Patrice Wendling

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

"Physicians are like big ships," said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. "By the time you can see that they are sinking, it's too late."

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. "Many physicians who are defendants say that being sued was the worst experience of their life," said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. "Physicians are starving at a banquet of social support," he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to "Dear fibromyalgia patients" and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the "hazing" model of training.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. "I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'" Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

"Physicians are like big ships," said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. "By the time you can see that they are sinking, it's too late."

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. "Many physicians who are defendants say that being sued was the worst experience of their life," said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. "Physicians are starving at a banquet of social support," he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to "Dear fibromyalgia patients" and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the "hazing" model of training.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. "I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'" Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

"Physicians are like big ships," said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. "By the time you can see that they are sinking, it's too late."

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. "Many physicians who are defendants say that being sued was the worst experience of their life," said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. "Physicians are starving at a banquet of social support," he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to "Dear fibromyalgia patients" and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the "hazing" model of training.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. "I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'" Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

MIAMI BEACH — Measuring airway responsiveness to inhaled adenosine helps discriminate between a diagnosis of asthma and chronic obstructive pulmonary disease.

It's also a valuable clinical tool for monitoring airway inflammation and response to anti-inflammatory treatment in asthma, Dr. Riccardo Polosa reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “AMP challenge is noninvasive, non-time consuming, low cost, has good reproducibility and patient acceptability, and safety is optimal,” he said.

Adenosine 5′-monophosphate (AMP) is a proinflammatory mediator that induces bronchoconstriction in patients with inflammatory lung diseases. Response to AMP is determined by measuring the concentration of inhaled AMP causing the forced expiratory volume in 1 second (FEV1) to decrease by 20%. The exact cutoff point between normal and abnormal PC20 AMP, as it is known, remains somewhat unclear. But a cutoff of 160 mg/mL has been used successfully to discriminate between asthmatics and healthy controls. AAAAI is considering standardizing and writing protocols for AMP and other indirect challenges, said session moderator Dr. Richard A. Nicklas, of George Washington University, Washington.

Dr. Polosa and his colleagues at the University of Catania (Italy) have shown that airway responsiveness to inhaled AMP is closely related to the number of eosinophils in the airways of atopic patients, whereas no association was observed with methacholine, an agent commonly used to assess bronchial hyperresponsiveness (Eur. Respir. J. 2000;15:30–5). Dr. Polosa and other researchers from the university also showed that PC20 AMP could detect inflammatory changes as early as the first week of treatment with inhaled budesonide 0.8 mg per day in mild to moderate asthmatics, while methacholine responsiveness and changes in the percentage of sputum eosinophils could be observed only by the fourth week (J. Allergy Clin. Immunol. 2002;110:855–61).

Investigators at King's College, London, were able to demonstrate in three consecutive studies that a single dose of intranasal fluticasone propionate 100–1,000 mcg inhibited an asthmatic response to AMP in just 2 hours in patients with mild, stable asthma. A single inhalation of fluticasone 1,000 mcg had no effect on airway responsiveness to histamine (J. Allergy Clin. Immunol. 2002;110:603–6).

But when Dr. Polosa's team performed a similarly designed randomized, double-blind study using a single inhalation of fluticasone 1,000 mcg in 14 patients with chronic obstructive pulmonary disease (COPD) and 13 with mild asthma, there was a change in response in only one of the COPD patients, he said. The experiment was repeated with similar results in 10 patients with a clear history of asthma and 10 patients with COPD and comparable fixed airway obstruction. “This tells me very nicely that AMP challenge can be used as a strong discriminator for COPD and asthma,” he said of the unpublished findings.

AMP also has been used to assess the nonsteroidal anti-inflammatory potential of several therapeutic agents including allergen immunotherapy (Clin. Exp. Allergy. 2003;33:873–81), the leukotriene receptor antagonist montelukast (Am. J. Respir. Crit. Care Med. 2003;167:1232–8), and the humanized monoclonal anti-IgE antibody omalizumab (Int. Arch. Allergy Immunol. 2006;139:122–31).

AMP may be a more useful and sensitive tool than methacholine and histamine because of its mechanism of action, Dr. Polosa said. Histamine and methacholine have a direct spasmogenic effect on airway smooth muscle cells. AMP acts indirectly via the secondary release of mediators. Inhaled AMP is rapidly converted to adenosine and mainly induces mast cell degranulation and release of mediators such as histamine, prostanoids, and eicosanoids that cause smooth muscle constriction and mucosal edema, resulting in bronchoconstriction.

MIAMI BEACH — Measuring airway responsiveness to inhaled adenosine helps discriminate between a diagnosis of asthma and chronic obstructive pulmonary disease.

It's also a valuable clinical tool for monitoring airway inflammation and response to anti-inflammatory treatment in asthma, Dr. Riccardo Polosa reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “AMP challenge is noninvasive, non-time consuming, low cost, has good reproducibility and patient acceptability, and safety is optimal,” he said.

Adenosine 5′-monophosphate (AMP) is a proinflammatory mediator that induces bronchoconstriction in patients with inflammatory lung diseases. Response to AMP is determined by measuring the concentration of inhaled AMP causing the forced expiratory volume in 1 second (FEV1) to decrease by 20%. The exact cutoff point between normal and abnormal PC20 AMP, as it is known, remains somewhat unclear. But a cutoff of 160 mg/mL has been used successfully to discriminate between asthmatics and healthy controls. AAAAI is considering standardizing and writing protocols for AMP and other indirect challenges, said session moderator Dr. Richard A. Nicklas, of George Washington University, Washington.

Dr. Polosa and his colleagues at the University of Catania (Italy) have shown that airway responsiveness to inhaled AMP is closely related to the number of eosinophils in the airways of atopic patients, whereas no association was observed with methacholine, an agent commonly used to assess bronchial hyperresponsiveness (Eur. Respir. J. 2000;15:30–5). Dr. Polosa and other researchers from the university also showed that PC20 AMP could detect inflammatory changes as early as the first week of treatment with inhaled budesonide 0.8 mg per day in mild to moderate asthmatics, while methacholine responsiveness and changes in the percentage of sputum eosinophils could be observed only by the fourth week (J. Allergy Clin. Immunol. 2002;110:855–61).

Investigators at King's College, London, were able to demonstrate in three consecutive studies that a single dose of intranasal fluticasone propionate 100–1,000 mcg inhibited an asthmatic response to AMP in just 2 hours in patients with mild, stable asthma. A single inhalation of fluticasone 1,000 mcg had no effect on airway responsiveness to histamine (J. Allergy Clin. Immunol. 2002;110:603–6).

But when Dr. Polosa's team performed a similarly designed randomized, double-blind study using a single inhalation of fluticasone 1,000 mcg in 14 patients with chronic obstructive pulmonary disease (COPD) and 13 with mild asthma, there was a change in response in only one of the COPD patients, he said. The experiment was repeated with similar results in 10 patients with a clear history of asthma and 10 patients with COPD and comparable fixed airway obstruction. “This tells me very nicely that AMP challenge can be used as a strong discriminator for COPD and asthma,” he said of the unpublished findings.

