Sherry Boschert

SAN DIEGO – Melatonin supplements may be popular to shift circadian rhythms, but bright-light therapy is more effective, Milton Erman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

People with sleep disorders from working night shifts especially may benefit from therapy to shift their circadian rhythms to match the imposed sleep schedule, said Dr. Erman of the University of California, San Diego.

If the patient mainly is bothered by disrupted or insufficient sleep (wakefulness) or by excessive sleepiness while awake, try focusing treatment on one or the other, he suggested. If sleep problems include both wakefulness and sleepiness, it may be best to try to shift the patient's circadian rhythm.

Light therapy is inexpensive and safe for shifting circadian rhythm. Bright light or light plus exercise worked better than exercise alone, melatonin alone, or placebo to treat night-shift workers in a 1999 study.

Light therapy or light plus exercise shifted sleep/wake phases by 7–8 hours, compared with approximately 5 hours for melatonin and 3 hours with placebo. Patients achieved close to 7.5 hours of sleep per sleep phase with light therapy or light plus exercise, compared with approximately 6.5 hours of sleep with melatonin or placebo, Dr. Erman said.

To shift the circadian sleep phase, the timing of therapy is critical, whether using light, exercise, or melatonin. Any of these in the morning will advance the circadian rhythm so the patient goes to sleep earlier. To stay up later than usual, delay sleep by exercising or using light or melatonin in the late afternoon or early evening, he said.

For patients complaining mainly of wakefulness, benzodiazepines or nonbenzodiazepine hypnotics such as zolpidem (Ambien) can improve the quantity and quality of sleep, but studies suggest that improvements in job performance are short term. For sleepiness, modafinil (Provigil) is safer than stimulants and is approved to treat chronic shift-work disorder.

Dr. Erman has been a speaker and consultant for, or received honoraria from, the companies that make zolpidem and modafinil.

SAN DIEGO – Melatonin supplements may be popular to shift circadian rhythms, but bright-light therapy is more effective, Milton Erman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

People with sleep disorders from working night shifts especially may benefit from therapy to shift their circadian rhythms to match the imposed sleep schedule, said Dr. Erman of the University of California, San Diego.

If the patient mainly is bothered by disrupted or insufficient sleep (wakefulness) or by excessive sleepiness while awake, try focusing treatment on one or the other, he suggested. If sleep problems include both wakefulness and sleepiness, it may be best to try to shift the patient's circadian rhythm.

Light therapy is inexpensive and safe for shifting circadian rhythm. Bright light or light plus exercise worked better than exercise alone, melatonin alone, or placebo to treat night-shift workers in a 1999 study.

Light therapy or light plus exercise shifted sleep/wake phases by 7–8 hours, compared with approximately 5 hours for melatonin and 3 hours with placebo. Patients achieved close to 7.5 hours of sleep per sleep phase with light therapy or light plus exercise, compared with approximately 6.5 hours of sleep with melatonin or placebo, Dr. Erman said.

To shift the circadian sleep phase, the timing of therapy is critical, whether using light, exercise, or melatonin. Any of these in the morning will advance the circadian rhythm so the patient goes to sleep earlier. To stay up later than usual, delay sleep by exercising or using light or melatonin in the late afternoon or early evening, he said.

For patients complaining mainly of wakefulness, benzodiazepines or nonbenzodiazepine hypnotics such as zolpidem (Ambien) can improve the quantity and quality of sleep, but studies suggest that improvements in job performance are short term. For sleepiness, modafinil (Provigil) is safer than stimulants and is approved to treat chronic shift-work disorder.

Dr. Erman has been a speaker and consultant for, or received honoraria from, the companies that make zolpidem and modafinil.

SAN DIEGO – Melatonin supplements may be popular to shift circadian rhythms, but bright-light therapy is more effective, Milton Erman, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

People with sleep disorders from working night shifts especially may benefit from therapy to shift their circadian rhythms to match the imposed sleep schedule, said Dr. Erman of the University of California, San Diego.

If the patient mainly is bothered by disrupted or insufficient sleep (wakefulness) or by excessive sleepiness while awake, try focusing treatment on one or the other, he suggested. If sleep problems include both wakefulness and sleepiness, it may be best to try to shift the patient's circadian rhythm.

Light therapy is inexpensive and safe for shifting circadian rhythm. Bright light or light plus exercise worked better than exercise alone, melatonin alone, or placebo to treat night-shift workers in a 1999 study.

Light therapy or light plus exercise shifted sleep/wake phases by 7–8 hours, compared with approximately 5 hours for melatonin and 3 hours with placebo. Patients achieved close to 7.5 hours of sleep per sleep phase with light therapy or light plus exercise, compared with approximately 6.5 hours of sleep with melatonin or placebo, Dr. Erman said.

To shift the circadian sleep phase, the timing of therapy is critical, whether using light, exercise, or melatonin. Any of these in the morning will advance the circadian rhythm so the patient goes to sleep earlier. To stay up later than usual, delay sleep by exercising or using light or melatonin in the late afternoon or early evening, he said.

For patients complaining mainly of wakefulness, benzodiazepines or nonbenzodiazepine hypnotics such as zolpidem (Ambien) can improve the quantity and quality of sleep, but studies suggest that improvements in job performance are short term. For sleepiness, modafinil (Provigil) is safer than stimulants and is approved to treat chronic shift-work disorder.

