Sherry Boschert

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65-102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health.”

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55-84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

A University of Chicago study showed that limiting sleep to 4 hours a night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65-102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health.”

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55-84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

A University of Chicago study showed that limiting sleep to 4 hours a night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Sleep should be viewed as a vital sign, and primary care physicians should address sleep disturbances routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

“Although there has been more than a decade of discussion about the prevalence and low detection rates of sleep problems, little has changed in primary care practice in recognition of sleep problems in the elderly,” said Dr. Bloom of the International Longevity Center, New York.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by his organization in collaboration with other groups, he said.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” Dr. Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65-102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said. “Sleep in older people really is a barometer of health.”

A growing database of studies directly associates sleep disorders with problems of attention and memory, depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55-84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

A University of Chicago study showed that limiting sleep to 4 hours a night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use.

In some patients, physicians may want to consider adjusting drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, said Dr. Rollin M. Wright of the University of Pittsburgh, at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70-79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study. The researchers gathered information about medication use from containers brought in by participants and assessed them for cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not linked to new-onset cognitive impairment (an 3MS score below 80) but was associated with new development of cognitive decline (a dip of 5 or more points on the 3MS).

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. Those using the highest cumulative dose of more than three standardized daily doses had an 82% increased risk of cognitive decline, compared with nonusers.

CNS-active drug use rose from 14% of participants at baseline to 15% of 2,284 subjects at year 3, with 3% of the cohort using the highest doses, 11% reporting long-term use, and 20% showing cognitive decline.

At year 5, 17% of 1,907 subjects were using CNS-active medications, again with 3% on the highest doses and 11% citing long-term use. After excluding those showing cognitive decline at year 3, 14% of subjects at year 5 showed new cognitive decline. Indications for CNS-active medication use included sleep problems (11%), anxiety (34%), osteoarthritis (15%), cancer (18%), depression (4%), and bodily pain (40%). The study cohort was 53% female and 37% black, with a mean age of 74 years.

Dr. Wright has no ties with makers of the drugs used in the study. It was partially funded by the National Institute on Aging.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use.

In some patients, physicians may want to consider adjusting drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, said Dr. Rollin M. Wright of the University of Pittsburgh, at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70-79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study. The researchers gathered information about medication use from containers brought in by participants and assessed them for cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not linked to new-onset cognitive impairment (an 3MS score below 80) but was associated with new development of cognitive decline (a dip of 5 or more points on the 3MS).

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. Those using the highest cumulative dose of more than three standardized daily doses had an 82% increased risk of cognitive decline, compared with nonusers.

CNS-active drug use rose from 14% of participants at baseline to 15% of 2,284 subjects at year 3, with 3% of the cohort using the highest doses, 11% reporting long-term use, and 20% showing cognitive decline.

At year 5, 17% of 1,907 subjects were using CNS-active medications, again with 3% on the highest doses and 11% citing long-term use. After excluding those showing cognitive decline at year 3, 14% of subjects at year 5 showed new cognitive decline. Indications for CNS-active medication use included sleep problems (11%), anxiety (34%), osteoarthritis (15%), cancer (18%), depression (4%), and bodily pain (40%). The study cohort was 53% female and 37% black, with a mean age of 74 years.

Dr. Wright has no ties with makers of the drugs used in the study. It was partially funded by the National Institute on Aging.

SAN FRANCISCO – Community-dwelling elderly people were more likely to show cognitive decline over a 5-year period if they took medications that act on the central nervous system, especially with higher cumulative doses or with longer use.

In some patients, physicians may want to consider adjusting drug doses to lower the cumulative CNS medications dose while retaining the benefits of each medication, said Dr. Rollin M. Wright of the University of Pittsburgh, at the annual meeting of the Gerontological Society of America.

In a longitudinal cohort study, Dr. Wright and her colleagues examined 2,737 cognitively intact adults aged 70-79 years old at baseline and again 3 and 5 years later. All of the participants could walk a quarter of a mile and climb a flight of stairs, and were enrolled in the Health, Aging, and Body Composition study. The researchers gathered information about medication use from containers brought in by participants and assessed them for cognitive function using Teng's Modified Mini-Mental State Examination (3MS), they wrote in their poster.

Use of CNS-active medications including benzodiazepines, opioid receptor agonists, antipsychotics, or antidepressants was not linked to new-onset cognitive impairment (an 3MS score below 80) but was associated with new development of cognitive decline (a dip of 5 or more points on the 3MS).

Any use of the CNS-active medications was associated with a 36% increased risk of cognitive decline after adjustment for the effects of sociodemographic factors, health behavior, health status, and the indications for CNS medication use. Long-term use of CNS-active medications, defined as 2 or more years of use, was associated with a 39% increased risk of cognitive decline, compared with no use of the medications.

Participants on the highest cumulative doses of CNS-active medications had the greatest increased risk for cognitive decline. Those using the highest cumulative dose of more than three standardized daily doses had an 82% increased risk of cognitive decline, compared with nonusers.

CNS-active drug use rose from 14% of participants at baseline to 15% of 2,284 subjects at year 3, with 3% of the cohort using the highest doses, 11% reporting long-term use, and 20% showing cognitive decline.

At year 5, 17% of 1,907 subjects were using CNS-active medications, again with 3% on the highest doses and 11% citing long-term use. After excluding those showing cognitive decline at year 3, 14% of subjects at year 5 showed new cognitive decline. Indications for CNS-active medication use included sleep problems (11%), anxiety (34%), osteoarthritis (15%), cancer (18%), depression (4%), and bodily pain (40%). The study cohort was 53% female and 37% black, with a mean age of 74 years.

Dr. Wright has no ties with makers of the drugs used in the study. It was partially funded by the National Institute on Aging.

SAN FRANCISCO – Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the brain to the outside world.

Tracts that expose the brain put a child “at higher risk for meningitis and abscess formation,” Dr. Brandie J. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location–the lateral third of an eyebrow–have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin. In some reports, almost half are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions. Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location. All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors. Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–“just a kind of yellow broadening of the tip of the nose or the nasal bridge,” Dr. Metz said. An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

“[In] a teenager with a dermoid cyst in a very classic location, you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful,” she said. If it is found that there is intracranial connection, the patient should be referred to a neurosurgeon for surgical removal of the connection.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dermoid cysts at the lateral third of the eyebrow don't need radiologic imaging.

Here, an MRI of a midline nasal dermoid confirms an intracranial connection. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO – Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the brain to the outside world.

Tracts that expose the brain put a child “at higher risk for meningitis and abscess formation,” Dr. Brandie J. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location–the lateral third of an eyebrow–have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin. In some reports, almost half are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions. Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location. All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors. Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–“just a kind of yellow broadening of the tip of the nose or the nasal bridge,” Dr. Metz said. An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

“[In] a teenager with a dermoid cyst in a very classic location, you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful,” she said. If it is found that there is intracranial connection, the patient should be referred to a neurosurgeon for surgical removal of the connection.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dermoid cysts at the lateral third of the eyebrow don't need radiologic imaging.

Here, an MRI of a midline nasal dermoid confirms an intracranial connection. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO – Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the brain to the outside world.

Tracts that expose the brain put a child “at higher risk for meningitis and abscess formation,” Dr. Brandie J. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location–the lateral third of an eyebrow–have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin. In some reports, almost half are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions. Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location. All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors. Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–“just a kind of yellow broadening of the tip of the nose or the nasal bridge,” Dr. Metz said. An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

“[In] a teenager with a dermoid cyst in a very classic location, you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful,” she said. If it is found that there is intracranial connection, the patient should be referred to a neurosurgeon for surgical removal of the connection.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dermoid cysts at the lateral third of the eyebrow don't need radiologic imaging.

