Sherry Boschert

SAN FRANCISCO — If you're not giving 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 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, said Dr. Bryant of 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 who get 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 said at the annual meeting of the AAP.

She suggested providers discuss the benefits and risks of the vaccine being administered, and that they note in the chart that the issues were discussed.

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 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 can be obtained 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 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. Providers should document that they've shown parents the form and discussed risks and benefits, and that the parents refused to sign, Dr. Bryant said.

A physician in the audience said 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 the practice. Dr. Bryant said the AAP urges physicians to avoid discharging vaccine refusers if possible.

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 Inc., Wyeth Pharmaceuticals, and GlaxoSmithKline Inc.

SAN FRANCISCO — If you're not giving 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 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, said Dr. Bryant of 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 who get 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 said at the annual meeting of the AAP.

She suggested providers discuss the benefits and risks of the vaccine being administered, and that they note in the chart that the issues were discussed.

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 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 can be obtained 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 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. Providers should document that they've shown parents the form and discussed risks and benefits, and that the parents refused to sign, Dr. Bryant said.

A physician in the audience said 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 the practice. Dr. Bryant said the AAP urges physicians to avoid discharging vaccine refusers if possible.

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 Inc., Wyeth Pharmaceuticals, and GlaxoSmithKline Inc.

SAN FRANCISCO — If you're not giving 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 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, said Dr. Bryant of 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 who get 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 said at the annual meeting of the AAP.

She suggested providers discuss the benefits and risks of the vaccine being administered, and that they note in the chart that the issues were discussed.

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 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 can be obtained 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 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. Providers should document that they've shown parents the form and discussed risks and benefits, and that the parents refused to sign, Dr. Bryant said.

A physician in the audience said 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 the practice. Dr. Bryant said the AAP urges physicians to avoid discharging vaccine refusers if possible.

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 Inc., Wyeth Pharmaceuticals, and GlaxoSmithKline Inc.

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 advised.

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 assured 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.”

“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.

Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. Erase all confidential information from hard drives before disposing of them.

Tips for Staying Out of Trouble

▸ Do not use your personal e-mail address to reply to e-mails from patients.

▸ 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 advised.

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 assured 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.”

“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.

Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. Erase all confidential information from hard drives before disposing of them.

Tips for Staying Out of Trouble

▸ Do not use your personal e-mail address to reply to e-mails from patients.

▸ 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 advised.

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 assured 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.”

“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.

Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. Erase all confidential information from hard drives before disposing of them.

Tips for Staying Out of Trouble

▸ Do not use your personal e-mail address to reply to e-mails from patients.

▸ 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 — When primary care physicians head home at the end of the day in one New York practice, mental health providers reopen the doors to children and families who need their help.

Offering the after-hours office space to mental health providers has helped physicians ensure that their patients get the care they need, allowed mental health providers to build their practices, and offered children and families a way to find affordable mental health care, William Bryson-Brockmann, Ph.D., said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

A full-time pediatric psychologist and a full-time behavioral pediatrician in the academic-based practice cannot handle all the requests for psychological services generated by their colleagues' patients. The practice also gets referrals from community pediatricians who do not offer mental health care in their own practices.

So the practice started offering low-cost office space to other mental health providers in 1993, and now has one psychologist and four clinical social workers who rent space for $20 per hour. Several exam rooms have desks and enough space for the chairs necessary to accommodate a family, said pediatric psychologist Bryson-Brockmann of Winthrop-University Hospital, Mineola, N.Y.

These mental health providers all work in the school system and see most of their private practice clients after 5 p.m., when the pediatric practice is closed. Some offer services on weekends or on weekdays after school, although they occasionally have difficulty reserving office space before 5 p.m., he said.

“We can usually find somebody for every family” who needs mental health care, and the pediatricians in the practice appreciate that they can refer patients to mental health providers with whom they're familiar, Dr. Bryson-Brockmann said.

Before this arrangement, it was much harder to connect patients with mental health services, he said. As many as 17% of 5- to 9-year-old children in pediatric practices may have mental health problems, a 2000 study suggested.

Numerous barriers prevent many children from getting mental health care, Dr. Jane M. Foy said in a separate session at the meeting. When a child is seen by a mental health provider, the child's pediatrician may not have a relationship with that provider.

“Finding access to a child psychiatrist is nearly impossible in many areas of the country,” said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “Eighty percent of children who need mental health services simply never get them.”

A survey of the five mental health providers who rent after-hours space in Dr. Bryson-Brockmann's practice found that they appreciated the easy access to pediatricians and the flexibility provided by the arrangement.

They set their own hours, purchase their own malpractice insurance, and handle their own records and billing, which minimizes any burden on the pediatric office staff, reported Dr. Bryson-Brockmann and his coauthor, Dr. Ronald V. Marino, also of the hospital.

“By making mental health services more easily accessible in the pediatric office, [we hope that] families will access this needed service,” Dr. Bryson-Brockmann said.

For the most part, the mental health providers are not in insurance plans. Because of their low overhead costs, however, the charge to patients typically is not much greater than copays in some managed-care mental health models. Some families reject this arrangement initially, but will often return when they can't find adequate insurance-based services, he said.

Three of the therapists work primarily with adolescent patients. Each of the five has developed an area of expertise, such as anxiety, eating disorders, adjustment reactions, or dysfunctional families.

SAN FRANCISCO — When primary care physicians head home at the end of the day in one New York practice, mental health providers reopen the doors to children and families who need their help.

Offering the after-hours office space to mental health providers has helped physicians ensure that their patients get the care they need, allowed mental health providers to build their practices, and offered children and families a way to find affordable mental health care, William Bryson-Brockmann, Ph.D., said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

A full-time pediatric psychologist and a full-time behavioral pediatrician in the academic-based practice cannot handle all the requests for psychological services generated by their colleagues' patients. The practice also gets referrals from community pediatricians who do not offer mental health care in their own practices.

So the practice started offering low-cost office space to other mental health providers in 1993, and now has one psychologist and four clinical social workers who rent space for $20 per hour. Several exam rooms have desks and enough space for the chairs necessary to accommodate a family, said pediatric psychologist Bryson-Brockmann of Winthrop-University Hospital, Mineola, N.Y.