Dr. Erman has been a speaker and consultant for, or received honoraria from, the companies that make zolpidem and modafinil.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

"We want to satisfy you, but you have to insist on being satisfied," Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, said Dr. Friend.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services. If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

"We want to satisfy you, but you have to insist on being satisfied," Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, said Dr. Friend.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services. If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?

When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.

A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

"We want to satisfy you, but you have to insist on being satisfied," Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.

To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:

▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.

She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.

▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.

If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.

Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.

▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, said Dr. Friend.

Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.

▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.

▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services. If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.

SAN DIEGO — Add a half step and a new rung to bring the World Health Organization's three-step “analgesic ladder” into the 21st century, Joshua P. Prager, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

The venerable World Health Organization (WHO) pain management guidelines, crafted about 15 years ago, described treatments for three levels of pain: mild, mild/moderate, or moderate/severe pain, he explained.

For mild pain, the WHO recommends nonopioid therapies like acetaminophen or traditional nonsteroidal anti-inflammatory drugs. Mild/moderate pain calls for an opioid (codeine, dihydrocodeine, hydrocodone, or oxycodone), often with a nonopioid. For moderate/severe pain, treat with a pure opioid in sustained-release or rescue therapy (morphine, fentanyl, oxycodone, or hydromorphone), the WHO suggests. At all levels, consider including adjuvant therapy.

One goal of these guidelines was to convince physicians in Third World countries that it's okay to give opiates for pain, said Dr. Prager, a pain specialist in Los Angeles. To make the analgesic ladder more relevant to U.S. physicians in the 21st century, he adds a half step between the mild and mild/moderate rungs to include new medications that have appeared since the guidelines were written.

These include tramadol (Ultram), gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), the lidocaine patch, and cyclooxygenase-2 (COX-2) inhibitors. Despite recent controversy around possible cardiovascular problems from long-term use of high-dose COX-2 inhibitors, Dr. Prager said those drugs have been a real boon to his practice when used in lower doses to avoid the GI toxicity associated with chronic use of traditional NSAIDs, he said.

Dr. Prager has been a speaker for the companies that make tramadol, gabapentin, pregabalin, and one of the COX-2 inhibitors. He has received research funding from the company that makes the lidocaine patch.

Beyond the moderate/severe pain level at the top of the analgesic ladder, Dr. Prager adds a fourth rung of severity and treatment that is not yet recognized by WHO recommendations. Treatments for patients in this fourth rung with intractable or refractory pain would include spinal cord stimulation, direct delivery of medications to the spinal fluid, and neuroablation.

Dr. Prager said that several other pain management guidelines are available:

▸ The American Pain Society's Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain.

▸ The American Society of Clinical Oncology's Cancer Pain Assessment and Treatment Curriculum Guidelines.

▸ The Oncology Nursing Society's Position Paper on Cancer Pain.

▸ American Society of Anesthesiologists guidelines.

Dr. Prager gives these guidelines to patients. “We find that if patients and families understand their rights to pain management, they will take a more active role.”

The WHO also provides important recommendations in its 1990 Cancer Pain Relief and Palliative Care guidelines on when to start palliative care, Dr. Prager noted; these guidelines focus on palliative care for cancer therapy, but they could be applied to any chronic disease with associated pain, including sarcoidosis, peripheral vascular disease, or multiple sclerosis.

Pain Guidelines—By the Letter

All the best advice from the various pain treatment guidelines might be condensed down to these precepts, Dr. Prager suggested:

Ask about pain regularly.

Assess pain systematically.

Believe the patient and family members in their reports of pain and what relieves it. Physicians who are not pain experts may be skeptical about this approach, he acknowledged. “I would rather make the mistake of giving a pain medication to somebody who doesn't have pain, and then figure out what's going on, than withhold pain medicine from somebody who really needs it. Of those two types of errors, I think one is much worse than the other.”

Choose pain control options appropriate for the patient, family, and setting. Take the family's beliefs into account when picking therapies and modes of delivery.

Deliver interventions in a timely, logical, and coordinated fashion. “There are a variety of ways of delivering drugs now that weren't available several years ago,” he noted.

Fentanyl citrate lozenges or “lollipops” may cost about $10 each, but they can deliver enough analgesia to avoid a more costly at-home fentanyl infusion.

Empower patients and their families.

Enable them to control their course to the greatest extent possible.

SAN DIEGO — Add a half step and a new rung to bring the World Health Organization's three-step “analgesic ladder” into the 21st century, Joshua P. Prager, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

The venerable World Health Organization (WHO) pain management guidelines, crafted about 15 years ago, described treatments for three levels of pain: mild, mild/moderate, or moderate/severe pain, he explained.

For mild pain, the WHO recommends nonopioid therapies like acetaminophen or traditional nonsteroidal anti-inflammatory drugs. Mild/moderate pain calls for an opioid (codeine, dihydrocodeine, hydrocodone, or oxycodone), often with a nonopioid. For moderate/severe pain, treat with a pure opioid in sustained-release or rescue therapy (morphine, fentanyl, oxycodone, or hydromorphone), the WHO suggests. At all levels, consider including adjuvant therapy.