Here, an MRI of a midline nasal dermoid confirms an intracranial connection. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO – The prevalence of diabetes mellitus in a study of 2,317 U.S. nursing home residents was 33%, higher than previous reports that pegged the prevalence at 11%-27% of nursing home residents.

Previous estimates predominantly relied on the Minimum Data Set, a standardized instrument used by all U.S. nursing homes that includes diabetes among 400 items assessed in each resident. The current retrospective study incorporated the Minimum Data Set plus an audit of medical charts and a review of pharmacy data on antidiabetic medications prescribed for residents, Sandra Molotsky reported in a poster presentation at the annual meeting of the Gerontological Society of America.

The study looked at residents aged 65 years or older in 23 randomly selected nursing homes who were neither receiving hospice care nor in persistent vegetative states. The study population had a mean age of 83 years and had been living in nursing homes for a mean of 3 years. Overall, 73% of participants were female and 84% were white.

Compared with the cohort as a whole, residents with diabetes were significantly more likely to be younger than 84 years, male (38% vs. 27% overall), and obese (48% vs. 22% overall). Of the 9% of residents who were Hispanic, 46% had diabetes; similarly, of the 7% of residents who were black, 40% had diabetes, said Ms. Molotsky, director of Omnicare Senior Health Outcomes LLC, King of Prussia, Pa. The company is a research division of Omnicare Inc., which provides pharmacy services in nursing homes. The study was funded by Sanofi-Aventis, which markets medications for diabetes.

The diabetic residents carried significantly more comorbid illnesses. Medical chart reviews found significantly higher rates of chronic renal insufficiency (10%) and dyslipidemia (15%) in residents with diabetes, compared with rates of renal insufficiency (5%) and dyslipidemia (8%) in nondiabetic residents, she and her associates reported.

Minimum Data Set results suggested no difference between groups in the rate of renal failure, but chart reviews found evidence of renal failure in a significantly higher proportion of diabetic (6%) than nondiabetic (2%) residents. The study also found trends for higher rates of neuropathy, peripheral neuropathy, or gastroparesis in diabetic residents, but these trends did not reach statistical significance.

Diabetic residents were 64% more likely to be hospitalized within 6 months of the start of the analysis, compared with nondiabetic residents. Also within that 6-month window, residents with diabetes were more likely to develop infection (18%) or have a cerebrovascular accident (27%), compared with nondiabetic residents, 11% of whom developed infections and 17% of whom had cerebrovascular accidents.

A large proportion of diabetic residents were on medications for comorbid disorders. They were twice as likely as nondiabetic residents to be taking ACE inhibitors, angiotensin II receptor blockers, and statins.

The prevalence of diabetes in U.S. adults aged 65 years or older is expected to increase by 56% in the coming years, which would mean 7.5 million older Americans with diabetes in 2020. “Management of diabetes mellitus in skilled nursing facilities will be an important aspect of resident management to reduce comorbidity and mortality,” the investigators concluded.

Data obtained in the analysis but not reported in the poster showed evidence of appropriate monitoring and treatment in 70% of residents with diabetes, Ms. Molotsky said. For the other 30%, “We didn't have hemoglobin A1c values. We didn't have any fasting blood glucose levels. There wasn't evidence of any monitoring whatsoever in the chart,” she said.

SAN FRANCISCO – The prevalence of diabetes mellitus in a study of 2,317 U.S. nursing home residents was 33%, higher than previous reports that pegged the prevalence at 11%-27% of nursing home residents.

Previous estimates predominantly relied on the Minimum Data Set, a standardized instrument used by all U.S. nursing homes that includes diabetes among 400 items assessed in each resident. The current retrospective study incorporated the Minimum Data Set plus an audit of medical charts and a review of pharmacy data on antidiabetic medications prescribed for residents, Sandra Molotsky reported in a poster presentation at the annual meeting of the Gerontological Society of America.

The study looked at residents aged 65 years or older in 23 randomly selected nursing homes who were neither receiving hospice care nor in persistent vegetative states. The study population had a mean age of 83 years and had been living in nursing homes for a mean of 3 years. Overall, 73% of participants were female and 84% were white.

Compared with the cohort as a whole, residents with diabetes were significantly more likely to be younger than 84 years, male (38% vs. 27% overall), and obese (48% vs. 22% overall). Of the 9% of residents who were Hispanic, 46% had diabetes; similarly, of the 7% of residents who were black, 40% had diabetes, said Ms. Molotsky, director of Omnicare Senior Health Outcomes LLC, King of Prussia, Pa. The company is a research division of Omnicare Inc., which provides pharmacy services in nursing homes. The study was funded by Sanofi-Aventis, which markets medications for diabetes.

The diabetic residents carried significantly more comorbid illnesses. Medical chart reviews found significantly higher rates of chronic renal insufficiency (10%) and dyslipidemia (15%) in residents with diabetes, compared with rates of renal insufficiency (5%) and dyslipidemia (8%) in nondiabetic residents, she and her associates reported.

Minimum Data Set results suggested no difference between groups in the rate of renal failure, but chart reviews found evidence of renal failure in a significantly higher proportion of diabetic (6%) than nondiabetic (2%) residents. The study also found trends for higher rates of neuropathy, peripheral neuropathy, or gastroparesis in diabetic residents, but these trends did not reach statistical significance.

Diabetic residents were 64% more likely to be hospitalized within 6 months of the start of the analysis, compared with nondiabetic residents. Also within that 6-month window, residents with diabetes were more likely to develop infection (18%) or have a cerebrovascular accident (27%), compared with nondiabetic residents, 11% of whom developed infections and 17% of whom had cerebrovascular accidents.

A large proportion of diabetic residents were on medications for comorbid disorders. They were twice as likely as nondiabetic residents to be taking ACE inhibitors, angiotensin II receptor blockers, and statins.

The prevalence of diabetes in U.S. adults aged 65 years or older is expected to increase by 56% in the coming years, which would mean 7.5 million older Americans with diabetes in 2020. “Management of diabetes mellitus in skilled nursing facilities will be an important aspect of resident management to reduce comorbidity and mortality,” the investigators concluded.

Data obtained in the analysis but not reported in the poster showed evidence of appropriate monitoring and treatment in 70% of residents with diabetes, Ms. Molotsky said. For the other 30%, “We didn't have hemoglobin A1c values. We didn't have any fasting blood glucose levels. There wasn't evidence of any monitoring whatsoever in the chart,” she said.

SAN FRANCISCO – The prevalence of diabetes mellitus in a study of 2,317 U.S. nursing home residents was 33%, higher than previous reports that pegged the prevalence at 11%-27% of nursing home residents.

Previous estimates predominantly relied on the Minimum Data Set, a standardized instrument used by all U.S. nursing homes that includes diabetes among 400 items assessed in each resident. The current retrospective study incorporated the Minimum Data Set plus an audit of medical charts and a review of pharmacy data on antidiabetic medications prescribed for residents, Sandra Molotsky reported in a poster presentation at the annual meeting of the Gerontological Society of America.

The study looked at residents aged 65 years or older in 23 randomly selected nursing homes who were neither receiving hospice care nor in persistent vegetative states. The study population had a mean age of 83 years and had been living in nursing homes for a mean of 3 years. Overall, 73% of participants were female and 84% were white.