These mental health providers all work in the school system and see most of their private practice clients after 5 p.m., when the pediatric practice is closed. Some offer services on weekends or on weekdays after school, although they occasionally have difficulty reserving office space before 5 p.m., he said.

“We can usually find somebody for every family” who needs mental health care, and the pediatricians in the practice appreciate that they can refer patients to mental health providers with whom they're familiar, Dr. Bryson-Brockmann said.

Before this arrangement, it was much harder to connect patients with mental health services, he said. As many as 17% of 5- to 9-year-old children in pediatric practices may have mental health problems, a 2000 study suggested.

Numerous barriers prevent many children from getting mental health care, Dr. Jane M. Foy said in a separate session at the meeting. When a child is seen by a mental health provider, the child's pediatrician may not have a relationship with that provider.

“Finding access to a child psychiatrist is nearly impossible in many areas of the country,” said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “Eighty percent of children who need mental health services simply never get them.”

A survey of the five mental health providers who rent after-hours space in Dr. Bryson-Brockmann's practice found that they appreciated the easy access to pediatricians and the flexibility provided by the arrangement.

They set their own hours, purchase their own malpractice insurance, and handle their own records and billing, which minimizes any burden on the pediatric office staff, reported Dr. Bryson-Brockmann and his coauthor, Dr. Ronald V. Marino, also of the hospital.

“By making mental health services more easily accessible in the pediatric office, [we hope that] families will access this needed service,” Dr. Bryson-Brockmann said.

For the most part, the mental health providers are not in insurance plans. Because of their low overhead costs, however, the charge to patients typically is not much greater than copays in some managed-care mental health models. Some families reject this arrangement initially, but will often return when they can't find adequate insurance-based services, he said.

Three of the therapists work primarily with adolescent patients. Each of the five has developed an area of expertise, such as anxiety, eating disorders, adjustment reactions, or dysfunctional families.

SAN FRANCISCO — When primary care physicians head home at the end of the day in one New York practice, mental health providers reopen the doors to children and families who need their help.

Offering the after-hours office space to mental health providers has helped physicians ensure that their patients get the care they need, allowed mental health providers to build their practices, and offered children and families a way to find affordable mental health care, William Bryson-Brockmann, Ph.D., said in a poster presentation at the annual meeting of the American Academy of Pediatrics.

A full-time pediatric psychologist and a full-time behavioral pediatrician in the academic-based practice cannot handle all the requests for psychological services generated by their colleagues' patients. The practice also gets referrals from community pediatricians who do not offer mental health care in their own practices.

So the practice started offering low-cost office space to other mental health providers in 1993, and now has one psychologist and four clinical social workers who rent space for $20 per hour. Several exam rooms have desks and enough space for the chairs necessary to accommodate a family, said pediatric psychologist Bryson-Brockmann of Winthrop-University Hospital, Mineola, N.Y.

These mental health providers all work in the school system and see most of their private practice clients after 5 p.m., when the pediatric practice is closed. Some offer services on weekends or on weekdays after school, although they occasionally have difficulty reserving office space before 5 p.m., he said.

“We can usually find somebody for every family” who needs mental health care, and the pediatricians in the practice appreciate that they can refer patients to mental health providers with whom they're familiar, Dr. Bryson-Brockmann said.

Before this arrangement, it was much harder to connect patients with mental health services, he said. As many as 17% of 5- to 9-year-old children in pediatric practices may have mental health problems, a 2000 study suggested.

Numerous barriers prevent many children from getting mental health care, Dr. Jane M. Foy said in a separate session at the meeting. When a child is seen by a mental health provider, the child's pediatrician may not have a relationship with that provider.

“Finding access to a child psychiatrist is nearly impossible in many areas of the country,” said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “Eighty percent of children who need mental health services simply never get them.”

A survey of the five mental health providers who rent after-hours space in Dr. Bryson-Brockmann's practice found that they appreciated the easy access to pediatricians and the flexibility provided by the arrangement.

They set their own hours, purchase their own malpractice insurance, and handle their own records and billing, which minimizes any burden on the pediatric office staff, reported Dr. Bryson-Brockmann and his coauthor, Dr. Ronald V. Marino, also of the hospital.

“By making mental health services more easily accessible in the pediatric office, [we hope that] families will access this needed service,” Dr. Bryson-Brockmann said.

For the most part, the mental health providers are not in insurance plans. Because of their low overhead costs, however, the charge to patients typically is not much greater than copays in some managed-care mental health models. Some families reject this arrangement initially, but will often return when they can't find adequate insurance-based services, he said.

Three of the therapists work primarily with adolescent patients. Each of the five has developed an area of expertise, such as anxiety, eating disorders, adjustment reactions, or dysfunctional families.

SAN FRANCISCO — Community-onset Clostridium difficile infection that is not antibiotic related has emerged as a multinational problem that can be life threatening, said Dr. Sarah S. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

The conventional way of thinking about C. difficile infection was that it was usually associated with antibiotic use, mainly affected adults, was not life threatening, and seldom produced severe diarrheal illness in children. “Throw that [way of thinking] away. You have to start thinking and worrying about C. difficile as community onset without antibiotic exposure,” Dr. Long said at the annual meeting of the American Academy of Pediatrics.

The more modern C. difficile shows antibiotic resistance that is probably caused by widespread use of fluoroquinolones. It has mutated to lose a regulatory gene that normally suppresses production of toxin by the organism. The mutated form produces 16–20 times the amount of toxin as that of the organism without the gene deletion.

The global occurrence of this antibiotic-resistant, highly toxin-producing organism could increasingly cause problems for “an unprepared planet,” she said.

Four healthy people died recently in Philadelphia from C. difficile infection after failing treatment with multiple antibiotics followed by colectomies. Two of the infections were in postpartum women. “C. difficile in pregnant ladies and post partum can be a very severe disease,” said Dr. Long.

Clinicians should consider C. difficile infection in otherwise healthy patients with diarrhea persisting beyond 3 days, whether or not the patient has been exposed to antibiotics, especially if there's blood in the stool or the patient is feverish or toxic appearing. “Put that on your list of things to worry about alongside Salmonella, Shigella, Campylobacter, and … Escherichia coli.”