One goal of these guidelines was to convince physicians in Third World countries that it's okay to give opiates for pain, said Dr. Prager, a pain specialist in Los Angeles. To make the analgesic ladder more relevant to U.S. physicians in the 21st century, he adds a half step between the mild and mild/moderate rungs to include new medications that have appeared since the guidelines were written.

These include tramadol (Ultram), gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), the lidocaine patch, and cyclooxygenase-2 (COX-2) inhibitors. Despite recent controversy around possible cardiovascular problems from long-term use of high-dose COX-2 inhibitors, Dr. Prager said those drugs have been a real boon to his practice when used in lower doses to avoid the GI toxicity associated with chronic use of traditional NSAIDs, he said.

Dr. Prager has been a speaker for the companies that make tramadol, gabapentin, pregabalin, and one of the COX-2 inhibitors. He has received research funding from the company that makes the lidocaine patch.

Beyond the moderate/severe pain level at the top of the analgesic ladder, Dr. Prager adds a fourth rung of severity and treatment that is not yet recognized by WHO recommendations. Treatments for patients in this fourth rung with intractable or refractory pain would include spinal cord stimulation, direct delivery of medications to the spinal fluid, and neuroablation.

Dr. Prager said that several other pain management guidelines are available:

▸ The American Pain Society's Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain.

▸ The American Society of Clinical Oncology's Cancer Pain Assessment and Treatment Curriculum Guidelines.

▸ The Oncology Nursing Society's Position Paper on Cancer Pain.

▸ American Society of Anesthesiologists guidelines.

Dr. Prager gives these guidelines to patients. “We find that if patients and families understand their rights to pain management, they will take a more active role.”

The WHO also provides important recommendations in its 1990 Cancer Pain Relief and Palliative Care guidelines on when to start palliative care, Dr. Prager noted; these guidelines focus on palliative care for cancer therapy, but they could be applied to any chronic disease with associated pain, including sarcoidosis, peripheral vascular disease, or multiple sclerosis.

Pain Guidelines—By the Letter

All the best advice from the various pain treatment guidelines might be condensed down to these precepts, Dr. Prager suggested:

Ask about pain regularly.

Assess pain systematically.

Believe the patient and family members in their reports of pain and what relieves it. Physicians who are not pain experts may be skeptical about this approach, he acknowledged. “I would rather make the mistake of giving a pain medication to somebody who doesn't have pain, and then figure out what's going on, than withhold pain medicine from somebody who really needs it. Of those two types of errors, I think one is much worse than the other.”

Choose pain control options appropriate for the patient, family, and setting. Take the family's beliefs into account when picking therapies and modes of delivery.

Deliver interventions in a timely, logical, and coordinated fashion. “There are a variety of ways of delivering drugs now that weren't available several years ago,” he noted.

Fentanyl citrate lozenges or “lollipops” may cost about $10 each, but they can deliver enough analgesia to avoid a more costly at-home fentanyl infusion.

Empower patients and their families.

Enable them to control their course to the greatest extent possible.

SAN DIEGO — Add a half step and a new rung to bring the World Health Organization's three-step “analgesic ladder” into the 21st century, Joshua P. Prager, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

The venerable World Health Organization (WHO) pain management guidelines, crafted about 15 years ago, described treatments for three levels of pain: mild, mild/moderate, or moderate/severe pain, he explained.

For mild pain, the WHO recommends nonopioid therapies like acetaminophen or traditional nonsteroidal anti-inflammatory drugs. Mild/moderate pain calls for an opioid (codeine, dihydrocodeine, hydrocodone, or oxycodone), often with a nonopioid. For moderate/severe pain, treat with a pure opioid in sustained-release or rescue therapy (morphine, fentanyl, oxycodone, or hydromorphone), the WHO suggests. At all levels, consider including adjuvant therapy.

One goal of these guidelines was to convince physicians in Third World countries that it's okay to give opiates for pain, said Dr. Prager, a pain specialist in Los Angeles. To make the analgesic ladder more relevant to U.S. physicians in the 21st century, he adds a half step between the mild and mild/moderate rungs to include new medications that have appeared since the guidelines were written.

These include tramadol (Ultram), gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), the lidocaine patch, and cyclooxygenase-2 (COX-2) inhibitors. Despite recent controversy around possible cardiovascular problems from long-term use of high-dose COX-2 inhibitors, Dr. Prager said those drugs have been a real boon to his practice when used in lower doses to avoid the GI toxicity associated with chronic use of traditional NSAIDs, he said.

Dr. Prager has been a speaker for the companies that make tramadol, gabapentin, pregabalin, and one of the COX-2 inhibitors. He has received research funding from the company that makes the lidocaine patch.

Beyond the moderate/severe pain level at the top of the analgesic ladder, Dr. Prager adds a fourth rung of severity and treatment that is not yet recognized by WHO recommendations. Treatments for patients in this fourth rung with intractable or refractory pain would include spinal cord stimulation, direct delivery of medications to the spinal fluid, and neuroablation.

Dr. Prager said that several other pain management guidelines are available:

▸ The American Pain Society's Quality Improvement Guidelines for the Treatment of Acute Pain and Cancer Pain.