Compared with the cohort as a whole, residents with diabetes were significantly more likely to be younger than 84 years, male (38% vs. 27% overall), and obese (48% vs. 22% overall). Of the 9% of residents who were Hispanic, 46% had diabetes; similarly, of the 7% of residents who were black, 40% had diabetes, said Ms. Molotsky, director of Omnicare Senior Health Outcomes LLC, King of Prussia, Pa. The company is a research division of Omnicare Inc., which provides pharmacy services in nursing homes. The study was funded by Sanofi-Aventis, which markets medications for diabetes.

The diabetic residents carried significantly more comorbid illnesses. Medical chart reviews found significantly higher rates of chronic renal insufficiency (10%) and dyslipidemia (15%) in residents with diabetes, compared with rates of renal insufficiency (5%) and dyslipidemia (8%) in nondiabetic residents, she and her associates reported.

Minimum Data Set results suggested no difference between groups in the rate of renal failure, but chart reviews found evidence of renal failure in a significantly higher proportion of diabetic (6%) than nondiabetic (2%) residents. The study also found trends for higher rates of neuropathy, peripheral neuropathy, or gastroparesis in diabetic residents, but these trends did not reach statistical significance.

Diabetic residents were 64% more likely to be hospitalized within 6 months of the start of the analysis, compared with nondiabetic residents. Also within that 6-month window, residents with diabetes were more likely to develop infection (18%) or have a cerebrovascular accident (27%), compared with nondiabetic residents, 11% of whom developed infections and 17% of whom had cerebrovascular accidents.

A large proportion of diabetic residents were on medications for comorbid disorders. They were twice as likely as nondiabetic residents to be taking ACE inhibitors, angiotensin II receptor blockers, and statins.

The prevalence of diabetes in U.S. adults aged 65 years or older is expected to increase by 56% in the coming years, which would mean 7.5 million older Americans with diabetes in 2020. “Management of diabetes mellitus in skilled nursing facilities will be an important aspect of resident management to reduce comorbidity and mortality,” the investigators concluded.

Data obtained in the analysis but not reported in the poster showed evidence of appropriate monitoring and treatment in 70% of residents with diabetes, Ms. Molotsky said. For the other 30%, “We didn't have hemoglobin A1c values. We didn't have any fasting blood glucose levels. There wasn't evidence of any monitoring whatsoever in the chart,” she said.

SAN FRANCISCO — Sleep should be viewed as a vital sign, and sleep disturbances should be addressed routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by the International Longevity Center, New York, in collaboration with other groups, said Dr. Bloom of the center.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” neurologist Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said.

“Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems relating to attention and memory as well as depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who reported more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO — Sleep should be viewed as a vital sign, and sleep disturbances should be addressed routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by the International Longevity Center, New York, in collaboration with other groups, said Dr. Bloom of the center.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” neurologist Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said.

“Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems relating to attention and memory as well as depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who reported more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO — Sleep should be viewed as a vital sign, and sleep disturbances should be addressed routinely in all visits with older adults, Dr. Harrison G. Bloom said at the annual meeting of the Gerontological Society of America.

A first draft of new guidelines for the assessment and treatment of sleep disorders in older people should be ready for discussion within the next few months, produced by the International Longevity Center, New York, in collaboration with other groups, said Dr. Bloom of the center.

“Sleep disorders are prevalent in older individuals and have important consequences, yet very seldom are looked at. It should be a vital sign,” neurologist Phyllis C. Zee said in a separate presentation at the same session.

She and her associates interviewed older adults aged 65–102 years in 11 primary care offices in the Chicago area and compared the findings with patient charts. Although 70% of the adults complained of some sort of sleep disturbance, only 11% of charts mentioned sleep disturbance, even for patients who reported five or more sleep problems (such as insomnia, difficulty falling asleep, early awakening, or restless legs syndrome).

“Sleep problems are so common with aging, yet they're not on the radar screen of most primary care physicians,” said Dr. Zee, professor of neurology and director of the sleep disorders center at Northwestern University, Chicago.

Symptoms of some treatable sleep disorders, particularly sleep apnea or rapid eye movement (REM) sleep behavior disorder, may be mistaken for cognitive decline or dementia in the elderly, she said.

Multiple factors contribute to the high prevalence of insomnia in the elderly, including medication use, comorbid medical or psychiatric conditions, and psychosocial factors such as bereavement.

An assessment of the quantity and quality of sleep should be integrated into the routine review of systems in all examinations of older adults, with further assessment to look for the causes of any sleep problems, Dr. Zee said.

“Sleep in older people really is a barometer of health,” she commented.

A growing database of studies directly associates sleep disorders with problems relating to attention and memory as well as depression, nighttime falls, metabolic dysfunction, and lower quality of life, Dr. Andrew A. Monjan said in the same session at the meeting.

Counter to common misconceptions, sleep disturbances are not a natural part of aging but are associated with comorbidities, according to an analysis of epidemiologic data on more than 10,000 adults, said Dr. Monjan of the National Institute on Aging.

A 2003 telephone poll of 1,500 older people (aged 55–84 years) randomly selected by the institute and the National Sleep Foundation also dispelled the notion that older people need less sleep. They reported needing as much sleep per night as many younger people.

People who had four or more medical problems were more likely to report getting less than 6 hours of sleep or having insomnia or excessive daytime sleepiness. Few said they had been diagnosed with insomnia by their physician, and even fewer had been treated for insomnia, he added.

People who reported bodily pain or who were obese were more likely to report sleep disturbances. The prevalence of all kinds of sleep disturbances decreased among people who reported more exercise.

A study at the University of Chicago showed that limiting sleep to 4 hours per night for 6 nights in healthy young adults produced evidence of impaired glucose clearance and increased insulin resistance, Dr. Monjan said. The proportion of people in the United States who report getting fewer than 6 hours of sleep per night increased to more than 25% in 2004. Sleep deprivation may be a contributing factor in the current epidemics of obesity and diabetes, he suggested.

SAN FRANCISCO — Give e-mail correspondence with patients the same care and attention you'd give to paper records, faxes, or phone calls in order to minimize medicolegal liability, Dr. Jeffrey L. Brown said.

Physicians should be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, he said at the annual meeting of the American Academy of Pediatrics.

At a minimum, your e-mail system should include an automated response to any e-mails received from patients, acknowledging that an e-mail message has been received and saying that you will respond within a set period of time, such as 24 or 48 hours, said Dr. Brown of Cornell University, New York, and in private practice in Rye Brook, N.Y. He has no association with companies that market e-mail systems or services.

The automated response should alert patients that confidentiality cannot always be ensured in e-mail correspondence, and that you cannot respond to urgent questions posed by e-mail. Patients should contact your office by phone for urgent matters.

The response also should inform patients that if they do not get a reply from you to any e-mail message within a reasonable period of time–“usually 48 hours,” Dr. Brown said—the patient should call your office, because you may not have received the e-mail. If you are away from the office when patients e-mail, the automated response should let them know that, and give the date of your return.

In the other direction, e-mails sent by physicians must be compliant with the Health Insurance Portability and Accountability Act (HIPAA). As with faxes, conventional e-mails must protect the confidentiality of sensitive information such as Social Security numbers, medical identification numbers, laboratory results, diagnoses, medications, and more.

To ensure confidentiality in e-mails, use an encrypted message system, Dr. Brown advised. Solo practitioners or small practices may want to do an Internet search for the term “encrypting e-mail systems” to find a list of encryption providers, he said. Typically, an outgoing e-mail would be sent to the provider, encrypted, and returned to the physician's system before going out to a patient.