AMP also has been used to assess the nonsteroidal anti-inflammatory potential of several therapeutic agents including allergen immunotherapy (Clin. Exp. Allergy. 2003;33:873–81), the leukotriene receptor antagonist montelukast (Am. J. Respir. Crit. Care Med. 2003;167:1232–8), and the humanized monoclonal anti-IgE antibody omalizumab (Int. Arch. Allergy Immunol. 2006;139:122–31).

AMP may be a more useful and sensitive tool than methacholine and histamine because of its mechanism of action, Dr. Polosa said. Histamine and methacholine have a direct spasmogenic effect on airway smooth muscle cells. AMP acts indirectly via the secondary release of mediators. Inhaled AMP is rapidly converted to adenosine and mainly induces mast cell degranulation and release of mediators such as histamine, prostanoids, and eicosanoids that cause smooth muscle constriction and mucosal edema, resulting in bronchoconstriction.

MIAMI BEACH — Measuring airway responsiveness to inhaled adenosine helps discriminate between a diagnosis of asthma and chronic obstructive pulmonary disease.

It's also a valuable clinical tool for monitoring airway inflammation and response to anti-inflammatory treatment in asthma, Dr. Riccardo Polosa reported at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “AMP challenge is noninvasive, non-time consuming, low cost, has good reproducibility and patient acceptability, and safety is optimal,” he said.

Adenosine 5′-monophosphate (AMP) is a proinflammatory mediator that induces bronchoconstriction in patients with inflammatory lung diseases. Response to AMP is determined by measuring the concentration of inhaled AMP causing the forced expiratory volume in 1 second (FEV1) to decrease by 20%. The exact cutoff point between normal and abnormal PC20 AMP, as it is known, remains somewhat unclear. But a cutoff of 160 mg/mL has been used successfully to discriminate between asthmatics and healthy controls. AAAAI is considering standardizing and writing protocols for AMP and other indirect challenges, said session moderator Dr. Richard A. Nicklas, of George Washington University, Washington.

Dr. Polosa and his colleagues at the University of Catania (Italy) have shown that airway responsiveness to inhaled AMP is closely related to the number of eosinophils in the airways of atopic patients, whereas no association was observed with methacholine, an agent commonly used to assess bronchial hyperresponsiveness (Eur. Respir. J. 2000;15:30–5). Dr. Polosa and other researchers from the university also showed that PC20 AMP could detect inflammatory changes as early as the first week of treatment with inhaled budesonide 0.8 mg per day in mild to moderate asthmatics, while methacholine responsiveness and changes in the percentage of sputum eosinophils could be observed only by the fourth week (J. Allergy Clin. Immunol. 2002;110:855–61).

Investigators at King's College, London, were able to demonstrate in three consecutive studies that a single dose of intranasal fluticasone propionate 100–1,000 mcg inhibited an asthmatic response to AMP in just 2 hours in patients with mild, stable asthma. A single inhalation of fluticasone 1,000 mcg had no effect on airway responsiveness to histamine (J. Allergy Clin. Immunol. 2002;110:603–6).

But when Dr. Polosa's team performed a similarly designed randomized, double-blind study using a single inhalation of fluticasone 1,000 mcg in 14 patients with chronic obstructive pulmonary disease (COPD) and 13 with mild asthma, there was a change in response in only one of the COPD patients, he said. The experiment was repeated with similar results in 10 patients with a clear history of asthma and 10 patients with COPD and comparable fixed airway obstruction. “This tells me very nicely that AMP challenge can be used as a strong discriminator for COPD and asthma,” he said of the unpublished findings.

AMP also has been used to assess the nonsteroidal anti-inflammatory potential of several therapeutic agents including allergen immunotherapy (Clin. Exp. Allergy. 2003;33:873–81), the leukotriene receptor antagonist montelukast (Am. J. Respir. Crit. Care Med. 2003;167:1232–8), and the humanized monoclonal anti-IgE antibody omalizumab (Int. Arch. Allergy Immunol. 2006;139:122–31).

AMP may be a more useful and sensitive tool than methacholine and histamine because of its mechanism of action, Dr. Polosa said. Histamine and methacholine have a direct spasmogenic effect on airway smooth muscle cells. AMP acts indirectly via the secondary release of mediators. Inhaled AMP is rapidly converted to adenosine and mainly induces mast cell degranulation and release of mediators such as histamine, prostanoids, and eicosanoids that cause smooth muscle constriction and mucosal edema, resulting in bronchoconstriction.

TUCSON, ARIZ. — Prazosin, an α₁-adrenergic blocker, substantially reduces posttraumatic stress disorder-related nightmares and sleep disturbances among veterans.

The drug is a safe and inexpensive treatment for night symptoms and also several daytime PTSD symptoms such as irritability, hypervigilance, and flashbacks, Dr. Murray Raskind reported at a psychopharmacology conference sponsored by the University of Arizona. “Many veterans say, 'It changed my life,'” he said.

Industry-supported trials in PTSD patients are unlikely for prazosin, which has been used for years as a generic antihypertensive. But Dr. Raskind, a professor at the University of Washington in Seattle and director of mental health services for the Veterans Administration Puget Sound, has compiled a growing body of evidence supporting the use of prazosin in this group.

He presented data from a parallel group study in which 34 Vietnam veterans with PTSD-related nightmares and sleep disturbances were randomized to prazosin at an average dose of 14 mg at bedtime or placebo. At 8 weeks, scores for the recurrent distressing dreams item of the Clinician-Administered PTSD Scale were significantly improved (6.5 at baseline to 2.9) among 17 prazosin patients, compared with 17 placebo patients (6.1 to 5.2).

Clinical Global Impression-Change scores were moderately or markedly improved in 12 of 17 prazosin patients and in only 2 of 17 placebo patients.

Another recent study included 28 combat veterans from Iraq who were treated with an average dose of 2 mg of prazosin every night for nightmares. Among the 23 patients with follow-up data, 20 had complete elimination of their nightmares, 2 had reduced frequency or intensity, and 1 had no change at 8 weeks (Military Med. 2005;170:513–5).

Sales of prazosin have risen in the Seattle area by about 30% since 1999 by word of mouth alone. But the drug has been criticized, because the results had not been replicated in a randomized trial, he said.

Although civilian trauma PTSD is helped somewhat by paroxetine (Paxil) and sertraline (Zoloft), results for selective serotonin reuptake inhibitors (SSRIs) have been disappointing among Vietnam veterans, especially for nightmares and sleep disruption.