▸ The American Society of Clinical Oncology's Cancer Pain Assessment and Treatment Curriculum Guidelines.

▸ The Oncology Nursing Society's Position Paper on Cancer Pain.

▸ American Society of Anesthesiologists guidelines.

Dr. Prager gives these guidelines to patients. “We find that if patients and families understand their rights to pain management, they will take a more active role.”

The WHO also provides important recommendations in its 1990 Cancer Pain Relief and Palliative Care guidelines on when to start palliative care, Dr. Prager noted; these guidelines focus on palliative care for cancer therapy, but they could be applied to any chronic disease with associated pain, including sarcoidosis, peripheral vascular disease, or multiple sclerosis.

Pain Guidelines—By the Letter

All the best advice from the various pain treatment guidelines might be condensed down to these precepts, Dr. Prager suggested:

Ask about pain regularly.

Assess pain systematically.

Believe the patient and family members in their reports of pain and what relieves it. Physicians who are not pain experts may be skeptical about this approach, he acknowledged. “I would rather make the mistake of giving a pain medication to somebody who doesn't have pain, and then figure out what's going on, than withhold pain medicine from somebody who really needs it. Of those two types of errors, I think one is much worse than the other.”

Choose pain control options appropriate for the patient, family, and setting. Take the family's beliefs into account when picking therapies and modes of delivery.

Deliver interventions in a timely, logical, and coordinated fashion. “There are a variety of ways of delivering drugs now that weren't available several years ago,” he noted.

Fentanyl citrate lozenges or “lollipops” may cost about $10 each, but they can deliver enough analgesia to avoid a more costly at-home fentanyl infusion.

Empower patients and their families.

Enable them to control their course to the greatest extent possible.

KOHALA COAST, HAWAII — Pimecrolimus cream 1% did a better and faster job of clearing inverse psoriasis in a randomized, double-blind, vehicle-controlled study of 57 patients, according to Mark Lebwohl, M.D.

The patients applied either the topical immunomodulator pimecrolimus cream 1% or a vehicle cream of identical appearance twice a day for 8 weeks. There were no significant differences at baseline in the two groups. All patients were adults with moderate to severe inverse psoriasis, a T-cell-mediated inflammatory skin disease involving intertriginous areas such as the groin, axilla, and skin folds or creases of the breasts and buttocks, he said in a poster presentation at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Skin in these areas is very susceptible to the cutaneous side effects of more common topical treatments for psoriasis such as corticosteroids, which can cause irritation or corticosteroid-induced atrophy and striae, wrote Dr. Lebwohl, professor and chairman of dermatology at the Mount Sinai School of Medicine, New York.

Previous data have shown pimecrolimus cream 1%, a nonsteroid topical calcineurin inhibitor, to be effective in treating psoriasis when used under occlusion. It is not approved by the Food and Drug Administration for this indication.

Investigators in the current study rated disease severity on a four-point Global Assessment Scale from 0 (clear) to 4 (severe disease). They selected a target area on each patient and rated erythema, induration, and scaling on a scale of 0 (absent) to 3 (severe); the sum of those three scores comprised the Target Area Score.

At week 8, 20 of 28 patients in the pimecrolimus group had an Investigator Global Assessment score of 0-1 (clear or almost clear), compared with 6 of 29 patients in the vehicle group, Dr. Lebwohl wrote.

Four patients in the pimecrolimus group and none in the vehicle group achieved a global assessment score of 0-1 by the third day of applying the cream.

The Target Area Scores (TAS) were significantly better in the pimecrolimus group than in the vehicle group at each assessment date: days 3 and 7, and weeks 2, 4, 6, and 8 of treatment. The TAS declined from 5.2 at baseline to 1.1 at the end of the study in the pimecrolimus group, and from 5.5 at baseline to 2.9 in the vehicle group.

The pimecrolimus cream was well tolerated, Dr. Lebwohl and his associates wrote. No serious adverse events were reported, and no patient in either group discontinued the cream because of adverse events.

Overall, two patients in the pimecrolimus group reported adverse events: One developed paresthesia at the application site, and the other developed shaving folliculitis, which was thought to be unrelated to the cream. Of the 10 adverse events reported in the vehicle group, only 1 was considered to be related to application of the vehicle cream: tenderness in the target area.

KOHALA COAST, HAWAII — Pimecrolimus cream 1% did a better and faster job of clearing inverse psoriasis in a randomized, double-blind, vehicle-controlled study of 57 patients, according to Mark Lebwohl, M.D.

The patients applied either the topical immunomodulator pimecrolimus cream 1% or a vehicle cream of identical appearance twice a day for 8 weeks. There were no significant differences at baseline in the two groups. All patients were adults with moderate to severe inverse psoriasis, a T-cell-mediated inflammatory skin disease involving intertriginous areas such as the groin, axilla, and skin folds or creases of the breasts and buttocks, he said in a poster presentation at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Skin in these areas is very susceptible to the cutaneous side effects of more common topical treatments for psoriasis such as corticosteroids, which can cause irritation or corticosteroid-induced atrophy and striae, wrote Dr. Lebwohl, professor and chairman of dermatology at the Mount Sinai School of Medicine, New York.

