective analysis revealed that the intervention group experienced significantly fewer episodes of Candida after controlling for gestational age, model of delivery, and number of days of central vascular access. However, exposure to a high humidity environment was significantly associated with an increased risk of Candida sepsis within the intervention group (odds ratio 10.5).

Overall infection rates remained in the 0%–3% range during 1999–2004.

WASHINGTON — Attention to diet will successfully manage cholesterol in many children, especially young ones, said Dr. Samuel S. Gidding of the Alfred I. duPont Hospital for Children in Wilmington, Del.

“Cholesterol levels are determined by genetics, plus or minus how bad your diet is,” he noted at the annual meeting of the American Academy of Pediatrics. Test cholesterol levels in all children at age 5 or 6 years, and again after puberty.

Dr. Gidding, who has received research funding from AstraZeneca, explained that he rarely puts children younger than 10 years on lipid-lowering drugs, and almost never starts girls younger than 13. Cholesterol levels vary greatly around puberty, with the lowest levels occurring during the pubertal growth spurt. If they remain high after puberty, they are likely to remain high without management.

A cholesterol treatment diet involves taking in less than 30% of calories from fat, less than 7% of calories from saturated fat, and fewer than 200 mg of cholesterol daily. Also, the diet must be sufficient in micronutrients and provide appropriate energy for normal growth.

Dr. Gidding was involved in a 3-year randomized trial in which children who underwent dietary intervention significantly reduced their cholesterol levels, compared with children who did not change their diets. Both groups grew equally well.

An oil that is liquid at room temperature contains monounsaturated or polyunsaturated fats, and is okay for children on controlled diets, Dr. Gidding noted. If the product is solid at room temperature, then it contains saturated fats or trans fats, and should be avoided.

Additional diet directions include reducing salt intake and encouraging children to increase their intake of dietary fiber through the consumption of fruits, vegetables, and legumes.

A low-fat diet can lower cholesterol in most children. Such a diet is safe and effective, but if the child's LDL cholesterol level is extremely high, such as 190 mg/dL, diet is not enough.

It was once thought that the liver was the main synthesizer of LDL cholesterol, but it is now known that the liver receives nearly 80% of its LDL cholesterol from synthesis in other parts of the body, as well as other sources, Dr. Gidding said.

The LDL cholesterol receptors sit on the liver cell and scavenge LDL cholesterol from the bloodstream. In children with genetic disorders, such as familial hypercholesterolemia, the liver receptors don't function and LDL cholesterol essentially gets stuck in the bloodstream. These children will have LDL levels of 160 mg/dL or higher. The main issue for these children is when—not whether—to start drug treatment. Diet remains extremely important as well, Dr. Gidding said.

When selecting children or adolescents for drug therapy, consider the child's age and gender; the family's prior experience with medications; the drug's safety; the child's likely compliance; and the goal of therapy. Also consider whether the child has either an LDL cholesterol level of at least 190 mg/dL, or an LDL level of at least 160 mg/dL plus multiple risk factors.

Statins can lower cholesterol by approximately 20%, and are generally safe and well tolerated, although risks increase with the use of multiple medications, Dr. Gidding said.

Starting doses range from 5 to 10 mg/day, and liver function, as well as cholesterol levels, must be monitored. Four statins available on the market—Lovastatin, Pravastatin, Simvastatin, and Atorvastatin—have demonstrated safety and efficacy for more than 1 year in children.

In addition to monitoring liver function, monitor children on statins for complaints of muscle pain. If a child reports such pain, stop the drug immediately and have the child evaluated for rhabdomyolysis, a rare but serious condition in which muscle pain is an important early symptom.

Adolescent girls who become pregnant or who are breast-feeding should not take statins.

There are no specific guidelines for the treatment of high triglyceride levels in children, Dr. Gidding said. Drugs that are currently approved for adults may have unfavorable side effects in children.

An elevated triglyceride level has emerged as a significant lipid problem in children because of the obesity epidemic; it also may be a marker for insulin resistance. High carbohydrate intake increases triglyceride levels.

Weight control and exercise are the primary treatments for high triglyceride levels, Dr. Gidding said. Simply limiting a child's intake of fruit juice or sweetened drinks to no more than 12 ounces daily can significantly reduce triglyceride levels.

Fish oil has been shown to lower triglyceride levels, and may be the best choice, but its anticoagulation properties may be a concern for children who are involved in sports that involve a lot of physical contact or a high risk of injury. For patients who want to try fish oil, Dr. Gidding recommends starting with 2 g daily. However, patients with triglyceride levels greater than 1,000 mg/dL require an individualized diet and must be seen by a specialist.

For user-friendly information about cholesterol and children, and about diet and nutrition, visit or direct patients to the American Heart Association's Web site: www.americanheart.org

WASHINGTON — Attention to diet will successfully manage cholesterol in many children, especially young ones, said Dr. Samuel S. Gidding of the Alfred I. duPont Hospital for Children in Wilmington, Del.