Confidential e-mail from physicians should contain a warning disclaimer similar to those used on fax transmissions. A typical disclaimer says the following: “Important notice: This e-mail contains confidential and privileged information. It is intended only for the individual or entity to whom it is addressed. If you are not the intended recipient, or if you have received this transmission in error, you are hereby instructed to notify the sender and to erase its content and all attachments immediately. Copying, disseminating, or otherwise utilizing any of its content is unlawful and strictly prohibited.”

However, “If you don't want to use this one, ask your attorney to fax you something,” and use the disclaimer you find in the attorney's fax, Dr. Brown suggested.

Treat e-mail messages like other patient correspondence, and file them appropriately, he added. Before erasing e-mail, save the patient's original e-mail and your response as hard copies in the patient's chart or electronically if you use electronic charts. You should also take precautions to protect confidential information on laptop computers and hard drives from thieves, as you would for other medical records. Be sure to use encryption software or change passwords frequently to prevent unauthorized access. And of course, it is curcial to erase all confidential information from hard drives before disposing of them.

“Even if you do all the right things, there is still a possibility that you will be subject to suits,” Dr. Brown said. “In the end, the best defense against legal action is practicing good medicine.”

E-Mail Etiquette for MDs

▸ Do not use your personal e-mail address to answer patient e-mails.

▸ Do not answer a new patient's e-mailed medical questions without first establishing a formal relationship. “You have no idea who they are and what their problems are,” he warned.

▸ Do not forward a patient's e-mail correspondence or address to a third party without first getting the patient's consent.

▸ Do not use an indiscreet topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line,” he said. Instead, use the same strategies you'd use when leaving a voice mail on a patient's answering machine. “Say, 'I have your lab work,' or something like that,” he suggested.

▸ Do not leave e-mail messages on a computer screen where they can be read by others.

Source: Dr. Brown

SAN FRANCISCO — Give e-mail correspondence with patients the same care and attention you'd give to paper records, faxes, or phone calls in order to minimize medicolegal liability, Dr. Jeffrey L. Brown said.

Physicians should be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, he said at the annual meeting of the American Academy of Pediatrics.

At a minimum, your e-mail system should include an automated response to any e-mails received from patients, acknowledging that an e-mail message has been received and saying that you will respond within a set period of time, such as 24 or 48 hours, said Dr. Brown of Cornell University, New York, and in private practice in Rye Brook, N.Y. He has no association with companies that market e-mail systems or services.

The automated response should alert patients that confidentiality cannot always be ensured in e-mail correspondence, and that you cannot respond to urgent questions posed by e-mail. Patients should contact your office by phone for urgent matters.

The response also should inform patients that if they do not get a reply from you to any e-mail message within a reasonable period of time–“usually 48 hours,” Dr. Brown said—the patient should call your office, because you may not have received the e-mail. If you are away from the office when patients e-mail, the automated response should let them know that, and give the date of your return.

In the other direction, e-mails sent by physicians must be compliant with the Health Insurance Portability and Accountability Act (HIPAA). As with faxes, conventional e-mails must protect the confidentiality of sensitive information such as Social Security numbers, medical identification numbers, laboratory results, diagnoses, medications, and more.

To ensure confidentiality in e-mails, use an encrypted message system, Dr. Brown advised. Solo practitioners or small practices may want to do an Internet search for the term “encrypting e-mail systems” to find a list of encryption providers, he said. Typically, an outgoing e-mail would be sent to the provider, encrypted, and returned to the physician's system before going out to a patient.

Confidential e-mail from physicians should contain a warning disclaimer similar to those used on fax transmissions. A typical disclaimer says the following: “Important notice: This e-mail contains confidential and privileged information. It is intended only for the individual or entity to whom it is addressed. If you are not the intended recipient, or if you have received this transmission in error, you are hereby instructed to notify the sender and to erase its content and all attachments immediately. Copying, disseminating, or otherwise utilizing any of its content is unlawful and strictly prohibited.”

However, “If you don't want to use this one, ask your attorney to fax you something,” and use the disclaimer you find in the attorney's fax, Dr. Brown suggested.

Treat e-mail messages like other patient correspondence, and file them appropriately, he added. Before erasing e-mail, save the patient's original e-mail and your response as hard copies in the patient's chart or electronically if you use electronic charts. You should also take precautions to protect confidential information on laptop computers and hard drives from thieves, as you would for other medical records. Be sure to use encryption software or change passwords frequently to prevent unauthorized access. And of course, it is curcial to erase all confidential information from hard drives before disposing of them.

“Even if you do all the right things, there is still a possibility that you will be subject to suits,” Dr. Brown said. “In the end, the best defense against legal action is practicing good medicine.”

E-Mail Etiquette for MDs

▸ Do not use your personal e-mail address to answer patient e-mails.

▸ Do not answer a new patient's e-mailed medical questions without first establishing a formal relationship. “You have no idea who they are and what their problems are,” he warned.

▸ Do not forward a patient's e-mail correspondence or address to a third party without first getting the patient's consent.

▸ Do not use an indiscreet topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line,” he said. Instead, use the same strategies you'd use when leaving a voice mail on a patient's answering machine. “Say, 'I have your lab work,' or something like that,” he suggested.

▸ Do not leave e-mail messages on a computer screen where they can be read by others.

Source: Dr. Brown

SAN FRANCISCO — Give e-mail correspondence with patients the same care and attention you'd give to paper records, faxes, or phone calls in order to minimize medicolegal liability, Dr. Jeffrey L. Brown said.

Physicians should be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, he said at the annual meeting of the American Academy of Pediatrics.

At a minimum, your e-mail system should include an automated response to any e-mails received from patients, acknowledging that an e-mail message has been received and saying that you will respond within a set period of time, such as 24 or 48 hours, said Dr. Brown of Cornell University, New York, and in private practice in Rye Brook, N.Y. He has no association with companies that market e-mail systems or services.

The automated response should alert patients that confidentiality cannot always be ensured in e-mail correspondence, and that you cannot respond to urgent questions posed by e-mail. Patients should contact your office by phone for urgent matters.

The response also should inform patients that if they do not get a reply from you to any e-mail message within a reasonable period of time–“usually 48 hours,” Dr. Brown said—the patient should call your office, because you may not have received the e-mail. If you are away from the office when patients e-mail, the automated response should let them know that, and give the date of your return.

In the other direction, e-mails sent by physicians must be compliant with the Health Insurance Portability and Accountability Act (HIPAA). As with faxes, conventional e-mails must protect the confidentiality of sensitive information such as Social Security numbers, medical identification numbers, laboratory results, diagnoses, medications, and more.

To ensure confidentiality in e-mails, use an encrypted message system, Dr. Brown advised. Solo practitioners or small practices may want to do an Internet search for the term “encrypting e-mail systems” to find a list of encryption providers, he said. Typically, an outgoing e-mail would be sent to the provider, encrypted, and returned to the physician's system before going out to a patient.

Confidential e-mail from physicians should contain a warning disclaimer similar to those used on fax transmissions. A typical disclaimer says the following: “Important notice: This e-mail contains confidential and privileged information. It is intended only for the individual or entity to whom it is addressed. If you are not the intended recipient, or if you have received this transmission in error, you are hereby instructed to notify the sender and to erase its content and all attachments immediately. Copying, disseminating, or otherwise utilizing any of its content is unlawful and strictly prohibited.”

However, “If you don't want to use this one, ask your attorney to fax you something,” and use the disclaimer you find in the attorney's fax, Dr. Brown suggested.