Dr. Raskind opted to take a different approach based on evidence that enhanced responsiveness of central nervous system α₁-adrenergic receptors contributes to PTSD pathophysiology, particularly at night. An initial clinical experience with the β-adrenergic blocker, propranolol, failed as the β-blocker drugs can intensify dreams. Brain α₁-adrenergic effects are often opposed to brain β-adrenergic effects, so he turned to prazosin.

Treatment was started in a single patient at a low dose of 1 mg nightly to avoid the “first-dose” hypotension that has earned prazosin and other α₁-blockers a black box warning. After 2 weeks of gradual dose increases to 6 mg nightly, the tortuous dreams of a Vietnam veteran who had accidentally killed his friend disappeared. After 8 years, the veteran is still nightmare free.

But several episodes of unintentional discontinuation led to a rapid return of intense nightmares. Therefore, Dr. Raskind recommends the drug be taken every night, starting at 1 mg for 3 nights, then 2 mg for 4 nights, and increasing by 2 mg weekly until a therapeutic dose is achieved. Some older, Vietnam veterans may need 20 mg nightly. Adding small doses in the morning is helpful for daytime flashbacks and hypervigilance.

Adverse effects can include first-dose hypertension, increased risk of priapism with concurrent use of trazodone, nasal congestion, peripheral edema, and headache. Caution should be used with Viagra. Long-acting Cialis and Levitra should be avoided. Helpful side effects include gentle blood pressure reduction, enhanced urine flow in older men with prostate hypertrophy, and enhanced erectile function, he said.

Scores for recurrent distressing dreams were significantly improved from 6.5 at baseline to 2.9. DR. RASKIND

TUCSON, ARIZ. — Prazosin, an α₁-adrenergic blocker, substantially reduces posttraumatic stress disorder-related nightmares and sleep disturbances among veterans.

The drug is a safe and inexpensive treatment for night symptoms and also several daytime PTSD symptoms such as irritability, hypervigilance, and flashbacks, Dr. Murray Raskind reported at a psychopharmacology conference sponsored by the University of Arizona. “Many veterans say, 'It changed my life,'” he said.

Industry-supported trials in PTSD patients are unlikely for prazosin, which has been used for years as a generic antihypertensive. But Dr. Raskind, a professor at the University of Washington in Seattle and director of mental health services for the Veterans Administration Puget Sound, has compiled a growing body of evidence supporting the use of prazosin in this group.

He presented data from a parallel group study in which 34 Vietnam veterans with PTSD-related nightmares and sleep disturbances were randomized to prazosin at an average dose of 14 mg at bedtime or placebo. At 8 weeks, scores for the recurrent distressing dreams item of the Clinician-Administered PTSD Scale were significantly improved (6.5 at baseline to 2.9) among 17 prazosin patients, compared with 17 placebo patients (6.1 to 5.2).

Clinical Global Impression-Change scores were moderately or markedly improved in 12 of 17 prazosin patients and in only 2 of 17 placebo patients.

Another recent study included 28 combat veterans from Iraq who were treated with an average dose of 2 mg of prazosin every night for nightmares. Among the 23 patients with follow-up data, 20 had complete elimination of their nightmares, 2 had reduced frequency or intensity, and 1 had no change at 8 weeks (Military Med. 2005;170:513–5).

Sales of prazosin have risen in the Seattle area by about 30% since 1999 by word of mouth alone. But the drug has been criticized, because the results had not been replicated in a randomized trial, he said.

Although civilian trauma PTSD is helped somewhat by paroxetine (Paxil) and sertraline (Zoloft), results for selective serotonin reuptake inhibitors (SSRIs) have been disappointing among Vietnam veterans, especially for nightmares and sleep disruption.

Dr. Raskind opted to take a different approach based on evidence that enhanced responsiveness of central nervous system α₁-adrenergic receptors contributes to PTSD pathophysiology, particularly at night. An initial clinical experience with the β-adrenergic blocker, propranolol, failed as the β-blocker drugs can intensify dreams. Brain α₁-adrenergic effects are often opposed to brain β-adrenergic effects, so he turned to prazosin.

Treatment was started in a single patient at a low dose of 1 mg nightly to avoid the “first-dose” hypotension that has earned prazosin and other α₁-blockers a black box warning. After 2 weeks of gradual dose increases to 6 mg nightly, the tortuous dreams of a Vietnam veteran who had accidentally killed his friend disappeared. After 8 years, the veteran is still nightmare free.

But several episodes of unintentional discontinuation led to a rapid return of intense nightmares. Therefore, Dr. Raskind recommends the drug be taken every night, starting at 1 mg for 3 nights, then 2 mg for 4 nights, and increasing by 2 mg weekly until a therapeutic dose is achieved. Some older, Vietnam veterans may need 20 mg nightly. Adding small doses in the morning is helpful for daytime flashbacks and hypervigilance.

Adverse effects can include first-dose hypertension, increased risk of priapism with concurrent use of trazodone, nasal congestion, peripheral edema, and headache. Caution should be used with Viagra. Long-acting Cialis and Levitra should be avoided. Helpful side effects include gentle blood pressure reduction, enhanced urine flow in older men with prostate hypertrophy, and enhanced erectile function, he said.

Scores for recurrent distressing dreams were significantly improved from 6.5 at baseline to 2.9. DR. RASKIND

TUCSON, ARIZ. — Prazosin, an α₁-adrenergic blocker, substantially reduces posttraumatic stress disorder-related nightmares and sleep disturbances among veterans.

The drug is a safe and inexpensive treatment for night symptoms and also several daytime PTSD symptoms such as irritability, hypervigilance, and flashbacks, Dr. Murray Raskind reported at a psychopharmacology conference sponsored by the University of Arizona. “Many veterans say, 'It changed my life,'” he said.

Industry-supported trials in PTSD patients are unlikely for prazosin, which has been used for years as a generic antihypertensive. But Dr. Raskind, a professor at the University of Washington in Seattle and director of mental health services for the Veterans Administration Puget Sound, has compiled a growing body of evidence supporting the use of prazosin in this group.

He presented data from a parallel group study in which 34 Vietnam veterans with PTSD-related nightmares and sleep disturbances were randomized to prazosin at an average dose of 14 mg at bedtime or placebo. At 8 weeks, scores for the recurrent distressing dreams item of the Clinician-Administered PTSD Scale were significantly improved (6.5 at baseline to 2.9) among 17 prazosin patients, compared with 17 placebo patients (6.1 to 5.2).

Clinical Global Impression-Change scores were moderately or markedly improved in 12 of 17 prazosin patients and in only 2 of 17 placebo patients.

Another recent study included 28 combat veterans from Iraq who were treated with an average dose of 2 mg of prazosin every night for nightmares. Among the 23 patients with follow-up data, 20 had complete elimination of their nightmares, 2 had reduced frequency or intensity, and 1 had no change at 8 weeks (Military Med. 2005;170:513–5).

Sales of prazosin have risen in the Seattle area by about 30% since 1999 by word of mouth alone. But the drug has been criticized, because the results had not been replicated in a randomized trial, he said.