Culture isn't helpful for diagnosis. A test for toxin in the stool is the diagnostic test of choice. An enzyme immunoassay for toxin, which can give a result in 2 hours, is a good test. Specialists also may order a cytotoxin assay on stool. Nearly 90% of patients will respond to treatment with metronidazole for 10 days, but 20%–25% will relapse. Of those, half will relapse again after retreatment. There is no standard therapy for chronic recurrences, but a number of antibiotic regimens or fecal transplants have been tried.

SAN FRANCISCO — Community-onset Clostridium difficile infection that is not antibiotic related has emerged as a multinational problem that can be life threatening, said Dr. Sarah S. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

The conventional way of thinking about C. difficile infection was that it was usually associated with antibiotic use, mainly affected adults, was not life threatening, and seldom produced severe diarrheal illness in children. “Throw that [way of thinking] away. You have to start thinking and worrying about C. difficile as community onset without antibiotic exposure,” Dr. Long said at the annual meeting of the American Academy of Pediatrics.

The more modern C. difficile shows antibiotic resistance that is probably caused by widespread use of fluoroquinolones. It has mutated to lose a regulatory gene that normally suppresses production of toxin by the organism. The mutated form produces 16–20 times the amount of toxin as that of the organism without the gene deletion.

The global occurrence of this antibiotic-resistant, highly toxin-producing organism could increasingly cause problems for “an unprepared planet,” she said.

Four healthy people died recently in Philadelphia from C. difficile infection after failing treatment with multiple antibiotics followed by colectomies. Two of the infections were in postpartum women. “C. difficile in pregnant ladies and post partum can be a very severe disease,” said Dr. Long.

Clinicians should consider C. difficile infection in otherwise healthy patients with diarrhea persisting beyond 3 days, whether or not the patient has been exposed to antibiotics, especially if there's blood in the stool or the patient is feverish or toxic appearing. “Put that on your list of things to worry about alongside Salmonella, Shigella, Campylobacter, and … Escherichia coli.”

Culture isn't helpful for diagnosis. A test for toxin in the stool is the diagnostic test of choice. An enzyme immunoassay for toxin, which can give a result in 2 hours, is a good test. Specialists also may order a cytotoxin assay on stool. Nearly 90% of patients will respond to treatment with metronidazole for 10 days, but 20%–25% will relapse. Of those, half will relapse again after retreatment. There is no standard therapy for chronic recurrences, but a number of antibiotic regimens or fecal transplants have been tried.

SAN FRANCISCO — Community-onset Clostridium difficile infection that is not antibiotic related has emerged as a multinational problem that can be life threatening, said Dr. Sarah S. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

The conventional way of thinking about C. difficile infection was that it was usually associated with antibiotic use, mainly affected adults, was not life threatening, and seldom produced severe diarrheal illness in children. “Throw that [way of thinking] away. You have to start thinking and worrying about C. difficile as community onset without antibiotic exposure,” Dr. Long said at the annual meeting of the American Academy of Pediatrics.

The more modern C. difficile shows antibiotic resistance that is probably caused by widespread use of fluoroquinolones. It has mutated to lose a regulatory gene that normally suppresses production of toxin by the organism. The mutated form produces 16–20 times the amount of toxin as that of the organism without the gene deletion.

The global occurrence of this antibiotic-resistant, highly toxin-producing organism could increasingly cause problems for “an unprepared planet,” she said.

Four healthy people died recently in Philadelphia from C. difficile infection after failing treatment with multiple antibiotics followed by colectomies. Two of the infections were in postpartum women. “C. difficile in pregnant ladies and post partum can be a very severe disease,” said Dr. Long.

Clinicians should consider C. difficile infection in otherwise healthy patients with diarrhea persisting beyond 3 days, whether or not the patient has been exposed to antibiotics, especially if there's blood in the stool or the patient is feverish or toxic appearing. “Put that on your list of things to worry about alongside Salmonella, Shigella, Campylobacter, and … Escherichia coli.”

Culture isn't helpful for diagnosis. A test for toxin in the stool is the diagnostic test of choice. An enzyme immunoassay for toxin, which can give a result in 2 hours, is a good test. Specialists also may order a cytotoxin assay on stool. Nearly 90% of patients will respond to treatment with metronidazole for 10 days, but 20%–25% will relapse. Of those, half will relapse again after retreatment. There is no standard therapy for chronic recurrences, but a number of antibiotic regimens or fecal transplants have been tried.

SAN FRANCISCO — Go beyond the usual questions about travel to other countries or the keeping of nontraditional pets, when asking parents about potential environmental exposures to diarrhea-causing agents, Dr. Sarah S. Long said at the annual meeting of the American Academy of Pediatrics.

Ask about two increasingly recognized sources of infection—petting zoos and swimming pools, said Dr. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

Agricultural fairs, petting zoos, and their equivalents are prime grounds for enteropathogens that can cause acute and often bloody diarrhea, especially in children younger than age 3 years who carry pacifiers, bottles, toys, or food in the vicinity of animals.

“I don't think we spend enough time asking about whether they've traveled to places where there are animals,” Dr. Long said.

Whether someone brings animals to a day care center or a family visits a local 4-H fair, the transient nature of most petting zoo environments usually results in poor hygiene. They often feature high-risk animals such as baby chicks, which harbor Salmonella species, or neonatal calves, which can transmit Escherichia coli. Children under age 5 years should not touch these animals, she said.

Advise parents that when they take children to these environments, bring nothing that a child might put in his or her mouth, and avoid eating food prepared there if possible. Most importantly, everyone should wash their hands with hand sanitizer when leaving, whether they touched anything or not.

The summer of 2007 saw 400 cases of Cryptosporidium-associated vomiting and diarrhea from an outbreak of infections around swimming pools in Philadelphia.

Cryptosporidium species also can be transmitted in day care centers and from farm animal contacts.

This protozoan is very chlorine resistant and remains in the stool of infected people for about 2 weeks after the diarrhea stops, unlike other agents that cause acute diarrhea. “We did anticipatory treatment of an awful lot of children” this past summer, Dr. Long said.

