Sherry Boschert

SAN FRANCISCO – A very low prevalence of childhood attention-deficit/hyperactivity disorder in New York's Chinatown seems to be attributable to underdiagnosis of the disorder, Dr. Loretta Au said at a poster presentation at the annual meeting of the American Academy of Pediatrics.

Surveys of 225 Chinese immigrant parents, 178 school faculty (mostly teachers), and 20 community-based pediatricians found that parents lacked knowledge about ADHD, and school staff and physicians reported a wide variety of obstacles to diagnosis and management of ADHD in the Chinatown population, reported Dr. Au of the Charles B. Wang Community Health Center, New York, and her associates.

The investigators designed the study after noticing that the 0.1%–0.2% prevalence rate for childhood ADHD at the center was far below reported prevalence rates of 4%–12% for broader populations. Faculty at five Chinatown elementary schools reported that 8% of 3,039 children in the schools exhibited signs of ADHD–a rate consistent with the wider prevalence rates for ADHD–but only 1% of students had official diagnoses for the disorder, the school survey found.

Among 20 pediatricians who returned anonymous, mailed surveys, 70% said they are aware of criteria and guidelines for diagnosing ADHD, and 95% said they would like more help in diagnosing the disorder. A majority of the pediatricians (65%) referred patients with suspected ADHD to neurologists or mental health providers for official diagnosis. Not handling ADHD in the patients' medical home may contribute to underdiagnosis, Dr. Au suggested.

Surveys that were translated into Chinese were answered by parents at schools and the Community Health Center. Only 15% knew of the symptoms of ADHD, and 33% knew about the consequences of untreated ADHD, although 58% of parents had heard of the disorder. Seventy-seven percent were interested in learning more, and 83% said their community needs more information on ADHD.

Common obstacles to diagnosis and management of ADHD reported by physicians were a lack of coordinated care (21%), parental mistrust or denial of the diagnosis (20%), and lack of bilingual mental health services (20%). School faculty also pointed to a lack of coordinated care (18%), a lack of resources (17%), and families who don't follow through on recommendations for evaluation or treatment of ADHD (23%).

“Especially for Chinese patients, and I think in general for Asian patients, ADHD is something that they might have heard about, but they might not think about as a medical problem,” Dr. Au said. “They might not present the problem to their doctor unless asked [about it]. They might be ashamed about the fact that their child is not doing well in school. A lot of times they are concerned about hyperactivity symptoms, but they might blame themselves for poor parenting.”

Busy pediatricians might not pursue the topic if parents don't ask about it, she added. In Chinese immigrant populations, “the pediatrician needs to be asking about school performance, and telling parents about ADHD, and that it might impact upon school performance and the future of the child.”

The results of the study prompted her center to take several steps to increase education and coordination of care around ADHD. The center staff created bilingual educational materials for parents and translated ADHD assessment scales into Chinese. An ADHD multidisciplinary team meets monthly on care management.

A pediatrician and social worker from the center give bilingual workshops in the community and schools about ADHD. Clinicians meet quarterly with school counselors, who now fax referrals to the center for children with ADHD symptoms. The center also started a support group for parents of children with ADHD.

SAN FRANCISCO – A very low prevalence of childhood attention-deficit/hyperactivity disorder in New York's Chinatown seems to be attributable to underdiagnosis of the disorder, Dr. Loretta Au said at a poster presentation at the annual meeting of the American Academy of Pediatrics.

Surveys of 225 Chinese immigrant parents, 178 school faculty (mostly teachers), and 20 community-based pediatricians found that parents lacked knowledge about ADHD, and school staff and physicians reported a wide variety of obstacles to diagnosis and management of ADHD in the Chinatown population, reported Dr. Au of the Charles B. Wang Community Health Center, New York, and her associates.

The investigators designed the study after noticing that the 0.1%–0.2% prevalence rate for childhood ADHD at the center was far below reported prevalence rates of 4%–12% for broader populations. Faculty at five Chinatown elementary schools reported that 8% of 3,039 children in the schools exhibited signs of ADHD–a rate consistent with the wider prevalence rates for ADHD–but only 1% of students had official diagnoses for the disorder, the school survey found.

Among 20 pediatricians who returned anonymous, mailed surveys, 70% said they are aware of criteria and guidelines for diagnosing ADHD, and 95% said they would like more help in diagnosing the disorder. A majority of the pediatricians (65%) referred patients with suspected ADHD to neurologists or mental health providers for official diagnosis. Not handling ADHD in the patients' medical home may contribute to underdiagnosis, Dr. Au suggested.