Although civilian trauma PTSD is helped somewhat by paroxetine (Paxil) and sertraline (Zoloft), results for selective serotonin reuptake inhibitors (SSRIs) have been disappointing among Vietnam veterans, especially for nightmares and sleep disruption.

Dr. Raskind opted to take a different approach based on evidence that enhanced responsiveness of central nervous system α₁-adrenergic receptors contributes to PTSD pathophysiology, particularly at night. An initial clinical experience with the β-adrenergic blocker, propranolol, failed as the β-blocker drugs can intensify dreams. Brain α₁-adrenergic effects are often opposed to brain β-adrenergic effects, so he turned to prazosin.

Treatment was started in a single patient at a low dose of 1 mg nightly to avoid the “first-dose” hypotension that has earned prazosin and other α₁-blockers a black box warning. After 2 weeks of gradual dose increases to 6 mg nightly, the tortuous dreams of a Vietnam veteran who had accidentally killed his friend disappeared. After 8 years, the veteran is still nightmare free.

But several episodes of unintentional discontinuation led to a rapid return of intense nightmares. Therefore, Dr. Raskind recommends the drug be taken every night, starting at 1 mg for 3 nights, then 2 mg for 4 nights, and increasing by 2 mg weekly until a therapeutic dose is achieved. Some older, Vietnam veterans may need 20 mg nightly. Adding small doses in the morning is helpful for daytime flashbacks and hypervigilance.

Adverse effects can include first-dose hypertension, increased risk of priapism with concurrent use of trazodone, nasal congestion, peripheral edema, and headache. Caution should be used with Viagra. Long-acting Cialis and Levitra should be avoided. Helpful side effects include gentle blood pressure reduction, enhanced urine flow in older men with prostate hypertrophy, and enhanced erectile function, he said.

Scores for recurrent distressing dreams were significantly improved from 6.5 at baseline to 2.9. DR. RASKIND

NICE, FRANCE — Self-collected vaginal swabs and urine samples provide clinicians with an opportunity to identify chlamydia and gonorrhea infections that would otherwise go undetected, Dr. Christian Hoebe said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

That conclusion emerged from a cross-sectional survey that showed the two tests were feasible and highly accepted among 413 women, aged 16–35 years, attending a public STD clinic.

The women reported in a questionnaire that the self-collected vaginal swabs and first-catch urine tests had clear instructions (reported by 97% and 93%, respectively); were easy to perform (95% and 92%); and were a “pleasant” method (98% and 99%).

Over three-fourths (77%) preferred the self-administered tests to a traditional gynecologic STD exam. The refusal rate was 1.5% for self-collected vaginal swab specimens and 0% for urine samples.

Analysis of the samples conducted using an amplified DNA assay (the BD ProbeTec ET System, from BD Diagnostics in Sparks, Md.) detected Chlamydia trachomatis in 45 of 413 of patients (11%) and Neisseria gonorrhoeae in 6 of 413 (1.5%).

Chlamydia was detected in 8 of 43 patients (19%) with a prior STD and in 39 of 312 of 16- to 25-year-old women (13%).

Overall, 68% of the women had never undergone STD testing before, and 11% of these tested positive (Sex Transm. Dis. 2006 Mar 16;[Epub ahead of print]).

The patients' mean age was 23 years; 56% had engaged in prior risky behaviors; 17% had a risky partner; and 29% were fearful of STDs.

Reasons for taking the tests were: anonymity/privacy (68%), easy access (61%), and not having to undergo an intimate vaginal exam (12%), said Dr. Hoebe of the South Limburg Public Health Service, Heerlen, the Netherlands.

The percent agreement of the tests was 98.8% for chlamydia and 99.3% for gonorrhea, he said.

NICE, FRANCE — Self-collected vaginal swabs and urine samples provide clinicians with an opportunity to identify chlamydia and gonorrhea infections that would otherwise go undetected, Dr. Christian Hoebe said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

That conclusion emerged from a cross-sectional survey that showed the two tests were feasible and highly accepted among 413 women, aged 16–35 years, attending a public STD clinic.

The women reported in a questionnaire that the self-collected vaginal swabs and first-catch urine tests had clear instructions (reported by 97% and 93%, respectively); were easy to perform (95% and 92%); and were a “pleasant” method (98% and 99%).

Over three-fourths (77%) preferred the self-administered tests to a traditional gynecologic STD exam. The refusal rate was 1.5% for self-collected vaginal swab specimens and 0% for urine samples.

Analysis of the samples conducted using an amplified DNA assay (the BD ProbeTec ET System, from BD Diagnostics in Sparks, Md.) detected Chlamydia trachomatis in 45 of 413 of patients (11%) and Neisseria gonorrhoeae in 6 of 413 (1.5%).

Chlamydia was detected in 8 of 43 patients (19%) with a prior STD and in 39 of 312 of 16- to 25-year-old women (13%).

Overall, 68% of the women had never undergone STD testing before, and 11% of these tested positive (Sex Transm. Dis. 2006 Mar 16;[Epub ahead of print]).

The patients' mean age was 23 years; 56% had engaged in prior risky behaviors; 17% had a risky partner; and 29% were fearful of STDs.

Reasons for taking the tests were: anonymity/privacy (68%), easy access (61%), and not having to undergo an intimate vaginal exam (12%), said Dr. Hoebe of the South Limburg Public Health Service, Heerlen, the Netherlands.

The percent agreement of the tests was 98.8% for chlamydia and 99.3% for gonorrhea, he said.

NICE, FRANCE — Self-collected vaginal swabs and urine samples provide clinicians with an opportunity to identify chlamydia and gonorrhea infections that would otherwise go undetected, Dr. Christian Hoebe said at the 16th European Congress of Clinical Microbiology and Infectious Diseases.

That conclusion emerged from a cross-sectional survey that showed the two tests were feasible and highly accepted among 413 women, aged 16–35 years, attending a public STD clinic.

The women reported in a questionnaire that the self-collected vaginal swabs and first-catch urine tests had clear instructions (reported by 97% and 93%, respectively); were easy to perform (95% and 92%); and were a “pleasant” method (98% and 99%).

Over three-fourths (77%) preferred the self-administered tests to a traditional gynecologic STD exam. The refusal rate was 1.5% for self-collected vaginal swab specimens and 0% for urine samples.

Analysis of the samples conducted using an amplified DNA assay (the BD ProbeTec ET System, from BD Diagnostics in Sparks, Md.) detected Chlamydia trachomatis in 45 of 413 of patients (11%) and Neisseria gonorrhoeae in 6 of 413 (1.5%).

Chlamydia was detected in 8 of 43 patients (19%) with a prior STD and in 39 of 312 of 16- to 25-year-old women (13%).

Overall, 68% of the women had never undergone STD testing before, and 11% of these tested positive (Sex Transm. Dis. 2006 Mar 16;[Epub ahead of print]).