Routine lab tests for ova and parasites will not detect Cryptosporidium. “You want to ask about swimming pools,” and order specific antigen detection on stool specimens if you suspect Cryptosporidium. Treatment with 3 days of nitazoxanide is approved for children aged 1 year or older.

To prevent this infection, one should advise parents of all young children not to change diapers at poolside. A child with diapers in the pool should be checked frequently and taken to the bathroom to clean their diapers and wash up. Anyone with a diarrheal illness in the very recent past should stay out of the pool. In addition, a pool associated with Cryptosporidium infection should be shut for 2 weeks and hyperchlorinated.

Animals can transmit enteropathogens that cause diarrhea in young children, especially those under age 3 years. Louise A. Koenig/Elsevier Global Medical News

SAN FRANCISCO — Go beyond the usual questions about travel to other countries or the keeping of nontraditional pets, when asking parents about potential environmental exposures to diarrhea-causing agents, Dr. Sarah S. Long said at the annual meeting of the American Academy of Pediatrics.

Ask about two increasingly recognized sources of infection—petting zoos and swimming pools, said Dr. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

Agricultural fairs, petting zoos, and their equivalents are prime grounds for enteropathogens that can cause acute and often bloody diarrhea, especially in children younger than age 3 years who carry pacifiers, bottles, toys, or food in the vicinity of animals.

“I don't think we spend enough time asking about whether they've traveled to places where there are animals,” Dr. Long said.

Whether someone brings animals to a day care center or a family visits a local 4-H fair, the transient nature of most petting zoo environments usually results in poor hygiene. They often feature high-risk animals such as baby chicks, which harbor Salmonella species, or neonatal calves, which can transmit Escherichia coli. Children under age 5 years should not touch these animals, she said.

Advise parents that when they take children to these environments, bring nothing that a child might put in his or her mouth, and avoid eating food prepared there if possible. Most importantly, everyone should wash their hands with hand sanitizer when leaving, whether they touched anything or not.

The summer of 2007 saw 400 cases of Cryptosporidium-associated vomiting and diarrhea from an outbreak of infections around swimming pools in Philadelphia.

Cryptosporidium species also can be transmitted in day care centers and from farm animal contacts.

This protozoan is very chlorine resistant and remains in the stool of infected people for about 2 weeks after the diarrhea stops, unlike other agents that cause acute diarrhea. “We did anticipatory treatment of an awful lot of children” this past summer, Dr. Long said.

Routine lab tests for ova and parasites will not detect Cryptosporidium. “You want to ask about swimming pools,” and order specific antigen detection on stool specimens if you suspect Cryptosporidium. Treatment with 3 days of nitazoxanide is approved for children aged 1 year or older.

To prevent this infection, one should advise parents of all young children not to change diapers at poolside. A child with diapers in the pool should be checked frequently and taken to the bathroom to clean their diapers and wash up. Anyone with a diarrheal illness in the very recent past should stay out of the pool. In addition, a pool associated with Cryptosporidium infection should be shut for 2 weeks and hyperchlorinated.

Animals can transmit enteropathogens that cause diarrhea in young children, especially those under age 3 years. Louise A. Koenig/Elsevier Global Medical News

SAN FRANCISCO — Go beyond the usual questions about travel to other countries or the keeping of nontraditional pets, when asking parents about potential environmental exposures to diarrhea-causing agents, Dr. Sarah S. Long said at the annual meeting of the American Academy of Pediatrics.

Ask about two increasingly recognized sources of infection—petting zoos and swimming pools, said Dr. Long, chief of infectious diseases at St. Christopher's Hospital for Children, Philadelphia.

Agricultural fairs, petting zoos, and their equivalents are prime grounds for enteropathogens that can cause acute and often bloody diarrhea, especially in children younger than age 3 years who carry pacifiers, bottles, toys, or food in the vicinity of animals.

“I don't think we spend enough time asking about whether they've traveled to places where there are animals,” Dr. Long said.

Whether someone brings animals to a day care center or a family visits a local 4-H fair, the transient nature of most petting zoo environments usually results in poor hygiene. They often feature high-risk animals such as baby chicks, which harbor Salmonella species, or neonatal calves, which can transmit Escherichia coli. Children under age 5 years should not touch these animals, she said.

Advise parents that when they take children to these environments, bring nothing that a child might put in his or her mouth, and avoid eating food prepared there if possible. Most importantly, everyone should wash their hands with hand sanitizer when leaving, whether they touched anything or not.

The summer of 2007 saw 400 cases of Cryptosporidium-associated vomiting and diarrhea from an outbreak of infections around swimming pools in Philadelphia.

Cryptosporidium species also can be transmitted in day care centers and from farm animal contacts.

This protozoan is very chlorine resistant and remains in the stool of infected people for about 2 weeks after the diarrhea stops, unlike other agents that cause acute diarrhea. “We did anticipatory treatment of an awful lot of children” this past summer, Dr. Long said.

Routine lab tests for ova and parasites will not detect Cryptosporidium. “You want to ask about swimming pools,” and order specific antigen detection on stool specimens if you suspect Cryptosporidium. Treatment with 3 days of nitazoxanide is approved for children aged 1 year or older.

To prevent this infection, one should advise parents of all young children not to change diapers at poolside. A child with diapers in the pool should be checked frequently and taken to the bathroom to clean their diapers and wash up. Anyone with a diarrheal illness in the very recent past should stay out of the pool. In addition, a pool associated with Cryptosporidium infection should be shut for 2 weeks and hyperchlorinated.

Animals can transmit enteropathogens that cause diarrhea in young children, especially those under age 3 years. Louise A. Koenig/Elsevier Global Medical News

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.

It is important to be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, Dr. Jeffrey L. Brown 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, who is affiliated with Cornell University, New York, and is 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 assured 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. 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. Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. 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 Don'ts

▸ 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 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. Jeffrey L. 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.

It is important to be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, Dr. Jeffrey L. Brown 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, who is affiliated with Cornell University, New York, and is 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 assured 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. 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. Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. 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 Don'ts

▸ 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 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. Jeffrey L. 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.