“Cholesterol levels are determined by genetics, plus or minus how bad your diet is,” he noted at the annual meeting of the American Academy of Pediatrics. Test cholesterol levels in all children at age 5 or 6 years, and again after puberty.

Dr. Gidding, who has received research funding from AstraZeneca, explained that he rarely puts children younger than 10 years on lipid-lowering drugs, and almost never starts girls younger than 13. Cholesterol levels vary greatly around puberty, with the lowest levels occurring during the pubertal growth spurt. If they remain high after puberty, they are likely to remain high without management.

A cholesterol treatment diet involves taking in less than 30% of calories from fat, less than 7% of calories from saturated fat, and fewer than 200 mg of cholesterol daily. Also, the diet must be sufficient in micronutrients and provide appropriate energy for normal growth.

Dr. Gidding was involved in a 3-year randomized trial in which children who underwent dietary intervention significantly reduced their cholesterol levels, compared with children who did not change their diets. Both groups grew equally well.

An oil that is liquid at room temperature contains monounsaturated or polyunsaturated fats, and is okay for children on controlled diets, Dr. Gidding noted. If the product is solid at room temperature, then it contains saturated fats or trans fats, and should be avoided.

Additional diet directions include reducing salt intake and encouraging children to increase their intake of dietary fiber through the consumption of fruits, vegetables, and legumes.

A low-fat diet can lower cholesterol in most children. Such a diet is safe and effective, but if the child's LDL cholesterol level is extremely high, such as 190 mg/dL, diet is not enough.

It was once thought that the liver was the main synthesizer of LDL cholesterol, but it is now known that the liver receives nearly 80% of its LDL cholesterol from synthesis in other parts of the body, as well as other sources, Dr. Gidding said.

The LDL cholesterol receptors sit on the liver cell and scavenge LDL cholesterol from the bloodstream. In children with genetic disorders, such as familial hypercholesterolemia, the liver receptors don't function and LDL cholesterol essentially gets stuck in the bloodstream. These children will have LDL levels of 160 mg/dL or higher. The main issue for these children is when—not whether—to start drug treatment. Diet remains extremely important as well, Dr. Gidding said.

When selecting children or adolescents for drug therapy, consider the child's age and gender; the family's prior experience with medications; the drug's safety; the child's likely compliance; and the goal of therapy. Also consider whether the child has either an LDL cholesterol level of at least 190 mg/dL, or an LDL level of at least 160 mg/dL plus multiple risk factors.

Statins can lower cholesterol by approximately 20%, and are generally safe and well tolerated, although risks increase with the use of multiple medications, Dr. Gidding said.

Starting doses range from 5 to 10 mg/day, and liver function, as well as cholesterol levels, must be monitored. Four statins available on the market—Lovastatin, Pravastatin, Simvastatin, and Atorvastatin—have demonstrated safety and efficacy for more than 1 year in children.

In addition to monitoring liver function, monitor children on statins for complaints of muscle pain. If a child reports such pain, stop the drug immediately and have the child evaluated for rhabdomyolysis, a rare but serious condition in which muscle pain is an important early symptom.

Adolescent girls who become pregnant or who are breast-feeding should not take statins.

There are no specific guidelines for the treatment of high triglyceride levels in children, Dr. Gidding said. Drugs that are currently approved for adults may have unfavorable side effects in children.

An elevated triglyceride level has emerged as a significant lipid problem in children because of the obesity epidemic; it also may be a marker for insulin resistance. High carbohydrate intake increases triglyceride levels.

Weight control and exercise are the primary treatments for high triglyceride levels, Dr. Gidding said. Simply limiting a child's intake of fruit juice or sweetened drinks to no more than 12 ounces daily can significantly reduce triglyceride levels.

Fish oil has been shown to lower triglyceride levels, and may be the best choice, but its anticoagulation properties may be a concern for children who are involved in sports that involve a lot of physical contact or a high risk of injury. For patients who want to try fish oil, Dr. Gidding recommends starting with 2 g daily. However, patients with triglyceride levels greater than 1,000 mg/dL require an individualized diet and must be seen by a specialist.

For user-friendly information about cholesterol and children, and about diet and nutrition, visit or direct patients to the American Heart Association's Web site: www.americanheart.org

WASHINGTON — Attention to diet will successfully manage cholesterol in many children, especially young ones, said Dr. Samuel S. Gidding of the Alfred I. duPont Hospital for Children in Wilmington, Del.

“Cholesterol levels are determined by genetics, plus or minus how bad your diet is,” he noted at the annual meeting of the American Academy of Pediatrics. Test cholesterol levels in all children at age 5 or 6 years, and again after puberty.

Dr. Gidding, who has received research funding from AstraZeneca, explained that he rarely puts children younger than 10 years on lipid-lowering drugs, and almost never starts girls younger than 13. Cholesterol levels vary greatly around puberty, with the lowest levels occurring during the pubertal growth spurt. If they remain high after puberty, they are likely to remain high without management.