The patients' mean age was 23 years; 56% had engaged in prior risky behaviors; 17% had a risky partner; and 29% were fearful of STDs.

Reasons for taking the tests were: anonymity/privacy (68%), easy access (61%), and not having to undergo an intimate vaginal exam (12%), said Dr. Hoebe of the South Limburg Public Health Service, Heerlen, the Netherlands.

The percent agreement of the tests was 98.8% for chlamydia and 99.3% for gonorrhea, he said.

NICE, FRANCE — Male gender, advanced age, and a history of several office visits in the past year were among the risk factors for a complicated urinary tract infection in a retrospective cohort study of older primary care patients with type 2 diabetes mellitus.

The findings were used to create a clinical prediction rule that could improve management of UTIs in patients aged 45 years and older, Leonie Muller said at the 16th European Congress of Clinical Microbiology and Infectious Diseases. Patients with type 2 diabetes are known to be at greater risk for urinary tract infections. But little is known about predictors of a complicated course.

Although the rule still needs to be validated in other populations, the idea is to use it to identify patients at high risk for serious UTI and educate them about the signs and risk factors for complicated infection, she said.

In a second retrospective cohort study, Ms. Muller and colleagues at the University Medical Center Utrecht, the Netherlands, created a similar rule for predicting complicated lower respiratory tract infections, which also are common in older patients with diabetes.

Using data from the Second Dutch National Survey of General Practice, the investigators conducted a 12-month, prospective cohort study that identified 6,343 patients, 45 years or older, with type 2 diabetes. The primary outcome was a complicated course UTI, defined as an episode of acute pyelonephritis or prostatitis, and recurrent cystitis. The mean age was 67 years, 46% were male, and 45% had recurrent cystitis.

Multivariate logistic regression analysis was used to develop a clinical prediction rule.

There were 179 (2.8%) complicated UTIs, 1 per 100 patient-years in females and 2 per 100 patient-years in males. Independent predictors were increasing age (odds ratio 1.7), male gender (OR 1.8), 12 or more office visits in the previous year (OR 11.5), urinary incontinence (OR 2.4), cerebrovascular disease or dementia (OR 2.14), and renal disease (OR 5.6).

Using a cut-off score of 4 points or more on a 12- point scale, 60% of patients would be selected for tailored care, and 8% of patients with a complicated course of UTI would be missed.

An example of how the rule might be applied in a diagnostic setting would be that a 75-year-old (1 point) male (1 point) patient with diabetes and renal disease (3 points) would be considered high risk, whereas his 73-year-old (1 point) wife with diabetes and urinary incontinence (2 points) would not. Ms. Muller, a doctoral student at the university, acknowledged that the model has the potential to identify a large percentage of high-risk patients, adding that future studies should focus on the cost-effectiveness of the rule.

In the second study, the investigators evaluated 20 predictors of death and/or 30-day hospitalization following an episode of lower respiratory tract infection in a subgroup of 1,693 patients, aged 65 years and older, with diabetes, from the same database. Among 445 episodes of lower respiratory tract infections including acute bronchitis, exacerbation of chronic obstructive pulmonary disease, asthma, or pneumonia, 13 were fatal and 55 required hospitalization.

Positive predictors of death and/or hospitalization were pneumonia (adjusted odds ratio 5.3), age greater than 80 years (OR 2.2), presence of heart failure (OR 2.1), and prednisone use (OR 2.4). The hospitalization/death rate was 5.2% among patients found to be at low risk and 36.6% among high-risk patients, Ms. Muller reported.

NICE, FRANCE — Male gender, advanced age, and a history of several office visits in the past year were among the risk factors for a complicated urinary tract infection in a retrospective cohort study of older primary care patients with type 2 diabetes mellitus.

The findings were used to create a clinical prediction rule that could improve management of UTIs in patients aged 45 years and older, Leonie Muller said at the 16th European Congress of Clinical Microbiology and Infectious Diseases. Patients with type 2 diabetes are known to be at greater risk for urinary tract infections. But little is known about predictors of a complicated course.

Although the rule still needs to be validated in other populations, the idea is to use it to identify patients at high risk for serious UTI and educate them about the signs and risk factors for complicated infection, she said.

In a second retrospective cohort study, Ms. Muller and colleagues at the University Medical Center Utrecht, the Netherlands, created a similar rule for predicting complicated lower respiratory tract infections, which also are common in older patients with diabetes.

Using data from the Second Dutch National Survey of General Practice, the investigators conducted a 12-month, prospective cohort study that identified 6,343 patients, 45 years or older, with type 2 diabetes. The primary outcome was a complicated course UTI, defined as an episode of acute pyelonephritis or prostatitis, and recurrent cystitis. The mean age was 67 years, 46% were male, and 45% had recurrent cystitis.

Multivariate logistic regression analysis was used to develop a clinical prediction rule.

There were 179 (2.8%) complicated UTIs, 1 per 100 patient-years in females and 2 per 100 patient-years in males. Independent predictors were increasing age (odds ratio 1.7), male gender (OR 1.8), 12 or more office visits in the previous year (OR 11.5), urinary incontinence (OR 2.4), cerebrovascular disease or dementia (OR 2.14), and renal disease (OR 5.6).

Using a cut-off score of 4 points or more on a 12- point scale, 60% of patients would be selected for tailored care, and 8% of patients with a complicated course of UTI would be missed.

An example of how the rule might be applied in a diagnostic setting would be that a 75-year-old (1 point) male (1 point) patient with diabetes and renal disease (3 points) would be considered high risk, whereas his 73-year-old (1 point) wife with diabetes and urinary incontinence (2 points) would not. Ms. Muller, a doctoral student at the university, acknowledged that the model has the potential to identify a large percentage of high-risk patients, adding that future studies should focus on the cost-effectiveness of the rule.

In the second study, the investigators evaluated 20 predictors of death and/or 30-day hospitalization following an episode of lower respiratory tract infection in a subgroup of 1,693 patients, aged 65 years and older, with diabetes, from the same database. Among 445 episodes of lower respiratory tract infections including acute bronchitis, exacerbation of chronic obstructive pulmonary disease, asthma, or pneumonia, 13 were fatal and 55 required hospitalization.

Positive predictors of death and/or hospitalization were pneumonia (adjusted odds ratio 5.3), age greater than 80 years (OR 2.2), presence of heart failure (OR 2.1), and prednisone use (OR 2.4). The hospitalization/death rate was 5.2% among patients found to be at low risk and 36.6% among high-risk patients, Ms. Muller reported.

NICE, FRANCE — Male gender, advanced age, and a history of several office visits in the past year were among the risk factors for a complicated urinary tract infection in a retrospective cohort study of older primary care patients with type 2 diabetes mellitus.