Surveys that were translated into Chinese were answered by parents at schools and the Community Health Center. Only 15% knew of the symptoms of ADHD, and 33% knew about the consequences of untreated ADHD, although 58% of parents had heard of the disorder. Seventy-seven percent were interested in learning more, and 83% said their community needs more information on ADHD.

Common obstacles to diagnosis and management of ADHD reported by physicians were a lack of coordinated care (21%), parental mistrust or denial of the diagnosis (20%), and lack of bilingual mental health services (20%). School faculty also pointed to a lack of coordinated care (18%), a lack of resources (17%), and families who don't follow through on recommendations for evaluation or treatment of ADHD (23%).

“Especially for Chinese patients, and I think in general for Asian patients, ADHD is something that they might have heard about, but they might not think about as a medical problem,” Dr. Au said. “They might not present the problem to their doctor unless asked [about it]. They might be ashamed about the fact that their child is not doing well in school. A lot of times they are concerned about hyperactivity symptoms, but they might blame themselves for poor parenting.”

Busy pediatricians might not pursue the topic if parents don't ask about it, she added. In Chinese immigrant populations, “the pediatrician needs to be asking about school performance, and telling parents about ADHD, and that it might impact upon school performance and the future of the child.”

The results of the study prompted her center to take several steps to increase education and coordination of care around ADHD. The center staff created bilingual educational materials for parents and translated ADHD assessment scales into Chinese. An ADHD multidisciplinary team meets monthly on care management.

A pediatrician and social worker from the center give bilingual workshops in the community and schools about ADHD. Clinicians meet quarterly with school counselors, who now fax referrals to the center for children with ADHD symptoms. The center also started a support group for parents of children with ADHD.

SAN FRANCISCO – A very low prevalence of childhood attention-deficit/hyperactivity disorder in New York's Chinatown seems to be attributable to underdiagnosis of the disorder, Dr. Loretta Au said at a poster presentation at the annual meeting of the American Academy of Pediatrics.

Surveys of 225 Chinese immigrant parents, 178 school faculty (mostly teachers), and 20 community-based pediatricians found that parents lacked knowledge about ADHD, and school staff and physicians reported a wide variety of obstacles to diagnosis and management of ADHD in the Chinatown population, reported Dr. Au of the Charles B. Wang Community Health Center, New York, and her associates.

The investigators designed the study after noticing that the 0.1%–0.2% prevalence rate for childhood ADHD at the center was far below reported prevalence rates of 4%–12% for broader populations. Faculty at five Chinatown elementary schools reported that 8% of 3,039 children in the schools exhibited signs of ADHD–a rate consistent with the wider prevalence rates for ADHD–but only 1% of students had official diagnoses for the disorder, the school survey found.

Among 20 pediatricians who returned anonymous, mailed surveys, 70% said they are aware of criteria and guidelines for diagnosing ADHD, and 95% said they would like more help in diagnosing the disorder. A majority of the pediatricians (65%) referred patients with suspected ADHD to neurologists or mental health providers for official diagnosis. Not handling ADHD in the patients' medical home may contribute to underdiagnosis, Dr. Au suggested.

Surveys that were translated into Chinese were answered by parents at schools and the Community Health Center. Only 15% knew of the symptoms of ADHD, and 33% knew about the consequences of untreated ADHD, although 58% of parents had heard of the disorder. Seventy-seven percent were interested in learning more, and 83% said their community needs more information on ADHD.

Common obstacles to diagnosis and management of ADHD reported by physicians were a lack of coordinated care (21%), parental mistrust or denial of the diagnosis (20%), and lack of bilingual mental health services (20%). School faculty also pointed to a lack of coordinated care (18%), a lack of resources (17%), and families who don't follow through on recommendations for evaluation or treatment of ADHD (23%).

“Especially for Chinese patients, and I think in general for Asian patients, ADHD is something that they might have heard about, but they might not think about as a medical problem,” Dr. Au said. “They might not present the problem to their doctor unless asked [about it]. They might be ashamed about the fact that their child is not doing well in school. A lot of times they are concerned about hyperactivity symptoms, but they might blame themselves for poor parenting.”

Busy pediatricians might not pursue the topic if parents don't ask about it, she added. In Chinese immigrant populations, “the pediatrician needs to be asking about school performance, and telling parents about ADHD, and that it might impact upon school performance and the future of the child.”

The results of the study prompted her center to take several steps to increase education and coordination of care around ADHD. The center staff created bilingual educational materials for parents and translated ADHD assessment scales into Chinese. An ADHD multidisciplinary team meets monthly on care management.

A pediatrician and social worker from the center give bilingual workshops in the community and schools about ADHD. Clinicians meet quarterly with school counselors, who now fax referrals to the center for children with ADHD symptoms. The center also started a support group for parents of children with ADHD.