A cholesterol treatment diet involves taking in less than 30% of calories from fat, less than 7% of calories from saturated fat, and fewer than 200 mg of cholesterol daily. Also, the diet must be sufficient in micronutrients and provide appropriate energy for normal growth.

Dr. Gidding was involved in a 3-year randomized trial in which children who underwent dietary intervention significantly reduced their cholesterol levels, compared with children who did not change their diets. Both groups grew equally well.

An oil that is liquid at room temperature contains monounsaturated or polyunsaturated fats, and is okay for children on controlled diets, Dr. Gidding noted. If the product is solid at room temperature, then it contains saturated fats or trans fats, and should be avoided.

Additional diet directions include reducing salt intake and encouraging children to increase their intake of dietary fiber through the consumption of fruits, vegetables, and legumes.

A low-fat diet can lower cholesterol in most children. Such a diet is safe and effective, but if the child's LDL cholesterol level is extremely high, such as 190 mg/dL, diet is not enough.

It was once thought that the liver was the main synthesizer of LDL cholesterol, but it is now known that the liver receives nearly 80% of its LDL cholesterol from synthesis in other parts of the body, as well as other sources, Dr. Gidding said.

The LDL cholesterol receptors sit on the liver cell and scavenge LDL cholesterol from the bloodstream. In children with genetic disorders, such as familial hypercholesterolemia, the liver receptors don't function and LDL cholesterol essentially gets stuck in the bloodstream. These children will have LDL levels of 160 mg/dL or higher. The main issue for these children is when—not whether—to start drug treatment. Diet remains extremely important as well, Dr. Gidding said.

When selecting children or adolescents for drug therapy, consider the child's age and gender; the family's prior experience with medications; the drug's safety; the child's likely compliance; and the goal of therapy. Also consider whether the child has either an LDL cholesterol level of at least 190 mg/dL, or an LDL level of at least 160 mg/dL plus multiple risk factors.

Statins can lower cholesterol by approximately 20%, and are generally safe and well tolerated, although risks increase with the use of multiple medications, Dr. Gidding said.

Starting doses range from 5 to 10 mg/day, and liver function, as well as cholesterol levels, must be monitored. Four statins available on the market—Lovastatin, Pravastatin, Simvastatin, and Atorvastatin—have demonstrated safety and efficacy for more than 1 year in children.

In addition to monitoring liver function, monitor children on statins for complaints of muscle pain. If a child reports such pain, stop the drug immediately and have the child evaluated for rhabdomyolysis, a rare but serious condition in which muscle pain is an important early symptom.

Adolescent girls who become pregnant or who are breast-feeding should not take statins.

There are no specific guidelines for the treatment of high triglyceride levels in children, Dr. Gidding said. Drugs that are currently approved for adults may have unfavorable side effects in children.

An elevated triglyceride level has emerged as a significant lipid problem in children because of the obesity epidemic; it also may be a marker for insulin resistance. High carbohydrate intake increases triglyceride levels.

Weight control and exercise are the primary treatments for high triglyceride levels, Dr. Gidding said. Simply limiting a child's intake of fruit juice or sweetened drinks to no more than 12 ounces daily can significantly reduce triglyceride levels.

Fish oil has been shown to lower triglyceride levels, and may be the best choice, but its anticoagulation properties may be a concern for children who are involved in sports that involve a lot of physical contact or a high risk of injury. For patients who want to try fish oil, Dr. Gidding recommends starting with 2 g daily. However, patients with triglyceride levels greater than 1,000 mg/dL require an individualized diet and must be seen by a specialist.

For user-friendly information about cholesterol and children, and about diet and nutrition, visit or direct patients to the American Heart Association's Web site: www.americanheart.org

WASHINGTON – Don't exclude a diagnosis of myocardial infarction unless you have done objective testing first, Dr. Corey M. Slovis said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of myocardial infarction (MI) is a leading cause of emergency department malpractice awards in the United States, noted Dr. Slovis, chairman of the emergency medicine department at Vanderbilt University, Nashville, Tenn. Even though chest pain is a hallmark of acute MI, this pain may be absent or fleeting, and it may not be substernal. In fact, chest pain may be stabbing, pleuritic, or palpable.

“My goal is for you to accept that in some cases, testing is better than clinical judgment,” Dr. Slovis said. “There are times when an objective test is better than no test.”

Enzymes can be helpful tools in diagnosing acute myocardial infarction, but they should not be used in isolation. “One set of negative enzymes does not mean the absence of acute coronary syndrome,” Dr. Slovis said. He cited a 2001 metaanalysis of 22 years' worth of studies, which showed that a single set of enzymes missed 51%-63% of all acute MIs.

Myoglobin, creatine kinase, and troponin can serve as markers of acute coronary syndrome, but troponin is usually the most sensitive. Even so, troponin is not 100% sensitive, nor does it reliably pick up unstable angina, Dr. Slovis said.

He emphasized several enzyme caveats:

▸ Enzymes are rarely positive early in an acute myocardial infarction.

▸ Enzymes are almost never initially positive in patients with nondiagnostic ECGs.