The findings were used to create a clinical prediction rule that could improve management of UTIs in patients aged 45 years and older, Leonie Muller said at the 16th European Congress of Clinical Microbiology and Infectious Diseases. Patients with type 2 diabetes are known to be at greater risk for urinary tract infections. But little is known about predictors of a complicated course.

Although the rule still needs to be validated in other populations, the idea is to use it to identify patients at high risk for serious UTI and educate them about the signs and risk factors for complicated infection, she said.

In a second retrospective cohort study, Ms. Muller and colleagues at the University Medical Center Utrecht, the Netherlands, created a similar rule for predicting complicated lower respiratory tract infections, which also are common in older patients with diabetes.

Using data from the Second Dutch National Survey of General Practice, the investigators conducted a 12-month, prospective cohort study that identified 6,343 patients, 45 years or older, with type 2 diabetes. The primary outcome was a complicated course UTI, defined as an episode of acute pyelonephritis or prostatitis, and recurrent cystitis. The mean age was 67 years, 46% were male, and 45% had recurrent cystitis.

Multivariate logistic regression analysis was used to develop a clinical prediction rule.

There were 179 (2.8%) complicated UTIs, 1 per 100 patient-years in females and 2 per 100 patient-years in males. Independent predictors were increasing age (odds ratio 1.7), male gender (OR 1.8), 12 or more office visits in the previous year (OR 11.5), urinary incontinence (OR 2.4), cerebrovascular disease or dementia (OR 2.14), and renal disease (OR 5.6).

Using a cut-off score of 4 points or more on a 12- point scale, 60% of patients would be selected for tailored care, and 8% of patients with a complicated course of UTI would be missed.

An example of how the rule might be applied in a diagnostic setting would be that a 75-year-old (1 point) male (1 point) patient with diabetes and renal disease (3 points) would be considered high risk, whereas his 73-year-old (1 point) wife with diabetes and urinary incontinence (2 points) would not. Ms. Muller, a doctoral student at the university, acknowledged that the model has the potential to identify a large percentage of high-risk patients, adding that future studies should focus on the cost-effectiveness of the rule.

In the second study, the investigators evaluated 20 predictors of death and/or 30-day hospitalization following an episode of lower respiratory tract infection in a subgroup of 1,693 patients, aged 65 years and older, with diabetes, from the same database. Among 445 episodes of lower respiratory tract infections including acute bronchitis, exacerbation of chronic obstructive pulmonary disease, asthma, or pneumonia, 13 were fatal and 55 required hospitalization.

Positive predictors of death and/or hospitalization were pneumonia (adjusted odds ratio 5.3), age greater than 80 years (OR 2.2), presence of heart failure (OR 2.1), and prednisone use (OR 2.4). The hospitalization/death rate was 5.2% among patients found to be at low risk and 36.6% among high-risk patients, Ms. Muller reported.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities, but several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the idea of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group who in large part have been competing with rather than relating to peers since grade school.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by noting that he'd had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians have worked while ill, and 52% have self-prescribed—and they visit their own doctor one-fourth as often as the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities, but several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the idea of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group who in large part have been competing with rather than relating to peers since grade school.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by noting that he'd had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians have worked while ill, and 52% have self-prescribed—and they visit their own doctor one-fourth as often as the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities, but several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the idea of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also a cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group who in large part have been competing with rather than relating to peers since grade school.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by noting that he'd had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians have worked while ill, and 52% have self-prescribed—and they visit their own doctor one-fourth as often as the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and some had tears in their eyes. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started one session by remarking that he had had to use the rest room for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and some had tears in their eyes. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started one session by remarking that he had had to use the rest room for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

TUCSON, ARIZ. — Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.

“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”

One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.

The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”

Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school. “Physicians are starving at a banquet of social support,” he said of the need to improve social connections.

When a few excerpts were shared at this conference, the audience went silent, heads nodded, and some had tears in their eyes. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.

Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts—in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.

Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started one session by remarking that he had had to use the rest room for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctor at a rate equal to one-fourth the national average. Another red flag is the internal use of self-deprecation as a motivator, one of the best predictors of depression, he said.

The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population.

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control investigation.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

“My first reaction was sort of like everyone else's—'This is crazy,'” she said in an interview. “But it does seem to bear out.”

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease.

The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test.

Electrodiagnostic studies were used to confirm the diagnosis of carpal tunnel in 119 patients and 175 hands, and cubital tunnel in 70 patients and 81 hands.

In the control group, testing was rarely positive, she said. In the 175 hands with carpal tunnel syndrome, 148 had a positive scratch-collapse test, 141 had a positive Tinel's sign, and 131 had a positive Phalen's test.

In the 81 hands with cubital tunnel syndrome, 64 had a positive scratch-collapse test, 64 had a positive Tinel's sign, and 56 had positive elbow flexion.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

Dr. Cheng and her colleagues have been using the test for about 2 years, in conjunction with other testing, to establish a diagnosis of carpal tunnel in patients. Part of the problem in establishing this diagnosis is that it remains primarily clinical, she explained.

The sensitivity and specificity of clinical tests vary widely, electrodiagnostic studies still have significant false-positive and false-negative values, and predictive values depend on the prevalence of disease.

“For something as common and presumably simple as carpal tunnel syndrome, it's not all that easy to diagnose because there really isn't a gold standard that you can use,” she said.

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control investigation.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

“My first reaction was sort of like everyone else's—'This is crazy,'” she said in an interview. “But it does seem to bear out.”

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease.

The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test.

Electrodiagnostic studies were used to confirm the diagnosis of carpal tunnel in 119 patients and 175 hands, and cubital tunnel in 70 patients and 81 hands.

In the control group, testing was rarely positive, she said. In the 175 hands with carpal tunnel syndrome, 148 had a positive scratch-collapse test, 141 had a positive Tinel's sign, and 131 had a positive Phalen's test.

In the 81 hands with cubital tunnel syndrome, 64 had a positive scratch-collapse test, 64 had a positive Tinel's sign, and 56 had positive elbow flexion.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

Dr. Cheng and her colleagues have been using the test for about 2 years, in conjunction with other testing, to establish a diagnosis of carpal tunnel in patients. Part of the problem in establishing this diagnosis is that it remains primarily clinical, she explained.

The sensitivity and specificity of clinical tests vary widely, electrodiagnostic studies still have significant false-positive and false-negative values, and predictive values depend on the prevalence of disease.

“For something as common and presumably simple as carpal tunnel syndrome, it's not all that easy to diagnose because there really isn't a gold standard that you can use,” she said.

TUCSON, ARIZ. — A novel test for diagnosing carpal and cubital tunnel syndromes was at least as accurate as conventional tests, according to the findings of a prospective, case-control investigation.

During the so-called scratch-collapse test, patients perform a simple resistive motor task, such as pressing their extended arms against a clinician, who then lightly scratches the site of peripheral nerve compression. The patient then immediately attempts to repeat the motor task. If the test is positive, there is a brief loss of proximal postural stability, or “collapse,” in the arm, Dr. Christine Cheng explained at the annual meeting of the American Association for Hand Surgery.