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty.

Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection, and overall wound complication rates of 1%–12%.

Diabetes patients may be more prone to perioperative urinary tract infection, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

Studies suggest diabetes patients are more likely than nondiabetics to be discharged to an inpatient facility after total knee arthroplasty.

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty.

Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection, and overall wound complication rates of 1%–12%.

Diabetes patients may be more prone to perioperative urinary tract infection, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

Studies suggest diabetes patients are more likely than nondiabetics to be discharged to an inpatient facility after total knee arthroplasty.

SAN FRANCISCO — Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A_1c levels, a retrospective study of 119 patients found.

The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A_1c (HbA_1c) level greater than 7%, and less than 40% in those with an HbA_1c level below 7%, study investigators reported.

“We believe that the HbA_1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty,” Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. “Patients with significantly elevated HbA_1c levels should have their glycemic control optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period.”

In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA_1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis.

Patients did not have to have a diagnosis of diabetes to be included in the study—just an HbA_1c measurement—because up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported.

In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty.

Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, 23% Hispanic, and 9% other races/ethnicities. Their mean body mass index was 34 kg/m

The investigators performed a multivariate analysis looking for associations between HbA_1c levels and outcomes within 3 months of the surgery, said Dr. Blum of Montefiore Medical Center, New York.

Higher HbA_1c levels were significantly associated with an increased risk for any complications, surgical site complications, and wound complications after total knee or hip arthroplasty, Dr. Blum and his associates reported.

Only four surgical site infections occurred—too few to demonstrate a specific association between HbA_1c levels and wound infection—but “it is notable that three of four infections occurred in patients with an HbA_1c [level] above 7.5%,” he said.

The current study found no association between HbA_1c level and the risk of non-surgical-site infections, urinary retention, or discharge after surgery to an inpatient facility.

Overall, 43% of the patients developed medical or surgical complications.

“Future studies with increased numbers of patients may help determine a cutoff HbA_1c level above which total hip arthroplasty or total knee arthroplasty can be considered too high risk,” Dr. Blum said.

Recommendations from the American Diabetes Association set a treatment goal of an HbA_1c level below 7%.

A 2003 review by other investigators of 290 diabetes patients who underwent noncardiac surgeries found that those with an HbA_1c level above 7% had a statistically significant increased risk for postoperative complications, Dr. Blum said.

There have been few studies in the past 2 decades on the results of total knee arthroplasty in diabetes patients, and even fewer studies on the results of total hip arthroplasty in diabetes patients, Dr. Blum noted. Some reports suggest a risk of 1%–7% for deep infection, and overall wound complication rates of 1%–12%.

Diabetes patients may be more prone to perioperative urinary tract infection, pneumonia, sepsis, cardiac problems, and postoperative neuropathy.

Studies suggest diabetes patients are more likely than nondiabetics to be discharged to an inpatient facility after total knee arthroplasty.

SAN FRANCISCO — Instilling purified capsaicin into a surgical wound after open mesh groin hernia repair and before wound closure reduced postoperative pain scores, compared with placebo, for 3 days after surgery, according to a randomized, double-blind, placebo-controlled study of 41 men.

There was no significant difference between groups, however, in the primary end point: average daily pain scores during the first week after surgery, Dr. Eske K. Aasvang reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Average pain scores, as assessed on a 100-point visual analog scale, were less than 15 after postoperative day 4 in both groups—too low to show a treatment difference in the second half of the week, suggested Dr. Aasvang of the University of Copenhagen and his associates.

Dr. Aasvang received a salary from the maker of the capsaicin formulation, Anesiva Inc., which also funded the study.

Patients received a single intraoperative instillation of 15 mL of medication containing either placebo or 1,000 mcg of Adlea, a formulation consisting of more than 98% capsaicin. All patients also were given acetaminophen and ibuprofen for postoperative analgesia and were allowed to take tramadol if needed.

The morning after surgery, median pain scores on the visual analog scale were approximately 13 in the capsaicin group and 33 in the placebo group. Median pain scores in the capsaicin group and the placebo group on the second morning after surgery were approximately 15 and 25, respectively, and on the third morning were approximately 7 and 17, respectively.

Four patients in the capsaicin group and none in the placebo group developed treatment-related adverse events, including increased blood pressure (two patients), decreased heart rate (one), and abnormal skin odor (one). Dr. Aasvang described the capsaicin formulation as “generally well tolerated” in this study.

All patients except one in the placebo group had normal wound healing in the week after surgery. One patient in the placebo group had surgical wound drainage, a serious adverse event that was thought to be unrelated to the study treatment.