▸ Delta values are more accurate than single values.

▸ Enzymes are not reliable for ruling out unstable angina.

In the area of ECGs, Dr. Slovis explained how to avoid mistakes. (See box.) “Remember that one ECG begets another,” he said. He cited data from several studies between 1977 and 2001 in which an average of 4%-5% of patients with documented MIs presented with normal ECGs.

Objective tests that can help diagnose ischemia are exercise tolerance tests, nuclear studies, stress echoes, or perhaps even CT coronary angiograms.

If you can't get an objective test on very low-risk patients–specifically young, healthy people you are ready to send home after you have decided there is “no chance” that it is a heart problem–have them run in place at the bedside. Calculate the patient's maximum heart rate (220 minus their age), then get their heart rate up to about 75% of maximum, and if they have chest pain or ST-segment changes, admit them. “It's not as good as a really expensive treadmill, but it is so much better than nothing,” Dr. Slovis said.

In addition to ischemia, doctors need to be on the lookout for aortic dissection, he said. They are required to ask three questions of patients with chest pain to be sure they don't miss that condition; unfortunately, many physicians ask only one or none of them:

▸ Did the pain start as a tearing or ripping sensation?

▸ Did the pain start at maximum intensity rather than building in intensity?

▸ Did the pain radiate to the back, abdomen, or legs?

Document as many variables as possible for two reasons: You are less likely to miss things, and you can code the patient's visit at a more appropriate higher level.

If you determine that a patient needs a cardiologist, call one. Document the exact time that you turned the patient over to a cardiologist–it can come back to haunt you in a lawsuit.

Atypical is typical, Dr. Slovis emphasized. Doctors are much more likely to miss acute MI in patients who present with a lack of typical symptoms. A diagnosis of acute myocardial ischemia is too important ever to miss, yet mistakes in MI diagnosis are made all the time.

“One missed MI can change your life, and that of your family and patients, forever,” he said. “When you miss an MI and get sued, you aren't notified on Monday and settle by Friday; it is 2-4 years of depositions, fact-finding, and interrogatories.”

Five Simple Rules for Catching MIs

Atypical is typical. No one is absolutely typical. Don't waste time trying to find that one thing that will let you avoid doing a full work-up.

Older patients are different. The elderly present with different symptoms than younger patients. The only symptoms an older patient may have are shortness of breath, weakness, syncope or near-syncope, diaphoresis, and nausea or vomiting. Older patients are often misdiagnosed because they don't present with “classic” MI symptoms.

ECGs: Read, reread, repeat. After reading an electrocardiogram, reread it and look for the five patterns of acute MI and for evidence of localized ischemia.

Perform delta enzyme analysis. One set of enzymes will be more likely to miss, rather than diagnose, an early acute MI.

Conduct an objective test. Develop a chest pain protocol that allows for an evidence-based approach to patient evaluation. Base the protocol on risk, ECG findings, age, and ability to run. Conduct one of the following: exercise tolerance test, nuclear study, echocardiography, or computed tomography.

Source: Dr. Slovis

ECG Mistakes Never to Make

▸ Failure to get an ECG in chest pain patients.

▸ Failure to get an ECG in older patients with signs of syncope, presyncope, weakness, vomiting, nausea, diaphoresis, or shortness of breath.

▸ Failure to look specifically for all acute MI-ischemic patterns.

▸ Failure to repeat the ECG, especially if it is abnormal or is from a high-risk patient.

▸ Failure to compare new ECGs with previous ones–ask to have them faxed from other hospitals.

Source: Dr. Slovis

WASHINGTON – Don't exclude a diagnosis of myocardial infarction unless you have done objective testing first, Dr. Corey M. Slovis said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of myocardial infarction (MI) is a leading cause of emergency department malpractice awards in the United States, noted Dr. Slovis, chairman of the emergency medicine department at Vanderbilt University, Nashville, Tenn. Even though chest pain is a hallmark of acute MI, this pain may be absent or fleeting, and it may not be substernal. In fact, chest pain may be stabbing, pleuritic, or palpable.

“My goal is for you to accept that in some cases, testing is better than clinical judgment,” Dr. Slovis said. “There are times when an objective test is better than no test.”

Enzymes can be helpful tools in diagnosing acute myocardial infarction, but they should not be used in isolation. “One set of negative enzymes does not mean the absence of acute coronary syndrome,” Dr. Slovis said. He cited a 2001 metaanalysis of 22 years' worth of studies, which showed that a single set of enzymes missed 51%-63% of all acute MIs.

Myoglobin, creatine kinase, and troponin can serve as markers of acute coronary syndrome, but troponin is usually the most sensitive. Even so, troponin is not 100% sensitive, nor does it reliably pick up unstable angina, Dr. Slovis said.

He emphasized several enzyme caveats:

▸ Enzymes are rarely positive early in an acute myocardial infarction.

▸ Enzymes are almost never initially positive in patients with nondiagnostic ECGs.

▸ Delta values are more accurate than single values.