It is important to be reasonably certain that the person requesting information by e-mail is authorized to receive it, just as would be done with phone calls, Dr. Jeffrey L. Brown 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, who is affiliated with Cornell University, New York, and is 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 assured 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. 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. Take precautions to protect confidential information on laptop computers and hard drives, as you would for other medical records. Use encryption software or change passwords frequently to prevent unauthorized access. 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 Don'ts

▸ 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 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. Jeffrey L. Brown

SAN FRANCISCO – In what may be the first study of the prevalence of vitamin D inadequacy in patients seeking treatment for chronic pain, those who were on opioids used significantly higher doses and had been taking opioids significantly longer if they had vitamin D inadequacy than if they had adequate vitamin D levels, Dr. W. Michael Hooten reported at the annual meeting of the American Society of Anesthesiologists.

Inadequate levels of vitamin D were detected in 26% of 267 patients admitted to a multidisciplinary pain rehabilitation center at a tertiary referral medical center from February through December of 2006. Of the 140 patients who were using opioids, 27% had inadequate levels of vitamin D, Dr. Hooten of the Mayo Clinic, Rochester, Minn., and his associates reported in a poster presentation.

“Vitamin D inadequacy may represent an underrecognized source of nociception and impaired neuromuscular functioning among patients with chronic pain,” he said.

In previous studies, inadequate levels of vitamin D have been associated with medication-refractory musculoskeletal pain and neuromuscular dysfunction.

In the current retrospective study, patients underwent vitamin D testing at admission, were questioned about opioid use, and completed the Short Form-36 Health Status Questionnaire (SF-36).

Serum 25-hydroxyvitamin D levels of 20 ng/mL or higher were considered adequate, and levels below 20 ng/mL were considered inadequate.

Both the adequate and inadequate vitamin D groups were nearly evenly split between opioid users and nonusers. Among 69 patients with vitamin D inadequacy, 38 were using opioids, and 31 were not. Among 198 patients with adequate vitamin D, 102 were using opioids and 96 were not.

Patients taking opioids used a mean morphine equivalent dose of 134 mg/day in the subgroup with vitamin D inadequacy and 70 mg/day in the subgroup with adequate vitamin D. Opioid users with inadequate vitamin D had been taking the medications for a mean of 71 months, compared with 44 months for opioid users with sufficient vitamin D.

The opioid users with inadequate vitamin D reported significantly worse health perceptions and physical functioning on the SF-36. Scores did not differ significantly between the vitamin D groups for bodily pain or “role-emotional.”

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – In what may be the first study of the prevalence of vitamin D inadequacy in patients seeking treatment for chronic pain, those who were on opioids used significantly higher doses and had been taking opioids significantly longer if they had vitamin D inadequacy than if they had adequate vitamin D levels, Dr. W. Michael Hooten reported at the annual meeting of the American Society of Anesthesiologists.

Inadequate levels of vitamin D were detected in 26% of 267 patients admitted to a multidisciplinary pain rehabilitation center at a tertiary referral medical center from February through December of 2006. Of the 140 patients who were using opioids, 27% had inadequate levels of vitamin D, Dr. Hooten of the Mayo Clinic, Rochester, Minn., and his associates reported in a poster presentation.

“Vitamin D inadequacy may represent an underrecognized source of nociception and impaired neuromuscular functioning among patients with chronic pain,” he said.

In previous studies, inadequate levels of vitamin D have been associated with medication-refractory musculoskeletal pain and neuromuscular dysfunction.

In the current retrospective study, patients underwent vitamin D testing at admission, were questioned about opioid use, and completed the Short Form-36 Health Status Questionnaire (SF-36).

Serum 25-hydroxyvitamin D levels of 20 ng/mL or higher were considered adequate, and levels below 20 ng/mL were considered inadequate.

Both the adequate and inadequate vitamin D groups were nearly evenly split between opioid users and nonusers. Among 69 patients with vitamin D inadequacy, 38 were using opioids, and 31 were not. Among 198 patients with adequate vitamin D, 102 were using opioids and 96 were not.

Patients taking opioids used a mean morphine equivalent dose of 134 mg/day in the subgroup with vitamin D inadequacy and 70 mg/day in the subgroup with adequate vitamin D. Opioid users with inadequate vitamin D had been taking the medications for a mean of 71 months, compared with 44 months for opioid users with sufficient vitamin D.

The opioid users with inadequate vitamin D reported significantly worse health perceptions and physical functioning on the SF-36. Scores did not differ significantly between the vitamin D groups for bodily pain or “role-emotional.”

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – In what may be the first study of the prevalence of vitamin D inadequacy in patients seeking treatment for chronic pain, those who were on opioids used significantly higher doses and had been taking opioids significantly longer if they had vitamin D inadequacy than if they had adequate vitamin D levels, Dr. W. Michael Hooten reported at the annual meeting of the American Society of Anesthesiologists.

Inadequate levels of vitamin D were detected in 26% of 267 patients admitted to a multidisciplinary pain rehabilitation center at a tertiary referral medical center from February through December of 2006. Of the 140 patients who were using opioids, 27% had inadequate levels of vitamin D, Dr. Hooten of the Mayo Clinic, Rochester, Minn., and his associates reported in a poster presentation.

“Vitamin D inadequacy may represent an underrecognized source of nociception and impaired neuromuscular functioning among patients with chronic pain,” he said.

In previous studies, inadequate levels of vitamin D have been associated with medication-refractory musculoskeletal pain and neuromuscular dysfunction.

In the current retrospective study, patients underwent vitamin D testing at admission, were questioned about opioid use, and completed the Short Form-36 Health Status Questionnaire (SF-36).

Serum 25-hydroxyvitamin D levels of 20 ng/mL or higher were considered adequate, and levels below 20 ng/mL were considered inadequate.

Both the adequate and inadequate vitamin D groups were nearly evenly split between opioid users and nonusers. Among 69 patients with vitamin D inadequacy, 38 were using opioids, and 31 were not. Among 198 patients with adequate vitamin D, 102 were using opioids and 96 were not.

Patients taking opioids used a mean morphine equivalent dose of 134 mg/day in the subgroup with vitamin D inadequacy and 70 mg/day in the subgroup with adequate vitamin D. Opioid users with inadequate vitamin D had been taking the medications for a mean of 71 months, compared with 44 months for opioid users with sufficient vitamin D.