“My first reaction was sort of like everyone else's—'This is crazy,'” she said in an interview. “But it does seem to bear out.”

The test was developed by San Diego orthopedic surgeon Dr. John Beck, based on observations of postural stimulation and muscle control in patients with Parkinson's disease.

The exact mechanism is not fully understood. But it is hypothesized that the test is detecting a short circuit or delay in the proximal muscles, said Dr. Cheng of Washington University, St. Louis.

She presented data from a prospective study in which 169 patients and 109 controls were evaluated for carpal and cubital tunnel syndromes using Tinel's sign, Phalen's test, elbow flexion, and the scratch-collapse test.

Electrodiagnostic studies were used to confirm the diagnosis of carpal tunnel in 119 patients and 175 hands, and cubital tunnel in 70 patients and 81 hands.

In the control group, testing was rarely positive, she said. In the 175 hands with carpal tunnel syndrome, 148 had a positive scratch-collapse test, 141 had a positive Tinel's sign, and 131 had a positive Phalen's test.

In the 81 hands with cubital tunnel syndrome, 64 had a positive scratch-collapse test, 64 had a positive Tinel's sign, and 56 had positive elbow flexion.

Sensitivity of the scratch-collapse test in subjects with carpal tunnel syndrome was 75%, compared with 37% for Tinel's sign and 47% for Phalen's test. Specificity was 62%, 75%, and 66%, respectively. Accuracy was 72%, 47%, and 54%.

Sensitivity of the scratch-collapse test in subjects with cubital tunnel syndrome was 83%, compared with 65% for Tinel's sign and 54% for elbow flexion. Specificity was 82%, 86%, and 81%, respectively. Accuracy was 82%, 77%, and 69%.

Dr. Cheng and her colleagues have been using the test for about 2 years, in conjunction with other testing, to establish a diagnosis of carpal tunnel in patients. Part of the problem in establishing this diagnosis is that it remains primarily clinical, she explained.

The sensitivity and specificity of clinical tests vary widely, electrodiagnostic studies still have significant false-positive and false-negative values, and predictive values depend on the prevalence of disease.

“For something as common and presumably simple as carpal tunnel syndrome, it's not all that easy to diagnose because there really isn't a gold standard that you can use,” she said.

TUCSON, ARIZ. — Gelfoam interposition is an effective, tendon-sparing alternative to the anchovy procedure for the treatment of trapeziometacarpal osteoarthritis, Dr. Ronald E. Palmer said at the annual meeting of the American Association for Hand Surgery.

The classic treatment for osteoarthritis of the trapezial metacarpal includes excision of the arthritic trapezium bone, with a ligament reconstruction using a forearm tendon, typically the flexor carpi radialis tendon. The remainder of the tendon is then rolled up like an anchovy filet when packaged in a can for sale and interposed in place of the trapezium, where it serves as a biological cushion and minimizes collapse.

Gelfoam interposition “is an effective procedure that is much easier to do” than the anchovy procedure, said Dr. Palmer of the Orthopedic Institute of Illinois in Peoria.

“It has few of the complications that the other procedures have—certainly no synovitis or osteolysis—and it spares the use of other tendons that may cause problems.” Dr. Palmer began using Gelfoam in 1996 and has now performed interpositions in 139 patients with symptomatic osteoarthritis of the trapezial metacarpal, Eaton classification stages II-IV.

All patients were evaluated with a clinical examination and questionnaire an average of 2 months after the procedure, said Dr. Palmer.

Pain relief was achieved in all cases, and all patients were satisfied with their postoperative results, he said, citing improved function and strength as measured by thumb carpal-metacarpal extension and abduction, thumb opposition, grip strength, pinch tip, palmar pinch, and lateral pinch.

The first web space did not atrophy after the procedure. There were no complications or morbidity.

Dr. Palmer said the anchovy procedure provides excellent pain relief.

But in his experience, there frequently wasn't enough tendon left with the anchovy procedure to adequately fill the space left by the excised trapezium.

TUCSON, ARIZ. — Gelfoam interposition is an effective, tendon-sparing alternative to the anchovy procedure for the treatment of trapeziometacarpal osteoarthritis, Dr. Ronald E. Palmer said at the annual meeting of the American Association for Hand Surgery.

The classic treatment for osteoarthritis of the trapezial metacarpal includes excision of the arthritic trapezium bone, with a ligament reconstruction using a forearm tendon, typically the flexor carpi radialis tendon. The remainder of the tendon is then rolled up like an anchovy filet when packaged in a can for sale and interposed in place of the trapezium, where it serves as a biological cushion and minimizes collapse.

Gelfoam interposition “is an effective procedure that is much easier to do” than the anchovy procedure, said Dr. Palmer of the Orthopedic Institute of Illinois in Peoria.

“It has few of the complications that the other procedures have—certainly no synovitis or osteolysis—and it spares the use of other tendons that may cause problems.” Dr. Palmer began using Gelfoam in 1996 and has now performed interpositions in 139 patients with symptomatic osteoarthritis of the trapezial metacarpal, Eaton classification stages II-IV.

All patients were evaluated with a clinical examination and questionnaire an average of 2 months after the procedure, said Dr. Palmer.

Pain relief was achieved in all cases, and all patients were satisfied with their postoperative results, he said, citing improved function and strength as measured by thumb carpal-metacarpal extension and abduction, thumb opposition, grip strength, pinch tip, palmar pinch, and lateral pinch.

The first web space did not atrophy after the procedure. There were no complications or morbidity.

Dr. Palmer said the anchovy procedure provides excellent pain relief.

But in his experience, there frequently wasn't enough tendon left with the anchovy procedure to adequately fill the space left by the excised trapezium.

TUCSON, ARIZ. — Gelfoam interposition is an effective, tendon-sparing alternative to the anchovy procedure for the treatment of trapeziometacarpal osteoarthritis, Dr. Ronald E. Palmer said at the annual meeting of the American Association for Hand Surgery.

The classic treatment for osteoarthritis of the trapezial metacarpal includes excision of the arthritic trapezium bone, with a ligament reconstruction using a forearm tendon, typically the flexor carpi radialis tendon. The remainder of the tendon is then rolled up like an anchovy filet when packaged in a can for sale and interposed in place of the trapezium, where it serves as a biological cushion and minimizes collapse.

Gelfoam interposition “is an effective procedure that is much easier to do” than the anchovy procedure, said Dr. Palmer of the Orthopedic Institute of Illinois in Peoria.

“It has few of the complications that the other procedures have—certainly no synovitis or osteolysis—and it spares the use of other tendons that may cause problems.” Dr. Palmer began using Gelfoam in 1996 and has now performed interpositions in 139 patients with symptomatic osteoarthritis of the trapezial metacarpal, Eaton classification stages II-IV.