▸ Enzymes are not reliable for ruling out unstable angina.

In the area of ECGs, Dr. Slovis explained how to avoid mistakes. (See box.) “Remember that one ECG begets another,” he said. He cited data from several studies between 1977 and 2001 in which an average of 4%-5% of patients with documented MIs presented with normal ECGs.

Objective tests that can help diagnose ischemia are exercise tolerance tests, nuclear studies, stress echoes, or perhaps even CT coronary angiograms.

If you can't get an objective test on very low-risk patients–specifically young, healthy people you are ready to send home after you have decided there is “no chance” that it is a heart problem–have them run in place at the bedside. Calculate the patient's maximum heart rate (220 minus their age), then get their heart rate up to about 75% of maximum, and if they have chest pain or ST-segment changes, admit them. “It's not as good as a really expensive treadmill, but it is so much better than nothing,” Dr. Slovis said.

In addition to ischemia, doctors need to be on the lookout for aortic dissection, he said. They are required to ask three questions of patients with chest pain to be sure they don't miss that condition; unfortunately, many physicians ask only one or none of them:

▸ Did the pain start as a tearing or ripping sensation?

▸ Did the pain start at maximum intensity rather than building in intensity?

▸ Did the pain radiate to the back, abdomen, or legs?

Document as many variables as possible for two reasons: You are less likely to miss things, and you can code the patient's visit at a more appropriate higher level.

If you determine that a patient needs a cardiologist, call one. Document the exact time that you turned the patient over to a cardiologist–it can come back to haunt you in a lawsuit.

Atypical is typical, Dr. Slovis emphasized. Doctors are much more likely to miss acute MI in patients who present with a lack of typical symptoms. A diagnosis of acute myocardial ischemia is too important ever to miss, yet mistakes in MI diagnosis are made all the time.

“One missed MI can change your life, and that of your family and patients, forever,” he said. “When you miss an MI and get sued, you aren't notified on Monday and settle by Friday; it is 2-4 years of depositions, fact-finding, and interrogatories.”

Five Simple Rules for Catching MIs

Atypical is typical. No one is absolutely typical. Don't waste time trying to find that one thing that will let you avoid doing a full work-up.

Older patients are different. The elderly present with different symptoms than younger patients. The only symptoms an older patient may have are shortness of breath, weakness, syncope or near-syncope, diaphoresis, and nausea or vomiting. Older patients are often misdiagnosed because they don't present with “classic” MI symptoms.

ECGs: Read, reread, repeat. After reading an electrocardiogram, reread it and look for the five patterns of acute MI and for evidence of localized ischemia.

Perform delta enzyme analysis. One set of enzymes will be more likely to miss, rather than diagnose, an early acute MI.

Conduct an objective test. Develop a chest pain protocol that allows for an evidence-based approach to patient evaluation. Base the protocol on risk, ECG findings, age, and ability to run. Conduct one of the following: exercise tolerance test, nuclear study, echocardiography, or computed tomography.

Source: Dr. Slovis

ECG Mistakes Never to Make

▸ Failure to get an ECG in chest pain patients.

▸ Failure to get an ECG in older patients with signs of syncope, presyncope, weakness, vomiting, nausea, diaphoresis, or shortness of breath.

▸ Failure to look specifically for all acute MI-ischemic patterns.

▸ Failure to repeat the ECG, especially if it is abnormal or is from a high-risk patient.

▸ Failure to compare new ECGs with previous ones–ask to have them faxed from other hospitals.

Source: Dr. Slovis

WASHINGTON – Don't exclude a diagnosis of myocardial infarction unless you have done objective testing first, Dr. Corey M. Slovis said at the annual meeting of the American College of Emergency Physicians.

A missed diagnosis of myocardial infarction (MI) is a leading cause of emergency department malpractice awards in the United States, noted Dr. Slovis, chairman of the emergency medicine department at Vanderbilt University, Nashville, Tenn. Even though chest pain is a hallmark of acute MI, this pain may be absent or fleeting, and it may not be substernal. In fact, chest pain may be stabbing, pleuritic, or palpable.

“My goal is for you to accept that in some cases, testing is better than clinical judgment,” Dr. Slovis said. “There are times when an objective test is better than no test.”

Enzymes can be helpful tools in diagnosing acute myocardial infarction, but they should not be used in isolation. “One set of negative enzymes does not mean the absence of acute coronary syndrome,” Dr. Slovis said. He cited a 2001 metaanalysis of 22 years' worth of studies, which showed that a single set of enzymes missed 51%-63% of all acute MIs.

Myoglobin, creatine kinase, and troponin can serve as markers of acute coronary syndrome, but troponin is usually the most sensitive. Even so, troponin is not 100% sensitive, nor does it reliably pick up unstable angina, Dr. Slovis said.

He emphasized several enzyme caveats:

▸ Enzymes are rarely positive early in an acute myocardial infarction.

▸ Enzymes are almost never initially positive in patients with nondiagnostic ECGs.

▸ Delta values are more accurate than single values.