Treat e-mail messages like other patient correspondence, and file them appropriately, he added. Before erasing e-mail, save the patient's original e-mail and your response as hard copies in the patient's chart or electronically if you use electronic charts. You should also take precautions to protect confidential information on laptop computers and hard drives from thieves, as you would for other medical records. Be sure to use encryption software or change passwords frequently to prevent unauthorized access. And of course, it is curcial to erase all confidential information from hard drives before disposing of them.

“Even if you do all the right things, there is still a possibility that you will be subject to suits,” Dr. Brown said. “In the end, the best defense against legal action is practicing good medicine.”

E-Mail Etiquette for MDs

▸ Do not use your personal e-mail address to answer patient e-mails.

▸ Do not answer a new patient's e-mailed medical questions without first establishing a formal relationship. “You have no idea who they are and what their problems are,” he warned.

▸ Do not forward a patient's e-mail correspondence or address to a third party without first getting the patient's consent.

▸ Do not use an indiscreet topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line,” he said. Instead, use the same strategies you'd use when leaving a voice mail on a patient's answering machine. “Say, 'I have your lab work,' or something like that,” he suggested.

▸ Do not leave e-mail messages on a computer screen where they can be read by others.

Source: Dr. Brown

SAN FRANCISCO – Tests for hepatitis B surface antigen, surface antibody, core antibody, and type “e” antigen each play an important role in diagnosing infection and level of infectivity, Dr. Tina Q. Tan said at the annual meeting of the American Academy of Pediatrics.

These serologic markers of the hepatitis B virus help distinguish infection with this virus from other hepatitis virus infections, all of which cause nonspecific signs, symptoms, and laboratory findings, said Dr. Tan of Northwestern University, Chicago.

Hepatitis B prodrome can cause fever; malaise; headache; myalgia; nausea or vomiting; and right upper-quadrant pain. Jaundice or hepatomegaly may be seen, but more than 50% of infections are asymptomatic.

A positive hepatitis B surface antigen (HBsAg) test almost always indicates that the patient is either acutely or chronically infected, she said. Very rare cases have been false positives. A positive hepatitis B surface antibody (HBsAb) test indicates that the patient is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or because the patient gained immunity by recovering from an acute infection.

A positive hepatitis B core antibody (HBcAb) test means different things, depending on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus. In rare cases, patients who have been vaccinated against hepatitis B will have false-positive HBcAb IgG results.

Knowing what each of these tests represents leads to a relatively simple three-step process for initial interpretation of the hepatitis B panel of tests, Dr. Tan suggested:

1. If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B, either through natural infection or through vaccination.

2. If the HBsAg is positive and the HBsAb is negative, then the patient has either acute or chronic hepatitis B infection.

3. If both the HBsAg and HBsAb are negative and the HBcAb is positive, this could be a false-positive result, or the patient is either chronically infected or recovering from acute infection, or the patient may be immune to hepatitis B but the HBsAb level is too low to be detected, Dr. Tan said.

A fourth serologic test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have very high concentrations of hepatitis B viral DNA in their bodies and are at very high risk of transmitting the infection to others.

These serologic marker tests may need to be repeated over time to serially assess the patient's status, she said. A chronic carrier of active hepatitis B who is HBeAg positive, for example, should be followed with HBeAg tests until a negative result suggests that the level of infectiousness has dropped.

Patients who are being followed or treated for acute hepatitis B infection should get repeated marker tests to look for hepatitis B surface antigens to appear, which would indicate that they've recovered from the infection. If HBsAg tests remain negative for more than 6 months, the patient is a chronic carrier of the virus. “This is what you're trying to prevent,” she said.

An estimated 78,000 new hepatitis B infections are diagnosed each year in the United States. Approximately 5,000 people each year die prematurely from chronic liver disease caused by chronic hepatitis B infection.

The childhood risk for an acute infection to become a chronic infection falls from a high of about 95% of babies who are infected at birth to about 10% of children who are infected with hepatitis B at age 5 years.

The risk for perinatal transmission of hepatitis B infection ranges from about 20% if the mother is HBsAg positive to as much as 90% if the mother also is HBeAg positive.

Use of hepatitis B vaccine and hepatitis B immune globulin can prevent perinatal transmission in about 95% of cases.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Tests for hepatitis B surface antigen, surface antibody, core antibody, and type “e” antigen each play an important role in diagnosing infection and level of infectivity, Dr. Tina Q. Tan said at the annual meeting of the American Academy of Pediatrics.

These serologic markers of the hepatitis B virus help distinguish infection with this virus from other hepatitis virus infections, all of which cause nonspecific signs, symptoms, and laboratory findings, said Dr. Tan of Northwestern University, Chicago.

Hepatitis B prodrome can cause fever; malaise; headache; myalgia; nausea or vomiting; and right upper-quadrant pain. Jaundice or hepatomegaly may be seen, but more than 50% of infections are asymptomatic.

A positive hepatitis B surface antigen (HBsAg) test almost always indicates that the patient is either acutely or chronically infected, she said. Very rare cases have been false positives. A positive hepatitis B surface antibody (HBsAb) test indicates that the patient is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or because the patient gained immunity by recovering from an acute infection.

A positive hepatitis B core antibody (HBcAb) test means different things, depending on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus. In rare cases, patients who have been vaccinated against hepatitis B will have false-positive HBcAb IgG results.

Knowing what each of these tests represents leads to a relatively simple three-step process for initial interpretation of the hepatitis B panel of tests, Dr. Tan suggested:

1. If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B, either through natural infection or through vaccination.

2. If the HBsAg is positive and the HBsAb is negative, then the patient has either acute or chronic hepatitis B infection.

3. If both the HBsAg and HBsAb are negative and the HBcAb is positive, this could be a false-positive result, or the patient is either chronically infected or recovering from acute infection, or the patient may be immune to hepatitis B but the HBsAb level is too low to be detected, Dr. Tan said.

A fourth serologic test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have very high concentrations of hepatitis B viral DNA in their bodies and are at very high risk of transmitting the infection to others.

These serologic marker tests may need to be repeated over time to serially assess the patient's status, she said. A chronic carrier of active hepatitis B who is HBeAg positive, for example, should be followed with HBeAg tests until a negative result suggests that the level of infectiousness has dropped.

Patients who are being followed or treated for acute hepatitis B infection should get repeated marker tests to look for hepatitis B surface antigens to appear, which would indicate that they've recovered from the infection. If HBsAg tests remain negative for more than 6 months, the patient is a chronic carrier of the virus. “This is what you're trying to prevent,” she said.

An estimated 78,000 new hepatitis B infections are diagnosed each year in the United States. Approximately 5,000 people each year die prematurely from chronic liver disease caused by chronic hepatitis B infection.

The childhood risk for an acute infection to become a chronic infection falls from a high of about 95% of babies who are infected at birth to about 10% of children who are infected with hepatitis B at age 5 years.

The risk for perinatal transmission of hepatitis B infection ranges from about 20% if the mother is HBsAg positive to as much as 90% if the mother also is HBeAg positive.

Use of hepatitis B vaccine and hepatitis B immune globulin can prevent perinatal transmission in about 95% of cases.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Tests for hepatitis B surface antigen, surface antibody, core antibody, and type “e” antigen each play an important role in diagnosing infection and level of infectivity, Dr. Tina Q. Tan said at the annual meeting of the American Academy of Pediatrics.