The opioid users with inadequate vitamin D reported significantly worse health perceptions and physical functioning on the SF-36. Scores did not differ significantly between the vitamin D groups for bodily pain or “role-emotional.”

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – The increasing use of methadone for pain management has been shadowed by steep increases in the number of emergency department visits and deaths associated with the drug, according to an analysis of two national databases.

The trend is worrisome, and studies to identify the causes of methadone-related morbidity and mortality–as well as potential solutions to the problem–are critically needed, said Mario Moric, Ph.D., in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His study gathered data from the Drug Abuse Warning Network, which draws on in-hospital emergency records and coroner's data, and from the National Vital Statistics System, which provides poisoning information from death certificate data.

Records of emergency department (ED) visits from 1999 to 2005 that included mention of methadone showed an increase of 659%, accounting for 41,216 visits in 2005, according to Dr. Moric and his associates at Rush University, Chicago.

Death certificates listing methadone poisoning as the cause showed an increase from 786 deaths in 1999 to 3,849 deaths in 2004, a 390% jump that roughly paralleled a 487% rise in ED visits mentioning methadone during that same period, they reported.

In the past decade, methadone has become increasingly popular in pain treatment regimens, Dr. Moric said. Efforts to correct the undertreatment of pain have been followed by reports of wide-ranging abuse of certain pain medications such as oxycodone, especially in its controlled-release formulation, he added.

His study also looked at ED visits and deaths related to oxycodone and to all narcotics from 1999 to 2005. ED visits mentioning oxycodone increased 566% in this period, which surprisingly was not as large as the 659% growth in methadone-associated visits, he said. In 2005, 42,810 emergency visits were associated with oxycodone.

When data on all narcotics were lumped together, ED visits that mentioned any narcotic increased by 132% from 1999 to 2005. All opioid-associated deaths totalled 5,242 in 2004, compared with the 3,849 deaths in 2004 that were associated with methadone.

The Food and Drug Association issued an alert in 2006 about reports of deaths and respiratory depression, cardiac arrhythmias, and other life-threatening problems in patients taking methadone for chronic pain (www.fda.gov/cder/drug/InfoSheets/HCP/methadoneHCP.pdf

Dr. Moric speculated that the upswing in ED visits and deaths associated with methadone may be attributable to cardiovascular issues related to methadone metabolites or to issues related to abuse or overdosing.

SAN FRANCISCO – The increasing use of methadone for pain management has been shadowed by steep increases in the number of emergency department visits and deaths associated with the drug, according to an analysis of two national databases.

The trend is worrisome, and studies to identify the causes of methadone-related morbidity and mortality–as well as potential solutions to the problem–are critically needed, said Mario Moric, Ph.D., in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His study gathered data from the Drug Abuse Warning Network, which draws on in-hospital emergency records and coroner's data, and from the National Vital Statistics System, which provides poisoning information from death certificate data.

Records of emergency department (ED) visits from 1999 to 2005 that included mention of methadone showed an increase of 659%, accounting for 41,216 visits in 2005, according to Dr. Moric and his associates at Rush University, Chicago.

Death certificates listing methadone poisoning as the cause showed an increase from 786 deaths in 1999 to 3,849 deaths in 2004, a 390% jump that roughly paralleled a 487% rise in ED visits mentioning methadone during that same period, they reported.

In the past decade, methadone has become increasingly popular in pain treatment regimens, Dr. Moric said. Efforts to correct the undertreatment of pain have been followed by reports of wide-ranging abuse of certain pain medications such as oxycodone, especially in its controlled-release formulation, he added.

His study also looked at ED visits and deaths related to oxycodone and to all narcotics from 1999 to 2005. ED visits mentioning oxycodone increased 566% in this period, which surprisingly was not as large as the 659% growth in methadone-associated visits, he said. In 2005, 42,810 emergency visits were associated with oxycodone.

When data on all narcotics were lumped together, ED visits that mentioned any narcotic increased by 132% from 1999 to 2005. All opioid-associated deaths totalled 5,242 in 2004, compared with the 3,849 deaths in 2004 that were associated with methadone.

The Food and Drug Association issued an alert in 2006 about reports of deaths and respiratory depression, cardiac arrhythmias, and other life-threatening problems in patients taking methadone for chronic pain (www.fda.gov/cder/drug/InfoSheets/HCP/methadoneHCP.pdf

Dr. Moric speculated that the upswing in ED visits and deaths associated with methadone may be attributable to cardiovascular issues related to methadone metabolites or to issues related to abuse or overdosing.

SAN FRANCISCO – The increasing use of methadone for pain management has been shadowed by steep increases in the number of emergency department visits and deaths associated with the drug, according to an analysis of two national databases.

The trend is worrisome, and studies to identify the causes of methadone-related morbidity and mortality–as well as potential solutions to the problem–are critically needed, said Mario Moric, Ph.D., in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His study gathered data from the Drug Abuse Warning Network, which draws on in-hospital emergency records and coroner's data, and from the National Vital Statistics System, which provides poisoning information from death certificate data.

Records of emergency department (ED) visits from 1999 to 2005 that included mention of methadone showed an increase of 659%, accounting for 41,216 visits in 2005, according to Dr. Moric and his associates at Rush University, Chicago.

Death certificates listing methadone poisoning as the cause showed an increase from 786 deaths in 1999 to 3,849 deaths in 2004, a 390% jump that roughly paralleled a 487% rise in ED visits mentioning methadone during that same period, they reported.

In the past decade, methadone has become increasingly popular in pain treatment regimens, Dr. Moric said. Efforts to correct the undertreatment of pain have been followed by reports of wide-ranging abuse of certain pain medications such as oxycodone, especially in its controlled-release formulation, he added.

His study also looked at ED visits and deaths related to oxycodone and to all narcotics from 1999 to 2005. ED visits mentioning oxycodone increased 566% in this period, which surprisingly was not as large as the 659% growth in methadone-associated visits, he said. In 2005, 42,810 emergency visits were associated with oxycodone.

When data on all narcotics were lumped together, ED visits that mentioned any narcotic increased by 132% from 1999 to 2005. All opioid-associated deaths totalled 5,242 in 2004, compared with the 3,849 deaths in 2004 that were associated with methadone.