Previous data have shown pimecrolimus cream 1%, a nonsteroid topical calcineurin inhibitor, to be effective in treating psoriasis when used under occlusion. It is not approved by the Food and Drug Administration for this indication.

Investigators in the current study rated disease severity on a four-point Global Assessment Scale from 0 (clear) to 4 (severe disease). They selected a target area on each patient and rated erythema, induration, and scaling on a scale of 0 (absent) to 3 (severe); the sum of those three scores comprised the Target Area Score.

At week 8, 20 of 28 patients in the pimecrolimus group had an Investigator Global Assessment score of 0-1 (clear or almost clear), compared with 6 of 29 patients in the vehicle group, Dr. Lebwohl wrote.

Four patients in the pimecrolimus group and none in the vehicle group achieved a global assessment score of 0-1 by the third day of applying the cream.

The Target Area Scores (TAS) were significantly better in the pimecrolimus group than in the vehicle group at each assessment date: days 3 and 7, and weeks 2, 4, 6, and 8 of treatment. The TAS declined from 5.2 at baseline to 1.1 at the end of the study in the pimecrolimus group, and from 5.5 at baseline to 2.9 in the vehicle group.

The pimecrolimus cream was well tolerated, Dr. Lebwohl and his associates wrote. No serious adverse events were reported, and no patient in either group discontinued the cream because of adverse events.

Overall, two patients in the pimecrolimus group reported adverse events: One developed paresthesia at the application site, and the other developed shaving folliculitis, which was thought to be unrelated to the cream. Of the 10 adverse events reported in the vehicle group, only 1 was considered to be related to application of the vehicle cream: tenderness in the target area.

KOHALA COAST, HAWAII — Pimecrolimus cream 1% did a better and faster job of clearing inverse psoriasis in a randomized, double-blind, vehicle-controlled study of 57 patients, according to Mark Lebwohl, M.D.

The patients applied either the topical immunomodulator pimecrolimus cream 1% or a vehicle cream of identical appearance twice a day for 8 weeks. There were no significant differences at baseline in the two groups. All patients were adults with moderate to severe inverse psoriasis, a T-cell-mediated inflammatory skin disease involving intertriginous areas such as the groin, axilla, and skin folds or creases of the breasts and buttocks, he said in a poster presentation at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Skin in these areas is very susceptible to the cutaneous side effects of more common topical treatments for psoriasis such as corticosteroids, which can cause irritation or corticosteroid-induced atrophy and striae, wrote Dr. Lebwohl, professor and chairman of dermatology at the Mount Sinai School of Medicine, New York.

Previous data have shown pimecrolimus cream 1%, a nonsteroid topical calcineurin inhibitor, to be effective in treating psoriasis when used under occlusion. It is not approved by the Food and Drug Administration for this indication.

Investigators in the current study rated disease severity on a four-point Global Assessment Scale from 0 (clear) to 4 (severe disease). They selected a target area on each patient and rated erythema, induration, and scaling on a scale of 0 (absent) to 3 (severe); the sum of those three scores comprised the Target Area Score.

At week 8, 20 of 28 patients in the pimecrolimus group had an Investigator Global Assessment score of 0-1 (clear or almost clear), compared with 6 of 29 patients in the vehicle group, Dr. Lebwohl wrote.

Four patients in the pimecrolimus group and none in the vehicle group achieved a global assessment score of 0-1 by the third day of applying the cream.

The Target Area Scores (TAS) were significantly better in the pimecrolimus group than in the vehicle group at each assessment date: days 3 and 7, and weeks 2, 4, 6, and 8 of treatment. The TAS declined from 5.2 at baseline to 1.1 at the end of the study in the pimecrolimus group, and from 5.5 at baseline to 2.9 in the vehicle group.

The pimecrolimus cream was well tolerated, Dr. Lebwohl and his associates wrote. No serious adverse events were reported, and no patient in either group discontinued the cream because of adverse events.

Overall, two patients in the pimecrolimus group reported adverse events: One developed paresthesia at the application site, and the other developed shaving folliculitis, which was thought to be unrelated to the cream. Of the 10 adverse events reported in the vehicle group, only 1 was considered to be related to application of the vehicle cream: tenderness in the target area.

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates. The role of E. coli fell with increasing age, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts in Worcester.

The study looked at rates of resistance to four antibiotic therapies. Trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, but guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the antibiotics across age groups. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

Enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates. The role of E. coli fell with increasing age, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts in Worcester.

The study looked at rates of resistance to four antibiotic therapies. Trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, but guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the antibiotics across age groups. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

Enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates. The role of E. coli fell with increasing age, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts in Worcester.

The study looked at rates of resistance to four antibiotic therapies. Trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, but guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted the fluoroquinolone levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the antibiotics across age groups. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

Enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

“Urine Gram stain is not a routine study done in our institution, but it may be warranted in this subset of patients to aid in the work-up of UTI,” Dr. Blehar said. “If gram-positive UTI is identified, we would add additional coverage for enterococcus.”

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

P Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the temptation to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, Mr. Sinclitico said.

▸ Don't add risk management comments like, “We need to do better” or “There weren't enough beds available.” Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. If you make your comments in that arena, it is unlikely that they will be accessible to lawyers.