These serologic markers of the hepatitis B virus help distinguish infection with this virus from other hepatitis virus infections, all of which cause nonspecific signs, symptoms, and laboratory findings, said Dr. Tan of Northwestern University, Chicago.

Hepatitis B prodrome can cause fever; malaise; headache; myalgia; nausea or vomiting; and right upper-quadrant pain. Jaundice or hepatomegaly may be seen, but more than 50% of infections are asymptomatic.

A positive hepatitis B surface antigen (HBsAg) test almost always indicates that the patient is either acutely or chronically infected, she said. Very rare cases have been false positives. A positive hepatitis B surface antibody (HBsAb) test indicates that the patient is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or because the patient gained immunity by recovering from an acute infection.

A positive hepatitis B core antibody (HBcAb) test means different things, depending on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus. In rare cases, patients who have been vaccinated against hepatitis B will have false-positive HBcAb IgG results.

Knowing what each of these tests represents leads to a relatively simple three-step process for initial interpretation of the hepatitis B panel of tests, Dr. Tan suggested:

1. If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B, either through natural infection or through vaccination.

2. If the HBsAg is positive and the HBsAb is negative, then the patient has either acute or chronic hepatitis B infection.

3. If both the HBsAg and HBsAb are negative and the HBcAb is positive, this could be a false-positive result, or the patient is either chronically infected or recovering from acute infection, or the patient may be immune to hepatitis B but the HBsAb level is too low to be detected, Dr. Tan said.

A fourth serologic test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have very high concentrations of hepatitis B viral DNA in their bodies and are at very high risk of transmitting the infection to others.

These serologic marker tests may need to be repeated over time to serially assess the patient's status, she said. A chronic carrier of active hepatitis B who is HBeAg positive, for example, should be followed with HBeAg tests until a negative result suggests that the level of infectiousness has dropped.

Patients who are being followed or treated for acute hepatitis B infection should get repeated marker tests to look for hepatitis B surface antigens to appear, which would indicate that they've recovered from the infection. If HBsAg tests remain negative for more than 6 months, the patient is a chronic carrier of the virus. “This is what you're trying to prevent,” she said.

An estimated 78,000 new hepatitis B infections are diagnosed each year in the United States. Approximately 5,000 people each year die prematurely from chronic liver disease caused by chronic hepatitis B infection.

The childhood risk for an acute infection to become a chronic infection falls from a high of about 95% of babies who are infected at birth to about 10% of children who are infected with hepatitis B at age 5 years.

The risk for perinatal transmission of hepatitis B infection ranges from about 20% if the mother is HBsAg positive to as much as 90% if the mother also is HBeAg positive.

Use of hepatitis B vaccine and hepatitis B immune globulin can prevent perinatal transmission in about 95% of cases.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – If you're not providing parents a copy of a Vaccine Information Statement every time they accept or reject a child's immunization, you're not meeting your obligations under the National Vaccine Injury Compensation Program and could even be increasing your legal liability, Dr. Kristina Bryant advised.

The no-fault civil litigation system known as the National Vaccine Injury Compensation Program (NVICP) has benefited U.S. physicians since 1988 by reducing injury claims against vaccine manufacturers– and, the American Academy of Pediatrics (AAP) believes, against health care providers in addition, said Dr. Bryant, an assistant professor of pediatrics at the University of Louisville (Ky.).

If an injury that's listed in the program's Vaccine Injury Table occurs within a specified time after immunization, claimants must file for compensation through the NVICP to cover costs for medical care, pain, and suffering before pursuing a civil lawsuit.

The program streamlines reimbursement for claimants, and those claimants who receive awards cannot file a suit.

“We get some benefit from this, and we have responsibilities” for communication and documentation that are spelled out by the AAP and the Centers for Disease Control and Prevention, Dr. Bryant emphasized in speaking at the annual meeting of the AAP.

Discuss the benefits and risks of the vaccine being administered. “We want to make sure we have an open dialogue with our patients” about this, she said.

Note in the chart that you discussed these, she advised.

Give parents the current version of the Vaccine Information Statement each time you administer a covered vaccine. Handing it to them once and then making copies available in exam or waiting rooms during subsequent immunization visits is not enough.

The most current versions can be found at www.immunize.orgwww.cdc.gov/nip/publications/VIS/default.htm

Document in the patient's chart the date of vaccine administration, the vaccine manufacturer, the vaccine lot number, your name and business address, the date of the Vaccine Information Statement version, and the date you gave parents the statement.

An informal poll of the audience at Dr. Bryant's AAPmeeting presentation suggests that perhaps 25% of physicians do not document the version of the statement given to parents, and the date it is given to them.

If a parent refuses a child vaccination, discuss the risk that the child will pose to others and the risk of disease and potential death for the child, and document in the chart that you addressed these topics, Dr. Bryant said.

Requirements for obtaining informed consent vary by state, so be familiar with your state's regulations, she added.

Review the risks and benefits of vaccination at each encounter and provide a Vaccine Information Statement. At every refusal, ask the parent to sign the NVICP Refusal to Vaccinate form, which you can find at www.cispimmunize.org

On the second page of the form, parents attest that they have read the Vaccine Information Statement, have had the opportunity to discuss this with the child's doctor or nurse, and recognize that the child could contract the illness that the vaccine is meant to prevent, and could moreover face consequences such as pneumonia, need for hospitalization, brain damage, meningitis, or death.

Some antivaccine Web sites advise parents to cross out portions of the Refusal to Vaccinate form, or to write comments in the margins about points of disagreement. Some parents even refuse to sign the form.

With the latter, document that you've shown them the form and discussed risks and benefits, and that they refused to sign, Dr. Bryant said.

A physician in the audience said that many pediatricians in his area have gone along with insurance carrier demands that patients who don't want to be vaccinated be asked to leave a physician's practice.

The AAP, however, urges physicians to avoid discharging vaccine refusers if possible, Dr. Bryant noted, while acknowledging that a lack of trust between parent and physician in some situations will lead to discharges.

Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

SAN FRANCISCO – If you're not providing parents a copy of a Vaccine Information Statement every time they accept or reject a child's immunization, you're not meeting your obligations under the National Vaccine Injury Compensation Program and could even be increasing your legal liability, Dr. Kristina Bryant advised.

The no-fault civil litigation system known as the National Vaccine Injury Compensation Program (NVICP) has benefited U.S. physicians since 1988 by reducing injury claims against vaccine manufacturers– and, the American Academy of Pediatrics (AAP) believes, against health care providers in addition, said Dr. Bryant, an assistant professor of pediatrics at the University of Louisville (Ky.).

If an injury that's listed in the program's Vaccine Injury Table occurs within a specified time after immunization, claimants must file for compensation through the NVICP to cover costs for medical care, pain, and suffering before pursuing a civil lawsuit.

The program streamlines reimbursement for claimants, and those claimants who receive awards cannot file a suit.

“We get some benefit from this, and we have responsibilities” for communication and documentation that are spelled out by the AAP and the Centers for Disease Control and Prevention, Dr. Bryant emphasized in speaking at the annual meeting of the AAP.

Discuss the benefits and risks of the vaccine being administered. “We want to make sure we have an open dialogue with our patients” about this, she said.

Note in the chart that you discussed these, she advised.

Give parents the current version of the Vaccine Information Statement each time you administer a covered vaccine. Handing it to them once and then making copies available in exam or waiting rooms during subsequent immunization visits is not enough.

The most current versions can be found at www.immunize.orgwww.cdc.gov/nip/publications/VIS/default.htm

Document in the patient's chart the date of vaccine administration, the vaccine manufacturer, the vaccine lot number, your name and business address, the date of the Vaccine Information Statement version, and the date you gave parents the statement.