▸ Enzymes are not reliable for ruling out unstable angina.

In the area of ECGs, Dr. Slovis explained how to avoid mistakes. (See box.) “Remember that one ECG begets another,” he said. He cited data from several studies between 1977 and 2001 in which an average of 4%-5% of patients with documented MIs presented with normal ECGs.

Objective tests that can help diagnose ischemia are exercise tolerance tests, nuclear studies, stress echoes, or perhaps even CT coronary angiograms.

If you can't get an objective test on very low-risk patients–specifically young, healthy people you are ready to send home after you have decided there is “no chance” that it is a heart problem–have them run in place at the bedside. Calculate the patient's maximum heart rate (220 minus their age), then get their heart rate up to about 75% of maximum, and if they have chest pain or ST-segment changes, admit them. “It's not as good as a really expensive treadmill, but it is so much better than nothing,” Dr. Slovis said.

In addition to ischemia, doctors need to be on the lookout for aortic dissection, he said. They are required to ask three questions of patients with chest pain to be sure they don't miss that condition; unfortunately, many physicians ask only one or none of them:

▸ Did the pain start as a tearing or ripping sensation?

▸ Did the pain start at maximum intensity rather than building in intensity?

▸ Did the pain radiate to the back, abdomen, or legs?

Document as many variables as possible for two reasons: You are less likely to miss things, and you can code the patient's visit at a more appropriate higher level.

If you determine that a patient needs a cardiologist, call one. Document the exact time that you turned the patient over to a cardiologist–it can come back to haunt you in a lawsuit.

Atypical is typical, Dr. Slovis emphasized. Doctors are much more likely to miss acute MI in patients who present with a lack of typical symptoms. A diagnosis of acute myocardial ischemia is too important ever to miss, yet mistakes in MI diagnosis are made all the time.

“One missed MI can change your life, and that of your family and patients, forever,” he said. “When you miss an MI and get sued, you aren't notified on Monday and settle by Friday; it is 2-4 years of depositions, fact-finding, and interrogatories.”

Five Simple Rules for Catching MIs

Atypical is typical. No one is absolutely typical. Don't waste time trying to find that one thing that will let you avoid doing a full work-up.

Older patients are different. The elderly present with different symptoms than younger patients. The only symptoms an older patient may have are shortness of breath, weakness, syncope or near-syncope, diaphoresis, and nausea or vomiting. Older patients are often misdiagnosed because they don't present with “classic” MI symptoms.

ECGs: Read, reread, repeat. After reading an electrocardiogram, reread it and look for the five patterns of acute MI and for evidence of localized ischemia.

Perform delta enzyme analysis. One set of enzymes will be more likely to miss, rather than diagnose, an early acute MI.

Conduct an objective test. Develop a chest pain protocol that allows for an evidence-based approach to patient evaluation. Base the protocol on risk, ECG findings, age, and ability to run. Conduct one of the following: exercise tolerance test, nuclear study, echocardiography, or computed tomography.

Source: Dr. Slovis

ECG Mistakes Never to Make

▸ Failure to get an ECG in chest pain patients.

▸ Failure to get an ECG in older patients with signs of syncope, presyncope, weakness, vomiting, nausea, diaphoresis, or shortness of breath.

▸ Failure to look specifically for all acute MI-ischemic patterns.

▸ Failure to repeat the ECG, especially if it is abnormal or is from a high-risk patient.

▸ Failure to compare new ECGs with previous ones–ask to have them faxed from other hospitals.

Source: Dr. Slovis

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Direct, honest, and consistent communication between a Mohs surgeon and his or her technician is necessary for a high-functioning, organized partnership, said Alex Lutz at a meeting sponsored by the American Society for Mohs Surgery.

Neither party should rely on assumptions regarding procedure. The physician should not assume that the technician has understood instructions and followed the proper process each time, nor should the technician assume that the physician has conducted the surgery the same way each time, said Mr. Lutz, a Mohs technician in Torrance, Calif.

The technician must be able to tell the surgeon that the technician has made a mistake and be honest enough to admit it, Mr. Lutz said. Likewise, the physician must be able to tell the technician if something went wrong—if the technician didn't get enough of a base for the specimen or did something differently from the agreed-upon standards. "Without that sort of communication, errors will be made," Mr. Lutz said. "It's all about checks and balances."

With this kind of communication in place, the Mohs surgeon and the technician can keep the surgical practice organized by agreeing upon a standard way to process specimens. If something about a specimen doesn't make sense, both parties must feel comfortable asking questions in order to avoid errors. For example, the surgeon who usually puts double hatch marks to indicate 12:00 on a specimen may put them at 3:00 for some reason, causing confusion for the technician.

He offered several standardization tips to enhance physician-technician harmony.

For the physicians:

▸ Choose a method to denote a true 12:00; it can be a pattern of marks or something else.

▸ Bring specimens to the technician in a petri dish of saline to avoid dehydration.

▸ Develop a standard inking format and a standard staining regimen.