The Food and Drug Association issued an alert in 2006 about reports of deaths and respiratory depression, cardiac arrhythmias, and other life-threatening problems in patients taking methadone for chronic pain (www.fda.gov/cder/drug/InfoSheets/HCP/methadoneHCP.pdf

Dr. Moric speculated that the upswing in ED visits and deaths associated with methadone may be attributable to cardiovascular issues related to methadone metabolites or to issues related to abuse or overdosing.

SAN FRANCISCO – An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits–beyond improvements in the skills trained directly–from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six adaptive, computerized listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Clinicians who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1-5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

The study recruited participants through direct mail, radio, newspaper ads, flyers, and presentations. Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately. During the study, 8% of those in the intervention group and 12% of those in the control group withdrew prematurely. The intervention group had significantly fewer men (42%) than did the control group (53%), but the groups did not differ in age, education level, MMSE scores, or other factors. The mean age was 75 years.

Many interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions. The current study is the largest on aging and cognitive training to use available products, she said.

The overall memory composite score rose from 97.1 to 101.4 in the intervention group. DR. ZELINSKI

SAN FRANCISCO – An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits–beyond improvements in the skills trained directly–from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six adaptive, computerized listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Clinicians who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1-5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

The study recruited participants through direct mail, radio, newspaper ads, flyers, and presentations. Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately. During the study, 8% of those in the intervention group and 12% of those in the control group withdrew prematurely. The intervention group had significantly fewer men (42%) than did the control group (53%), but the groups did not differ in age, education level, MMSE scores, or other factors. The mean age was 75 years.

Many interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions. The current study is the largest on aging and cognitive training to use available products, she said.

The overall memory composite score rose from 97.1 to 101.4 in the intervention group. DR. ZELINSKI

SAN FRANCISCO – An auditory training program designed to improve brain plasticity bestowed the side benefit of improved memory in a randomized, controlled, double-blind trial in 468 adults older than 65 years with normal cognition.

The study is one of the first to show generalized benefits–beyond improvements in the skills trained directly–from an intervention aiming to improve cognition or memory, Elizabeth M. Zelinski, Ph.D., and her associates reported in a poster presentation at the annual meeting of the Gerontological Society of America.

They asked the 232 participants in the intervention group to spend an hour a day, 5 days a week for 10 weeks doing six adaptive, computerized listening exercises meant to increase the speed and accuracy of aural information processing and the production of neuromodulators associated with learning and memory.

The 236 participants in the control group were asked to spend the same amount of time using a DVD-based educational training program on a computer and taking written quizzes that probed memory and content comprehension. The control activities were modeled on physicians' usual treatments for memory complaints and were matched for novelty level and intensity to the study intervention.

At the end of the study, people in the intervention group were significantly more likely to say that they perceived improvements in their everyday cognitive function; objective measures supported their reports in intention-to-treat analyses of the results, said Dr. Zelinski of the University of Southern California, Los Angeles. She receives per diem honoraria from the company that markets the brain fitness program, Posit Science Corp., which also funded the study.

Clinicians who were blinded to randomization performed neuropsychological evaluations to measure the results. Scores in both groups improved on most measures, but they improved significantly more in the intervention group.

For the primary outcome, scores in the intervention group on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) global auditory memory score improved significantly from 95.4 to 99.2, compared with a change from 95.6 to 98.3 in the control group, Dr. Zelinski said. The RBANS global auditory memory score was derived from stub tests on list learning, story memory, digit span forward, delayed free list recall, delayed list recognition, and delayed free story recall.

Secondary outcome measures included the Rey Auditory Verbal Learning Test (RAVLT), the Wechsler Memory Scale (WMS-III), and the Rivermead Behavioral Memory Test (RBMT). Significantly greater improvements were seen in the intervention group on RAVLT and WMS-III measures, but not on the RBMT. The overall memory composite score increased from 97.1 to 101.4 in the intervention group, which was significantly more than the control group's improvement from 96.9 to 97.9, she said.

Scores on the RAVLT for trials 1-5 increased from 39.3 to 40.6 in the intervention group and declined from 40.1 to 39.2 in the control group. Scores on the RAVLT delayed recall test improved from 6.3 to 6.9 in the intervention group and held steady at 6.6 in the control group.

On the WMS-III, scores on the digit span backward test increased from 7.3 to 7.9 in the intervention group and from 7.1 to 7.3 in the control group. Scores on the WMS-III letter-number sequencing test improved from 9.5 to 10.2 in the intervention group and from 9.4 to 9.5 in the control group.

The study recruited participants through direct mail, radio, newspaper ads, flyers, and presentations. Participants were older than 65 years, had Mini-Mental State Examination (MMSE) scores greater than 26, and could read 14-point type and hear adequately. During the study, 8% of those in the intervention group and 12% of those in the control group withdrew prematurely. The intervention group had significantly fewer men (42%) than did the control group (53%), but the groups did not differ in age, education level, MMSE scores, or other factors. The mean age was 75 years.

Many interventions claim to improve cognition and memory in people with normal age-related cognitive decline, there is little empiric evidence of the efficacy of such interventions. The current study is the largest on aging and cognitive training to use available products, she said.

The overall memory composite score rose from 97.1 to 101.4 in the intervention group. DR. ZELINSKI

SAN FRANCISCO – Depressed girls reported more negative life events in the past year compared with nondepressed girls, and the depressed girls felt greater effects from bad events, a study of 166 girls found.

The findings support cognitive models of depression that describe a person's dysfunctional thinking and attitudes leading to depression, and the depression biasing the person's interpretation of experiences, Nicole Moody and her associates reported in a poster presentation at the annual meeting of the American Psychological Association.

Ms. Moody is a graduate student in educational psychology at the University of Texas, Austin.

As part of an ongoing study of depression in central Texas, girls aged 9-14 years completed the Life Events Checklist, a self-report measure that assesses major life events during the past 12 months.

The measure lists events related to family health, family member changes, family moves, money, crises, unexpected news, parent's marital relationship, parent-child relationship, school, and family resources.

The girls were asked to check any of the listed events that happened to them and to indicate whether the event was “good” or “bad” and to rate how much of an effect it had on their lives.