All patients were evaluated with a clinical examination and questionnaire an average of 2 months after the procedure, said Dr. Palmer.

Pain relief was achieved in all cases, and all patients were satisfied with their postoperative results, he said, citing improved function and strength as measured by thumb carpal-metacarpal extension and abduction, thumb opposition, grip strength, pinch tip, palmar pinch, and lateral pinch.

The first web space did not atrophy after the procedure. There were no complications or morbidity.

Dr. Palmer said the anchovy procedure provides excellent pain relief.

But in his experience, there frequently wasn't enough tendon left with the anchovy procedure to adequately fill the space left by the excised trapezium.

MIAMI BEACH — High maternal vitamin D intake in pregnancy may help protect children from asthma and wheezing illnesses during early childhood, results of a large, prospective study suggest.

In multivariate analyses, every 100-IU increase in maternal vitamin D intake was associated with about a 10% lower risk for any wheeze (odds ratio 0.90) and with nearly a 20% lower risk of having a child at high risk for asthma (OR 0.82). This inverse association was present whether vitamin D came from diet or nutritional supplements and remained after controlling for 10 confounding factors, Dr. Carlos A. Camargo Jr. reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology.

“This is a new hypothesis, but the vitamin D story is going to be one that you're going to hear more and more about in the years ahead,” he told reporters at the meeting. “Already this year there is a lot of discussion going on about vitamin D and cancer. But to link this to asthma and allergic diseases is very exciting.”

The best explanation for the observed protective effect is that vitamin D, which is known to have some immunologic effects, influences IL-10 secretion by regulatory T cells, said Dr. Camargo of the department of epidemiology at Harvard Medical School in Boston.

The findings suggest that vitamin D insufficiency is a reality, particularly in northern parts of the country. Exactly what the correct amount of daily vitamin D intake is remains unclear, in part because of emerging data from this and studies in other specialties, he said. “Most people in the field would recommend 800–1,000 IU/day, and yet you'll see recommendations of 200–400 IU in the literature,” he said.

The mean vitamin D intake during pregnancy was 548 IU/day in the study, which included 1,194 mother-child pairs in Project Viva, a prospective prepartum cohort study in Massachusetts. Intake was assessed using a validated food questionnaire in the first and second trimesters and was averaged for analyses.

Dr. Camargo and his colleagues defined any wheeze as a mother-reported wheeze or physician-diagnosed asthma, wheezing, or reactive airway disease at ages 1, 2, or 3 years. High risk of asthma was defined as the subset of children with two or more reports of wheezing at 1, 2, or 3 years, plus either parental history of asthma or child diagnosis of eczema.

Most people in the field would recommend 800–1,000 IU/day, yet recommendations of 200–400 IU are in the literature. DR. CAMARGO

MIAMI BEACH — High maternal vitamin D intake in pregnancy may help protect children from asthma and wheezing illnesses during early childhood, results of a large, prospective study suggest.

In multivariate analyses, every 100-IU increase in maternal vitamin D intake was associated with about a 10% lower risk for any wheeze (odds ratio 0.90) and with nearly a 20% lower risk of having a child at high risk for asthma (OR 0.82). This inverse association was present whether vitamin D came from diet or nutritional supplements and remained after controlling for 10 confounding factors, Dr. Carlos A. Camargo Jr. reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology.

“This is a new hypothesis, but the vitamin D story is going to be one that you're going to hear more and more about in the years ahead,” he told reporters at the meeting. “Already this year there is a lot of discussion going on about vitamin D and cancer. But to link this to asthma and allergic diseases is very exciting.”

The best explanation for the observed protective effect is that vitamin D, which is known to have some immunologic effects, influences IL-10 secretion by regulatory T cells, said Dr. Camargo of the department of epidemiology at Harvard Medical School in Boston.

The findings suggest that vitamin D insufficiency is a reality, particularly in northern parts of the country. Exactly what the correct amount of daily vitamin D intake is remains unclear, in part because of emerging data from this and studies in other specialties, he said. “Most people in the field would recommend 800–1,000 IU/day, and yet you'll see recommendations of 200–400 IU in the literature,” he said.

The mean vitamin D intake during pregnancy was 548 IU/day in the study, which included 1,194 mother-child pairs in Project Viva, a prospective prepartum cohort study in Massachusetts. Intake was assessed using a validated food questionnaire in the first and second trimesters and was averaged for analyses.

Dr. Camargo and his colleagues defined any wheeze as a mother-reported wheeze or physician-diagnosed asthma, wheezing, or reactive airway disease at ages 1, 2, or 3 years. High risk of asthma was defined as the subset of children with two or more reports of wheezing at 1, 2, or 3 years, plus either parental history of asthma or child diagnosis of eczema.

Most people in the field would recommend 800–1,000 IU/day, yet recommendations of 200–400 IU are in the literature. DR. CAMARGO

MIAMI BEACH — High maternal vitamin D intake in pregnancy may help protect children from asthma and wheezing illnesses during early childhood, results of a large, prospective study suggest.

In multivariate analyses, every 100-IU increase in maternal vitamin D intake was associated with about a 10% lower risk for any wheeze (odds ratio 0.90) and with nearly a 20% lower risk of having a child at high risk for asthma (OR 0.82). This inverse association was present whether vitamin D came from diet or nutritional supplements and remained after controlling for 10 confounding factors, Dr. Carlos A. Camargo Jr. reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology.

“This is a new hypothesis, but the vitamin D story is going to be one that you're going to hear more and more about in the years ahead,” he told reporters at the meeting. “Already this year there is a lot of discussion going on about vitamin D and cancer. But to link this to asthma and allergic diseases is very exciting.”

The best explanation for the observed protective effect is that vitamin D, which is known to have some immunologic effects, influences IL-10 secretion by regulatory T cells, said Dr. Camargo of the department of epidemiology at Harvard Medical School in Boston.

The findings suggest that vitamin D insufficiency is a reality, particularly in northern parts of the country. Exactly what the correct amount of daily vitamin D intake is remains unclear, in part because of emerging data from this and studies in other specialties, he said. “Most people in the field would recommend 800–1,000 IU/day, and yet you'll see recommendations of 200–400 IU in the literature,” he said.

The mean vitamin D intake during pregnancy was 548 IU/day in the study, which included 1,194 mother-child pairs in Project Viva, a prospective prepartum cohort study in Massachusetts. Intake was assessed using a validated food questionnaire in the first and second trimesters and was averaged for analyses.

Dr. Camargo and his colleagues defined any wheeze as a mother-reported wheeze or physician-diagnosed asthma, wheezing, or reactive airway disease at ages 1, 2, or 3 years. High risk of asthma was defined as the subset of children with two or more reports of wheezing at 1, 2, or 3 years, plus either parental history of asthma or child diagnosis of eczema.

Most people in the field would recommend 800–1,000 IU/day, yet recommendations of 200–400 IU are in the literature. DR. CAMARGO