An informal poll of the audience at Dr. Bryant's AAPmeeting presentation suggests that perhaps 25% of physicians do not document the version of the statement given to parents, and the date it is given to them.

If a parent refuses a child vaccination, discuss the risk that the child will pose to others and the risk of disease and potential death for the child, and document in the chart that you addressed these topics, Dr. Bryant said.

Requirements for obtaining informed consent vary by state, so be familiar with your state's regulations, she added.

Review the risks and benefits of vaccination at each encounter and provide a Vaccine Information Statement. At every refusal, ask the parent to sign the NVICP Refusal to Vaccinate form, which you can find at www.cispimmunize.org

On the second page of the form, parents attest that they have read the Vaccine Information Statement, have had the opportunity to discuss this with the child's doctor or nurse, and recognize that the child could contract the illness that the vaccine is meant to prevent, and could moreover face consequences such as pneumonia, need for hospitalization, brain damage, meningitis, or death.

Some antivaccine Web sites advise parents to cross out portions of the Refusal to Vaccinate form, or to write comments in the margins about points of disagreement. Some parents even refuse to sign the form.

With the latter, document that you've shown them the form and discussed risks and benefits, and that they refused to sign, Dr. Bryant said.

A physician in the audience said that many pediatricians in his area have gone along with insurance carrier demands that patients who don't want to be vaccinated be asked to leave a physician's practice.

The AAP, however, urges physicians to avoid discharging vaccine refusers if possible, Dr. Bryant noted, while acknowledging that a lack of trust between parent and physician in some situations will lead to discharges.

Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

SAN FRANCISCO – If you're not providing parents a copy of a Vaccine Information Statement every time they accept or reject a child's immunization, you're not meeting your obligations under the National Vaccine Injury Compensation Program and could even be increasing your legal liability, Dr. Kristina Bryant advised.

The no-fault civil litigation system known as the National Vaccine Injury Compensation Program (NVICP) has benefited U.S. physicians since 1988 by reducing injury claims against vaccine manufacturers– and, the American Academy of Pediatrics (AAP) believes, against health care providers in addition, said Dr. Bryant, an assistant professor of pediatrics at the University of Louisville (Ky.).

If an injury that's listed in the program's Vaccine Injury Table occurs within a specified time after immunization, claimants must file for compensation through the NVICP to cover costs for medical care, pain, and suffering before pursuing a civil lawsuit.

The program streamlines reimbursement for claimants, and those claimants who receive awards cannot file a suit.

“We get some benefit from this, and we have responsibilities” for communication and documentation that are spelled out by the AAP and the Centers for Disease Control and Prevention, Dr. Bryant emphasized in speaking at the annual meeting of the AAP.

Discuss the benefits and risks of the vaccine being administered. “We want to make sure we have an open dialogue with our patients” about this, she said.

Note in the chart that you discussed these, she advised.

Give parents the current version of the Vaccine Information Statement each time you administer a covered vaccine. Handing it to them once and then making copies available in exam or waiting rooms during subsequent immunization visits is not enough.

The most current versions can be found at www.immunize.orgwww.cdc.gov/nip/publications/VIS/default.htm

Document in the patient's chart the date of vaccine administration, the vaccine manufacturer, the vaccine lot number, your name and business address, the date of the Vaccine Information Statement version, and the date you gave parents the statement.

An informal poll of the audience at Dr. Bryant's AAPmeeting presentation suggests that perhaps 25% of physicians do not document the version of the statement given to parents, and the date it is given to them.

If a parent refuses a child vaccination, discuss the risk that the child will pose to others and the risk of disease and potential death for the child, and document in the chart that you addressed these topics, Dr. Bryant said.

Requirements for obtaining informed consent vary by state, so be familiar with your state's regulations, she added.

Review the risks and benefits of vaccination at each encounter and provide a Vaccine Information Statement. At every refusal, ask the parent to sign the NVICP Refusal to Vaccinate form, which you can find at www.cispimmunize.org

On the second page of the form, parents attest that they have read the Vaccine Information Statement, have had the opportunity to discuss this with the child's doctor or nurse, and recognize that the child could contract the illness that the vaccine is meant to prevent, and could moreover face consequences such as pneumonia, need for hospitalization, brain damage, meningitis, or death.

Some antivaccine Web sites advise parents to cross out portions of the Refusal to Vaccinate form, or to write comments in the margins about points of disagreement. Some parents even refuse to sign the form.

With the latter, document that you've shown them the form and discussed risks and benefits, and that they refused to sign, Dr. Bryant said.

A physician in the audience said that many pediatricians in his area have gone along with insurance carrier demands that patients who don't want to be vaccinated be asked to leave a physician's practice.

The AAP, however, urges physicians to avoid discharging vaccine refusers if possible, Dr. Bryant noted, while acknowledging that a lack of trust between parent and physician in some situations will lead to discharges.

Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

SAN FRANCISCO – Mothers who bite their babies' nails instead of clipping or filing them can spread herpesvirus infection unwittingly, Dr. Meg C. Fisher warned.

Biting off infant nails “is a very common thing, particularly among Hispanic mothers or any young mothers who are afraid to use nail clippers,” said Dr. Fisher, chief of pediatrics at Monmouth Medical Center, Long Branch, N.J.

Advise parents who are afraid to use clippers on the nails of tiny fingers and toes to use an emery board, but not to bite, she suggested at the annual meeting of the American Academy of Pediatrics.

Herpesvirus infection is ubiquitous among adults and almost always asymptomatic. Most people infected with herpes don't know that they've got the virus. Carriers shed the virus when herpes sores develop but also intermittently when no sores are present.

When a herpetic whitlow develops–a painful herpes infection typically on the fingers or around fingernails–it may be misdiagnosed as a bacterial infection because of the lesion's disturbingly dark coloring. “It really does look like it's gangrenous. These lesions look horrible” yet distinctive, once you're familiar with them, Dr. Fisher said. “There's nothing else that turns your finger black like that.”

She described a 9-month-old patient who was treated for a week with cephalexin for presumed bacterial infection in a finger, with no improvement. The lesion was a herpetic whitlow caused by infection from her mother biting the child's nails.

Treating it with acyclovir probably does not make sense unless you catch the lesion early, she said. “This will get better if you do nothing. Wait it out.”

Warn parents that some herpetic whitlows recur. Treating such a lesion with acyclovir in the early phases might shorten its duration if parents bring it to your attention within the first couple of days.

“The one thing you don't want to do is to send them to a surgeon” who will be tempted to incise and drain the lesion, thinking it's a bacterial infection, she added. That can lead to superinfection with staphylococcus or other bacteria in addition to the herpetic whitlow.

Even worse, a herpetic whitlow mistaken for hand cellulitis usually results in the patient being admitted to a hospital “and gets a hand surgeon or orthopedic surgeon excited,” often leading to an unnecessary procedure, Dr. Fisher said.

“If you can, don't admit them [to the hospital]. If you want to give IV therapy, give IV acyclovir. You don't need antibiotics,” Dr. Fisher said.

Prophylactic therapy might make sense for patients who are prone to herpetic whitlows. Teenage wrestlers, for example, may need prophylaxis during the competitive season. Prescribing valacyclovir or famcyclovir, each of which requires fewer daily doses than acyclovir, may be the best choice to ensure compliance in these cases, she said.