▸ Don't include peer-review comments. Saying things such as “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

P Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the temptation to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, Mr. Sinclitico said.

▸ Don't add risk management comments like, “We need to do better” or “There weren't enough beds available.” Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. If you make your comments in that arena, it is unlikely that they will be accessible to lawyers.

▸ Don't include peer-review comments. Saying things such as “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

P Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the temptation to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, Mr. Sinclitico said.

▸ Don't add risk management comments like, “We need to do better” or “There weren't enough beds available.” Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. If you make your comments in that arena, it is unlikely that they will be accessible to lawyers.

▸ Don't include peer-review comments. Saying things such as “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

SAN DIEGO — A door-to-door survey found higher immunization rates among African American toddlers in Los Angeles than expected and revealed ways to improve vaccination rates further, Alvin Nelson El Amin, M.D., said at the annual meeting of the National Medical Association.

Physicians might consider implementing a reminder/recall system or participating in a computerized immunization registry with a reminder/recall feature, said Dr. El Amin of the Los Angeles County Department of Health Services.

“Parents and guardians for the most part relied on their child's health care provider to inform them of when the child's next immunization was due,” he said.

The main reason for missing vaccination appointments was a lack of transportation. “Consider collaborative arrangements with nonprofit community agencies that provide bus tokens or taxi vouchers in order to address the transportation problem,” Dr. El Amin said.

Investigators used cluster survey methodology to identify five contiguous zip codes with a high percentage of African American residents. Then they randomly selected 50 clusters of blocks with at least 20 toddlers according to U.S. Census data, and interviewed the parents or guardians of 10 children from each cluster. They reviewed the child's immunization card during the interview or obtained permission to contact the child's health care provider for immunization information.

Of a total of 500 children aged 24-47 months, 74% had received the 4:3:1 series of vaccinations (four DTP shots, three polio shots, and one MMR shot), compared with 55% of 144 African American children and 71% of 2,475 children overall in the 2003 California Kindergarten Retrospective Survey (KRS). The KRS assessed 5-year-olds to retrospectively determine toddler vaccination rates and may not reflect current immunization levels, he said.

Vaccination rates were below the Healthy People 2010 goal of 90% coverage for all universally recommended vaccinations among children aged 19-35 months. Coverage rates for series of immunizations in the current study also lagged rates reported for all Los Angeles children of comparable ages reported in the 2002 National Immunization Survey (NIS). The sample of African American children in the NIS was too small to estimate coverage rates for that population.

In the NIS, 79% of children had received the 4:3:1 series of vaccinations. In the current survey, coverage rates for some individual vaccinations were comparable to those seen for all Los Angeles children in the NIS, Dr. El Amin noted.

Survey results suggest that health care providers should pay particular attention to increasing the rates of three vaccinations in this population: Haemophilus influenzae type b, hepatitis B, and pneumococcal conjugate vaccines.

The current study showed that health care providers were the main source of information on vaccinations, influencing 82% of parents and guardians. Most parents and guardians had positive attitudes toward immunizations.

Overall, 97% said that they felt respected by the physician or clinic providing the vaccinations, and 97% said that they trusted the physician or clinic.

A large majority of parents and guardians (88%) said that they scheduled appointments for immunizations, and 74% of these kept the appointments. Only 47% of those who missed an appointment, however, received a reminder from the health care provider to reschedule the visit.

The survey results were limited by the fact that the data came only from parents and guardians who were available and willing to be interviewed, which may be a population with more positive attitudes toward immunizations, Dr. El Amin explained.

SAN DIEGO — A door-to-door survey found higher immunization rates among African American toddlers in Los Angeles than expected and revealed ways to improve vaccination rates further, Alvin Nelson El Amin, M.D., said at the annual meeting of the National Medical Association.

Physicians might consider implementing a reminder/recall system or participating in a computerized immunization registry with a reminder/recall feature, said Dr. El Amin of the Los Angeles County Department of Health Services.

“Parents and guardians for the most part relied on their child's health care provider to inform them of when the child's next immunization was due,” he said.

The main reason for missing vaccination appointments was a lack of transportation. “Consider collaborative arrangements with nonprofit community agencies that provide bus tokens or taxi vouchers in order to address the transportation problem,” Dr. El Amin said.

Investigators used cluster survey methodology to identify five contiguous zip codes with a high percentage of African American residents. Then they randomly selected 50 clusters of blocks with at least 20 toddlers according to U.S. Census data, and interviewed the parents or guardians of 10 children from each cluster. They reviewed the child's immunization card during the interview or obtained permission to contact the child's health care provider for immunization information.

Of a total of 500 children aged 24-47 months, 74% had received the 4:3:1 series of vaccinations (four DTP shots, three polio shots, and one MMR shot), compared with 55% of 144 African American children and 71% of 2,475 children overall in the 2003 California Kindergarten Retrospective Survey (KRS). The KRS assessed 5-year-olds to retrospectively determine toddler vaccination rates and may not reflect current immunization levels, he said.

Vaccination rates were below the Healthy People 2010 goal of 90% coverage for all universally recommended vaccinations among children aged 19-35 months. Coverage rates for series of immunizations in the current study also lagged rates reported for all Los Angeles children of comparable ages reported in the 2002 National Immunization Survey (NIS). The sample of African American children in the NIS was too small to estimate coverage rates for that population.