▸ Send the Mohs map to the technician along with the slides. "Don't get into the habit of making the map later; the technicians need it," Lutz said.

For the technicians:

▸ Pick up slides the same way each time, and determine the surgeon's preference as to whether they want the first cut closer to the frosted edge or the opposite.

▸ Note the time and location of all tissue cuts on the Mohs map.

▸ Process multiple specimens in an organized fashion. Technicians should label slides and place them in the cryostat the same way each time.

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

SAN DIEGO — Certain areas of the body are more challenging than others when it comes to Mohs surgery: the nose, ears, and eyelids, as well as urology cases and orthopedic cases on the hands and feet.

These are the places where surgeons, especially beginners, are more likely to get into trouble and where tumors tend to be more aggressive. "Anywhere the skin is closer to bone, the tumor is more likely to spread in an unpredictable manner," Dr. Roger I. Ceilley said at a meeting sponsored by the American Society of Mohs Surgery.

To tackle the tough Mohs surgery cases, physicians need a lot of experience and time spent working with other surgeons, said Dr. Ceilley, a Mohs surgeon and dermatologist in practice in Iowa.

Cancers in the nose, which tend to be deeply invasive and can be hard to detect, have a higher recurrence rate, compared with cancers in other areas, he said. Particularly tricky areas around the nose are the columella, nasolabial groove, supra tip area, and lateral nasal dorsum. Before performing Mohs surgery on tumors of the nose, physicians should conduct a scouting biopsy to determine the extent of the lesions and to remove all scar tissue. Be aware that a tumor of the nose could be the tip of a larger iceberg, and prepare in advance for possible collaboration with a head and neck surgeon, he advised.

Treating cancer of the ear with Mohs surgery may involve working around the parotid gland, as well as around many nerves. Skin cancers of the ear have a 16%–47% recurrence rate, which is higher than that of skin cancers elsewhere. For these cases, it is important to know the anatomy of the ear, especially the nerve distribution and nerve supply. The anatomy of the ear is complex, and the surgeon must anticipate that the tumor may be much larger than it appears clinically. That said, the back of the ear is a good place to perfect one's skin flap technique, he noted.

Most surgeons can handle procedures on the lower eyelid, but upper eyelid tumors require an immediate repair and the use of an eye shield to protect the cornea and prevent corneal dryness.

"I wouldn't tackle tumors on the upper eyelid if you think it will be full thickness because you need to do an immediate repair, and you have to keep a corneal shield in place on the eye to prevent drying of the cornea. A little carbon char can cause a corneal abrasion. Make sure you use plenty of ointment before and after surgery," he said.

If you plan to perform Mohs surgery in the genital area, arrange ahead of time to work with a urologist. Dr. Ceilley discussed a patient with penile cancer who was slated for a penectomy, but was not enthusiastic about that idea and wanted to try Mohs surgery. (See photo.)

The surgery involved use of a catheter, and the tumor had to be followed into the urethra. After excision of the tumor, the wound was not sutured, but allowed to heal by second intention. The patient has had no recurrence of cancer to date. "He has to watch where he points, but he has a functional penis," Dr. Ceilley said.

Mohs surgery also may be used to successfully treat cancer, especially squamous cell carcinoma, on the extremities. In the case of a verrucous squamous cell carcinoma, "the tumor went nearly through to the other side of the foot," he said. Dr. Ceilley collaborated with an orthopedic surgeon, who amputated several toes. The surgeon used the skin from those toes to create skin flaps and give the patient a functional foot. (See photo.)

Expect the unexpected in Mohs cases. "You can find tumors that look like a basal cell carcinoma and turn out to be a Merkel cell carcinoma," he said.

Microcystic adnexal carcinoma, a rare but deeply infiltrating tumor, can be treated by an experienced Mohs surgeon. Characteristic features of microcystic adnexal carcinoma include a bland appearance, ambiguous histopathology with bizarrely shaped parent cells, and aggressive clinical behavior. Permanent horizontal sections are highly useful in these cases, Dr. Ceilley said.

Lentigo maligna also can be treated with Mohs surgery, and surgeons can use imiquimod (Aldara) to decrease the size of the area prior to surgery and to facilitate healing after surgery.

Finally, for challenging or complex cases, Dr. Ceilley recommends getting permanent paraffin-embedded sections, in addition to the multiple frozen sections that may be needed.

A squamous cell carcinoma of the penis was successfully excised.

After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley

Tips to Ensure Successful Mohs Surgery

I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.

Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.

Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.

After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."

A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.

If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.

Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study. The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties. Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference. This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University. The intervention itself included specific courses on the importance of preventive medicine for the students and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted. During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took about 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs. However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine. Data from the 16-school natural history study currently under review also show the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, she said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their own health habits, Dr. Frank noted. She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her own health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Fam. Med. 2000:9:287–90). Overall, patients who viewed the physician-disclosure video rated that physician as significantly more believable and motivating than did viewers who rated the physician in the nondisclosure video.

But many doctors still balk at talking to patients about such subjects as diet, smoking, and exercise.