Advise athletes on herpes prophylaxis that the medication must be taken daily, and that care should be taken not to get dehydrated, which could damage the kidneys, she said. Tell the patient that ongoing treatment could cause his or her viral isolate to develop drug resistance.

Some sports coaches can get carried away with the idea of prophylaxis, Dr. Fisher added. A summer wrestling camp in her area informed parents in early 2007 that every student should be taking acyclovir and fluconazole to avoid herpes and fungal infections.

Local pediatricians called Dr. Fisher, asking if she thought this was a good idea. “I said, 'No.' This is the kind of pressure that these elite athletes are getting,” she said. The pediatricians she spoke with all refused to prescribe the drugs for uninfected athletes, and none of the students were excluded from the camp, so far as she knows.

She said she advises coaches or athletes to disinfect wrestling mats with bleach in a 1:100 dilution in water. That kills the herpesvirus and common bacteria.

SAN FRANCISCO – Mothers who bite their babies' nails instead of clipping or filing them can spread herpesvirus infection unwittingly, Dr. Meg C. Fisher warned.

Biting off infant nails “is a very common thing, particularly among Hispanic mothers or any young mothers who are afraid to use nail clippers,” said Dr. Fisher, chief of pediatrics at Monmouth Medical Center, Long Branch, N.J.

Advise parents who are afraid to use clippers on the nails of tiny fingers and toes to use an emery board, but not to bite, she suggested at the annual meeting of the American Academy of Pediatrics.

Herpesvirus infection is ubiquitous among adults and almost always asymptomatic. Most people infected with herpes don't know that they've got the virus. Carriers shed the virus when herpes sores develop but also intermittently when no sores are present.

When a herpetic whitlow develops–a painful herpes infection typically on the fingers or around fingernails–it may be misdiagnosed as a bacterial infection because of the lesion's disturbingly dark coloring. “It really does look like it's gangrenous. These lesions look horrible” yet distinctive, once you're familiar with them, Dr. Fisher said. “There's nothing else that turns your finger black like that.”

She described a 9-month-old patient who was treated for a week with cephalexin for presumed bacterial infection in a finger, with no improvement. The lesion was a herpetic whitlow caused by infection from her mother biting the child's nails.

Treating it with acyclovir probably does not make sense unless you catch the lesion early, she said. “This will get better if you do nothing. Wait it out.”

Warn parents that some herpetic whitlows recur. Treating such a lesion with acyclovir in the early phases might shorten its duration if parents bring it to your attention within the first couple of days.

“The one thing you don't want to do is to send them to a surgeon” who will be tempted to incise and drain the lesion, thinking it's a bacterial infection, she added. That can lead to superinfection with staphylococcus or other bacteria in addition to the herpetic whitlow.

Even worse, a herpetic whitlow mistaken for hand cellulitis usually results in the patient being admitted to a hospital “and gets a hand surgeon or orthopedic surgeon excited,” often leading to an unnecessary procedure, Dr. Fisher said.

“If you can, don't admit them [to the hospital]. If you want to give IV therapy, give IV acyclovir. You don't need antibiotics,” Dr. Fisher said.

Prophylactic therapy might make sense for patients who are prone to herpetic whitlows. Teenage wrestlers, for example, may need prophylaxis during the competitive season. Prescribing valacyclovir or famcyclovir, each of which requires fewer daily doses than acyclovir, may be the best choice to ensure compliance in these cases, she said.

Advise athletes on herpes prophylaxis that the medication must be taken daily, and that care should be taken not to get dehydrated, which could damage the kidneys, she said. Tell the patient that ongoing treatment could cause his or her viral isolate to develop drug resistance.

Some sports coaches can get carried away with the idea of prophylaxis, Dr. Fisher added. A summer wrestling camp in her area informed parents in early 2007 that every student should be taking acyclovir and fluconazole to avoid herpes and fungal infections.

Local pediatricians called Dr. Fisher, asking if she thought this was a good idea. “I said, 'No.' This is the kind of pressure that these elite athletes are getting,” she said. The pediatricians she spoke with all refused to prescribe the drugs for uninfected athletes, and none of the students were excluded from the camp, so far as she knows.

She said she advises coaches or athletes to disinfect wrestling mats with bleach in a 1:100 dilution in water. That kills the herpesvirus and common bacteria.

SAN FRANCISCO – Mothers who bite their babies' nails instead of clipping or filing them can spread herpesvirus infection unwittingly, Dr. Meg C. Fisher warned.

Biting off infant nails “is a very common thing, particularly among Hispanic mothers or any young mothers who are afraid to use nail clippers,” said Dr. Fisher, chief of pediatrics at Monmouth Medical Center, Long Branch, N.J.

Advise parents who are afraid to use clippers on the nails of tiny fingers and toes to use an emery board, but not to bite, she suggested at the annual meeting of the American Academy of Pediatrics.

Herpesvirus infection is ubiquitous among adults and almost always asymptomatic. Most people infected with herpes don't know that they've got the virus. Carriers shed the virus when herpes sores develop but also intermittently when no sores are present.

When a herpetic whitlow develops–a painful herpes infection typically on the fingers or around fingernails–it may be misdiagnosed as a bacterial infection because of the lesion's disturbingly dark coloring. “It really does look like it's gangrenous. These lesions look horrible” yet distinctive, once you're familiar with them, Dr. Fisher said. “There's nothing else that turns your finger black like that.”

She described a 9-month-old patient who was treated for a week with cephalexin for presumed bacterial infection in a finger, with no improvement. The lesion was a herpetic whitlow caused by infection from her mother biting the child's nails.

Treating it with acyclovir probably does not make sense unless you catch the lesion early, she said. “This will get better if you do nothing. Wait it out.”

Warn parents that some herpetic whitlows recur. Treating such a lesion with acyclovir in the early phases might shorten its duration if parents bring it to your attention within the first couple of days.

“The one thing you don't want to do is to send them to a surgeon” who will be tempted to incise and drain the lesion, thinking it's a bacterial infection, she added. That can lead to superinfection with staphylococcus or other bacteria in addition to the herpetic whitlow.

Even worse, a herpetic whitlow mistaken for hand cellulitis usually results in the patient being admitted to a hospital “and gets a hand surgeon or orthopedic surgeon excited,” often leading to an unnecessary procedure, Dr. Fisher said.

“If you can, don't admit them [to the hospital]. If you want to give IV therapy, give IV acyclovir. You don't need antibiotics,” Dr. Fisher said.

Prophylactic therapy might make sense for patients who are prone to herpetic whitlows. Teenage wrestlers, for example, may need prophylaxis during the competitive season. Prescribing valacyclovir or famcyclovir, each of which requires fewer daily doses than acyclovir, may be the best choice to ensure compliance in these cases, she said.

Advise athletes on herpes prophylaxis that the medication must be taken daily, and that care should be taken not to get dehydrated, which could damage the kidneys, she said. Tell the patient that ongoing treatment could cause his or her viral isolate to develop drug resistance.

Some sports coaches can get carried away with the idea of prophylaxis, Dr. Fisher added. A summer wrestling camp in her area informed parents in early 2007 that every student should be taking acyclovir and fluconazole to avoid herpes and fungal infections.

Local pediatricians called Dr. Fisher, asking if she thought this was a good idea. “I said, 'No.' This is the kind of pressure that these elite athletes are getting,” she said. The pediatricians she spoke with all refused to prescribe the drugs for uninfected athletes, and none of the students were excluded from the camp, so far as she knows.

She said she advises coaches or athletes to disinfect wrestling mats with bleach in a 1:100 dilution in water. That kills the herpesvirus and common bacteria.