In the NIS, 79% of children had received the 4:3:1 series of vaccinations. In the current survey, coverage rates for some individual vaccinations were comparable to those seen for all Los Angeles children in the NIS, Dr. El Amin noted.

Survey results suggest that health care providers should pay particular attention to increasing the rates of three vaccinations in this population: Haemophilus influenzae type b, hepatitis B, and pneumococcal conjugate vaccines.

The current study showed that health care providers were the main source of information on vaccinations, influencing 82% of parents and guardians. Most parents and guardians had positive attitudes toward immunizations.

Overall, 97% said that they felt respected by the physician or clinic providing the vaccinations, and 97% said that they trusted the physician or clinic.

A large majority of parents and guardians (88%) said that they scheduled appointments for immunizations, and 74% of these kept the appointments. Only 47% of those who missed an appointment, however, received a reminder from the health care provider to reschedule the visit.

The survey results were limited by the fact that the data came only from parents and guardians who were available and willing to be interviewed, which may be a population with more positive attitudes toward immunizations, Dr. El Amin explained.

SAN DIEGO — A door-to-door survey found higher immunization rates among African American toddlers in Los Angeles than expected and revealed ways to improve vaccination rates further, Alvin Nelson El Amin, M.D., said at the annual meeting of the National Medical Association.

Physicians might consider implementing a reminder/recall system or participating in a computerized immunization registry with a reminder/recall feature, said Dr. El Amin of the Los Angeles County Department of Health Services.

“Parents and guardians for the most part relied on their child's health care provider to inform them of when the child's next immunization was due,” he said.

The main reason for missing vaccination appointments was a lack of transportation. “Consider collaborative arrangements with nonprofit community agencies that provide bus tokens or taxi vouchers in order to address the transportation problem,” Dr. El Amin said.

Investigators used cluster survey methodology to identify five contiguous zip codes with a high percentage of African American residents. Then they randomly selected 50 clusters of blocks with at least 20 toddlers according to U.S. Census data, and interviewed the parents or guardians of 10 children from each cluster. They reviewed the child's immunization card during the interview or obtained permission to contact the child's health care provider for immunization information.

Of a total of 500 children aged 24-47 months, 74% had received the 4:3:1 series of vaccinations (four DTP shots, three polio shots, and one MMR shot), compared with 55% of 144 African American children and 71% of 2,475 children overall in the 2003 California Kindergarten Retrospective Survey (KRS). The KRS assessed 5-year-olds to retrospectively determine toddler vaccination rates and may not reflect current immunization levels, he said.

Vaccination rates were below the Healthy People 2010 goal of 90% coverage for all universally recommended vaccinations among children aged 19-35 months. Coverage rates for series of immunizations in the current study also lagged rates reported for all Los Angeles children of comparable ages reported in the 2002 National Immunization Survey (NIS). The sample of African American children in the NIS was too small to estimate coverage rates for that population.

In the NIS, 79% of children had received the 4:3:1 series of vaccinations. In the current survey, coverage rates for some individual vaccinations were comparable to those seen for all Los Angeles children in the NIS, Dr. El Amin noted.

Survey results suggest that health care providers should pay particular attention to increasing the rates of three vaccinations in this population: Haemophilus influenzae type b, hepatitis B, and pneumococcal conjugate vaccines.

The current study showed that health care providers were the main source of information on vaccinations, influencing 82% of parents and guardians. Most parents and guardians had positive attitudes toward immunizations.

Overall, 97% said that they felt respected by the physician or clinic providing the vaccinations, and 97% said that they trusted the physician or clinic.

A large majority of parents and guardians (88%) said that they scheduled appointments for immunizations, and 74% of these kept the appointments. Only 47% of those who missed an appointment, however, received a reminder from the health care provider to reschedule the visit.

The survey results were limited by the fact that the data came only from parents and guardians who were available and willing to be interviewed, which may be a population with more positive attitudes toward immunizations, Dr. El Amin explained.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

He described several infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said at the conference, sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery.

Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury. Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing.

Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia.

Clinical findings become extremely important in differentiating the two, he said.

Infarction of the basal ganglia due to streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury. The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however. Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging. Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is the best modality for imaging the neonatal central nervous system; CT scans can help you look for brain calcifications, Dr. Zimmerman commented.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

He described several infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said at the conference, sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery.

Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury. Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing.

Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia.

Clinical findings become extremely important in differentiating the two, he said.

Infarction of the basal ganglia due to streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury. The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however. Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging. Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is the best modality for imaging the neonatal central nervous system; CT scans can help you look for brain calcifications, Dr. Zimmerman commented.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

He described several infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said at the conference, sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery.

Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury. Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing.

Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia.

Clinical findings become extremely important in differentiating the two, he said.

Infarction of the basal ganglia due to streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury. The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however. Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging. Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is the best modality for imaging the neonatal central nervous system; CT scans can help you look for brain calcifications, Dr. Zimmerman commented.