“I think part of the issue is that many doctors don't want the additional responsibility of being role models,” she said, adding “I think that's naive, because we've got it even if we don't want it.”

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study. The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties. Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference. This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University. The intervention itself included specific courses on the importance of preventive medicine for the students and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted. During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took about 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs. However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine. Data from the 16-school natural history study currently under review also show the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, she said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their own health habits, Dr. Frank noted. She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her own health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Fam. Med. 2000:9:287–90). Overall, patients who viewed the physician-disclosure video rated that physician as significantly more believable and motivating than did viewers who rated the physician in the nondisclosure video.

But many doctors still balk at talking to patients about such subjects as diet, smoking, and exercise.

“I think part of the issue is that many doctors don't want the additional responsibility of being role models,” she said, adding “I think that's naive, because we've got it even if we don't want it.”

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.

Teach medical students to have a healthy lifestyle, and they are more likely to counsel patients to do the same, according to Erica Frank, M.D., M.P.H., of Emory University, and her colleagues.

The “Healthy Doc-Healthy Patient” project, a study involving 17 medical schools, tracked the history of medical students' attitudes about health and their subsequent counseling behaviors.

Previous studies have shown that doctors tend to preach what they practice; physicians who have healthy personal habits themselves are more likely to encourage their patients to adopt healthy habits as well, Dr. Frank said in an interview.

Dr. Frank, who serves as the education coordinator of Emory University's preventive medicine residency program, and her colleagues initially collected data on 4,501 women physicians in the United States as part of the Women Physicians' Health Study. The study included data from surveys of practicing women physicians aged 30–70 years, and showed a significant association between self-reported healthy habits and self-reported counseling and screening practices (Arch. Family Med. 2000;9:359–67).

In general, primary care physicians and ob.gyns. were more likely to report patient counseling compared with physicians in other specialties. Furthermore, physicians in group practices and those in government offices were more likely to report screening or counseling patients compared with those in hospitals or solo practices.

After adjusting for other personal and professional variables, physicians who reported healthy personal habits were significantly more likely to report counseling patients on issues such as smoking cessation, hormone therapy use, skin cancer self-examination, breast cancer self-examination, and annual influenza vaccination.

“We have seen in every behavior we've studied that if you practice a healthy behavior yourself, you are more likely to encourage it in others,” Dr. Frank said.

Promoting and encouraging those healthy habits before the physicians-to-be enter practice appear to make a difference. This theory was shown in a 4-year national natural history study in 16 medical schools, and in a 4-year curricular and extracurricular intervention project conducted with the medical school class of 2003 at Emory University. The intervention itself included specific courses on the importance of preventive medicine for the students and for their future patients. Lectures included such topics as skin cancer prevention, tobacco and alcohol use, exercise, nutrition, and behavioral science.

“We learned a lot at Emory, including how not to make your medical students mad at you,” Dr. Frank said. An intervention program for students must be sensitive to the needs and desires of the student population, she noted. During follow-up focus groups, the students complained that the questionnaires about their healthy habits—or lack thereof—were too long and repetitive. The surveys took about 30 minutes to complete and were given three times during the 4 years of school.

Extracurricular and optional interventions during the students' years in medical school included healthy-cooking classes, weekly yoga classes, e-mails summarizing prevention-related studies, and personal health prescriptions based on lifestyle reviews with the primary investigator.

Overall, the students were supportive of interventions in which faculty members were involved, such as dinners and activities like hikes or runs. However, students also complained that they were being nagged, despite the investigators' best efforts to convey that their emphasis on student health was to produce better physicians, and not to criticize the students' personal behaviors.

Promoting good health among medical students is “an efficient and powerful way to improve the health of whole populations,” Dr. Frank said. Based on the Emory student surveys, those who engaged in healthy behaviors were more likely to counsel patients about preventive medicine. Data from the 16-school natural history study currently under review also show the degree to which the school encourages students to be healthy increases the likelihood that students would counsel patients about healthy behavior, she said.

Physicians can enhance their credibility to motivate patients to live healthier lives by spending as little as 30 seconds sharing their own health habits, Dr. Frank noted. She conducted a study a few years ago in which patients were shown two videos of a physician talking about healthy behaviors. In one video, the physician mentioned her own health practices, with a bike helmet and apple visible on her desk. In the other video, the physician gave the same talk, but without the helmet and apple, and without the disclosure of personal health habits (Arch. Fam. Med. 2000:9:287–90). Overall, patients who viewed the physician-disclosure video rated that physician as significantly more believable and motivating than did viewers who rated the physician in the nondisclosure video.

But many doctors still balk at talking to patients about such subjects as diet, smoking, and exercise.

“I think part of the issue is that many doctors don't want the additional responsibility of being role models,” she said, adding “I think that's naive, because we've got it even if we don't want it.”

Dr. Frank continues to study the effect of healthier medical students in an evidence-based way, and she has consulted on the development of programs to promote healthy behavior among medical students at schools in the United States and other countries.