Doctoral students in the school of psychiatry then administered the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, a semistructured clinical interview.

Using results of this measure plus child and parent reports of depressive symptoms in the girls, 118 girls were diagnosed as depressed. The 48 nondepressed girls served as the control group.

Girls in the depressed group reported a mean of 6.3 negative events during the past year, compared with a mean of 4.6 negative events for girls in the control group. The difference was statistically significant.

The depressed girls also reported that the negative events had a significantly greater effect on them, compared with the nondepressed girls.

The results support the literature suggesting that negative life events play a role in activating a depressive episode and that depression colors the way a person interprets life events, Ms. Moody said. “Are the depressed girls actually experiencing more negative life events, or is their depression distorting the way in which they interpret life events and their effects?”

The role that negative life events play in depression is still up for debate, she added.

The study cohort was 42% white, 32% Hispanic, 12% black, 5% multiracial, 3% Asian, and 7% unspecified race (numbers do not add up to 100% because of rounding).

An estimated 60%–70% of depressed individuals have experienced at least one stressful life event before the onset of depression, the literature suggests. Depressed people report up to six times as many negative life events compared with nondepressed individuals, other reports indicate.

The aim of cognitive-behavioral therapy is to guide patients toward more realistic evaluation of experiences and to modify their thinking to produce an improvement in mood and behavior, Ms. Moody noted. Better understanding of factors contributing to the onset and maintenance of depression will better inform the treatment of early adolescent girls with depression.

SAN FRANCISCO – Depressed girls reported more negative life events in the past year compared with nondepressed girls, and the depressed girls felt greater effects from bad events, a study of 166 girls found.

The findings support cognitive models of depression that describe a person's dysfunctional thinking and attitudes leading to depression, and the depression biasing the person's interpretation of experiences, Nicole Moody and her associates reported in a poster presentation at the annual meeting of the American Psychological Association.

Ms. Moody is a graduate student in educational psychology at the University of Texas, Austin.

As part of an ongoing study of depression in central Texas, girls aged 9-14 years completed the Life Events Checklist, a self-report measure that assesses major life events during the past 12 months.

The measure lists events related to family health, family member changes, family moves, money, crises, unexpected news, parent's marital relationship, parent-child relationship, school, and family resources.

The girls were asked to check any of the listed events that happened to them and to indicate whether the event was “good” or “bad” and to rate how much of an effect it had on their lives.

Doctoral students in the school of psychiatry then administered the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, a semistructured clinical interview.

Using results of this measure plus child and parent reports of depressive symptoms in the girls, 118 girls were diagnosed as depressed. The 48 nondepressed girls served as the control group.

Girls in the depressed group reported a mean of 6.3 negative events during the past year, compared with a mean of 4.6 negative events for girls in the control group. The difference was statistically significant.

The depressed girls also reported that the negative events had a significantly greater effect on them, compared with the nondepressed girls.

The results support the literature suggesting that negative life events play a role in activating a depressive episode and that depression colors the way a person interprets life events, Ms. Moody said. “Are the depressed girls actually experiencing more negative life events, or is their depression distorting the way in which they interpret life events and their effects?”

The role that negative life events play in depression is still up for debate, she added.

The study cohort was 42% white, 32% Hispanic, 12% black, 5% multiracial, 3% Asian, and 7% unspecified race (numbers do not add up to 100% because of rounding).

An estimated 60%–70% of depressed individuals have experienced at least one stressful life event before the onset of depression, the literature suggests. Depressed people report up to six times as many negative life events compared with nondepressed individuals, other reports indicate.

The aim of cognitive-behavioral therapy is to guide patients toward more realistic evaluation of experiences and to modify their thinking to produce an improvement in mood and behavior, Ms. Moody noted. Better understanding of factors contributing to the onset and maintenance of depression will better inform the treatment of early adolescent girls with depression.

SAN FRANCISCO – Depressed girls reported more negative life events in the past year compared with nondepressed girls, and the depressed girls felt greater effects from bad events, a study of 166 girls found.

The findings support cognitive models of depression that describe a person's dysfunctional thinking and attitudes leading to depression, and the depression biasing the person's interpretation of experiences, Nicole Moody and her associates reported in a poster presentation at the annual meeting of the American Psychological Association.

Ms. Moody is a graduate student in educational psychology at the University of Texas, Austin.

As part of an ongoing study of depression in central Texas, girls aged 9-14 years completed the Life Events Checklist, a self-report measure that assesses major life events during the past 12 months.

The measure lists events related to family health, family member changes, family moves, money, crises, unexpected news, parent's marital relationship, parent-child relationship, school, and family resources.

The girls were asked to check any of the listed events that happened to them and to indicate whether the event was “good” or “bad” and to rate how much of an effect it had on their lives.

Doctoral students in the school of psychiatry then administered the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, a semistructured clinical interview.

Using results of this measure plus child and parent reports of depressive symptoms in the girls, 118 girls were diagnosed as depressed. The 48 nondepressed girls served as the control group.

Girls in the depressed group reported a mean of 6.3 negative events during the past year, compared with a mean of 4.6 negative events for girls in the control group. The difference was statistically significant.

The depressed girls also reported that the negative events had a significantly greater effect on them, compared with the nondepressed girls.

The results support the literature suggesting that negative life events play a role in activating a depressive episode and that depression colors the way a person interprets life events, Ms. Moody said. “Are the depressed girls actually experiencing more negative life events, or is their depression distorting the way in which they interpret life events and their effects?”

The role that negative life events play in depression is still up for debate, she added.

The study cohort was 42% white, 32% Hispanic, 12% black, 5% multiracial, 3% Asian, and 7% unspecified race (numbers do not add up to 100% because of rounding).

An estimated 60%–70% of depressed individuals have experienced at least one stressful life event before the onset of depression, the literature suggests. Depressed people report up to six times as many negative life events compared with nondepressed individuals, other reports indicate.

The aim of cognitive-behavioral therapy is to guide patients toward more realistic evaluation of experiences and to modify their thinking to produce an improvement in mood and behavior, Ms. Moody noted. Better understanding of factors contributing to the onset and maintenance of depression will better inform the treatment of early adolescent girls with depression.