KOHALA COAST, HAWAII — Dermatophytes are common copathogens in nails with pseudomonas infection or in abnormal-looking nails with psoriasis, Boni E. Elewski, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Look twice to catch onychomycosis in patients with green nails typical of bacterial infection with pseudomonas, she suggested. It's reasonable to assume that a green-nailed patient has pseudomonas and to treat it with a quinolone antibiotic. A culture for onychomycosis at this stage will be negative because pseudomonas inhibits the growth of dermatophytes, although a potassium hydroxide (KOH) test probably will be positive for dermatophytes.

To be sure, see the patient again after you've eradicated the pseudomonas to check for onychomycosis, said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

When Dr. Elewski sees a patient whose psoriasis doesn't warrant systemic treatment but whose nails look abnormal, she cultures the nails for fungus.

KOHALA COAST, HAWAII — Dermatophytes are common copathogens in nails with pseudomonas infection or in abnormal-looking nails with psoriasis, Boni E. Elewski, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Look twice to catch onychomycosis in patients with green nails typical of bacterial infection with pseudomonas, she suggested. It's reasonable to assume that a green-nailed patient has pseudomonas and to treat it with a quinolone antibiotic. A culture for onychomycosis at this stage will be negative because pseudomonas inhibits the growth of dermatophytes, although a potassium hydroxide (KOH) test probably will be positive for dermatophytes.

To be sure, see the patient again after you've eradicated the pseudomonas to check for onychomycosis, said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

When Dr. Elewski sees a patient whose psoriasis doesn't warrant systemic treatment but whose nails look abnormal, she cultures the nails for fungus.

KOHALA COAST, HAWAII — Dermatophytes are common copathogens in nails with pseudomonas infection or in abnormal-looking nails with psoriasis, Boni E. Elewski, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Look twice to catch onychomycosis in patients with green nails typical of bacterial infection with pseudomonas, she suggested. It's reasonable to assume that a green-nailed patient has pseudomonas and to treat it with a quinolone antibiotic. A culture for onychomycosis at this stage will be negative because pseudomonas inhibits the growth of dermatophytes, although a potassium hydroxide (KOH) test probably will be positive for dermatophytes.

To be sure, see the patient again after you've eradicated the pseudomonas to check for onychomycosis, said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

When Dr. Elewski sees a patient whose psoriasis doesn't warrant systemic treatment but whose nails look abnormal, she cultures the nails for fungus.

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin/clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5-1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7-10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim are also options. Depending on how the patient responds, combination therapy may be needed. These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and two other types of mycobacteria that are seen commonly. One, M. marinum, causes papules or plaque on the hands after exposure to water in fish tanks. The other, M. tuberculosis, can cause tender calf nodules and erythema induratum.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned.

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin/clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5-1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7-10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim are also options. Depending on how the patient responds, combination therapy may be needed. These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and two other types of mycobacteria that are seen commonly. One, M. marinum, causes papules or plaque on the hands after exposure to water in fish tanks. The other, M. tuberculosis, can cause tender calf nodules and erythema induratum.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned.

KOHALA COAST, HAWAII — Nail salons that offer pedicures may be peddling infections along with pretty toes.

If a female patient complains of recurrent folliculitis of the lower legs, ask if she's had a pedicure lately and if she shaves her legs before going to the nail salon. The shaved skin can be a portal of entry for mycobacteria that exist in tap water and that grow in the filter systems of whirlpool footbaths used in nail salons, said Timothy G. Berger, M.D.

“You can scrub the inside of the salon tub all you want, but it's in the filter and irrigation system, and you can't clean that,” he said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Pedicures are popular in the San Francisco Bay area. “We've had outbreaks affecting hundreds of patients with this,” said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco.

He described a typical patient: a 37-year-old woman referred to him by her primary care physician for chronic folliculitis of the lower legs who failed sequential treatment with ciprofloxacin, cephalexin, and amoxicillin/clavulanate potassium (Augmentin). She had multiple, firm, focally ulcerated and eroded lesions 0.5-1.5 cm in size below the knees. The dermal and subcutaneous nodules had left multiple scars.

A biopsy suggested she might have mycobacterial infection, and a culture of the tissue biopsy grew one of the rapidly growing types of mycobacteria, such as Mycobacterium fortuitum and M. chelonae, which can be seen in cultures in 7-10 days.

Some patients may be followed with observation, but they usually require a prolonged course of antibiotic treatment for 6 months. “If you're lucky enough to grow the bug, then you can get sensitivities” to help pick the antibiotic, he said.

If you don't know the bug's antibiotic sensitivity, treat with monotherapy using doxycycline, clarithromycin, azithromycin, or ciprofloxacin, he suggested. Sulfonamides and trimethoprim are also options. Depending on how the patient responds, combination therapy may be needed. These rapidly growing mycobacteria do not respond to antimicrobials used to treat tuberculosis, such as isoniazid or ethambutol.

Dr. Berger distinguished between the rapid growers such as M. chelonae and M. fortuitum and two other types of mycobacteria that are seen commonly. One, M. marinum, causes papules or plaque on the hands after exposure to water in fish tanks. The other, M. tuberculosis, can cause tender calf nodules and erythema induratum.

Sometimes biopsies from patients with erythema induratum will show polyarteritis nodosa (PAN). If cutaneous TB is the cause, putting those patients on steroids will make them worse, Dr. Berger cautioned.