The study results suggest that purified capsaicin may have a role to play in reducing acute postoperative pain, the investigators concluded.

SAN FRANCISCO — Instilling purified capsaicin into a surgical wound after open mesh groin hernia repair and before wound closure reduced postoperative pain scores, compared with placebo, for 3 days after surgery, according to a randomized, double-blind, placebo-controlled study of 41 men.

There was no significant difference between groups, however, in the primary end point: average daily pain scores during the first week after surgery, Dr. Eske K. Aasvang reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Average pain scores, as assessed on a 100-point visual analog scale, were less than 15 after postoperative day 4 in both groups—too low to show a treatment difference in the second half of the week, suggested Dr. Aasvang of the University of Copenhagen and his associates.

Dr. Aasvang received a salary from the maker of the capsaicin formulation, Anesiva Inc., which also funded the study.

Patients received a single intraoperative instillation of 15 mL of medication containing either placebo or 1,000 mcg of Adlea, a formulation consisting of more than 98% capsaicin. All patients also were given acetaminophen and ibuprofen for postoperative analgesia and were allowed to take tramadol if needed.

The morning after surgery, median pain scores on the visual analog scale were approximately 13 in the capsaicin group and 33 in the placebo group. Median pain scores in the capsaicin group and the placebo group on the second morning after surgery were approximately 15 and 25, respectively, and on the third morning were approximately 7 and 17, respectively.

Four patients in the capsaicin group and none in the placebo group developed treatment-related adverse events, including increased blood pressure (two patients), decreased heart rate (one), and abnormal skin odor (one). Dr. Aasvang described the capsaicin formulation as “generally well tolerated” in this study.

All patients except one in the placebo group had normal wound healing in the week after surgery. One patient in the placebo group had surgical wound drainage, a serious adverse event that was thought to be unrelated to the study treatment.

The study results suggest that purified capsaicin may have a role to play in reducing acute postoperative pain, the investigators concluded.

SAN FRANCISCO — Instilling purified capsaicin into a surgical wound after open mesh groin hernia repair and before wound closure reduced postoperative pain scores, compared with placebo, for 3 days after surgery, according to a randomized, double-blind, placebo-controlled study of 41 men.

There was no significant difference between groups, however, in the primary end point: average daily pain scores during the first week after surgery, Dr. Eske K. Aasvang reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Average pain scores, as assessed on a 100-point visual analog scale, were less than 15 after postoperative day 4 in both groups—too low to show a treatment difference in the second half of the week, suggested Dr. Aasvang of the University of Copenhagen and his associates.

Dr. Aasvang received a salary from the maker of the capsaicin formulation, Anesiva Inc., which also funded the study.

Patients received a single intraoperative instillation of 15 mL of medication containing either placebo or 1,000 mcg of Adlea, a formulation consisting of more than 98% capsaicin. All patients also were given acetaminophen and ibuprofen for postoperative analgesia and were allowed to take tramadol if needed.

The morning after surgery, median pain scores on the visual analog scale were approximately 13 in the capsaicin group and 33 in the placebo group. Median pain scores in the capsaicin group and the placebo group on the second morning after surgery were approximately 15 and 25, respectively, and on the third morning were approximately 7 and 17, respectively.

Four patients in the capsaicin group and none in the placebo group developed treatment-related adverse events, including increased blood pressure (two patients), decreased heart rate (one), and abnormal skin odor (one). Dr. Aasvang described the capsaicin formulation as “generally well tolerated” in this study.

All patients except one in the placebo group had normal wound healing in the week after surgery. One patient in the placebo group had surgical wound drainage, a serious adverse event that was thought to be unrelated to the study treatment.

The study results suggest that purified capsaicin may have a role to play in reducing acute postoperative pain, the investigators concluded.

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, said Dr. Jeffrey L. Brown.

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, 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—"usually 48 hours," said Dr. Brown—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.

Confidential e-mail from physicians should contain a warning disclaimer like those used on fax transmissions. A typical disclaimer says: "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, 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.

Rx for Security: 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 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, said Dr. Jeffrey L. Brown.

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, 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—"usually 48 hours," said Dr. Brown—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.

Confidential e-mail from physicians should contain a warning disclaimer like those used on fax transmissions. A typical disclaimer says: "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, 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.

Rx for Security: 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 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, said Dr. Jeffrey L. Brown.

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, 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—"usually 48 hours," said Dr. Brown—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.

Confidential e-mail from physicians should contain a warning disclaimer like those used on fax transmissions. A typical disclaimer says: "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, 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.

Rx for Security: 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 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 — A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as "fish tank granuloma," said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1–4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point clinicians toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank. M. marinum infects fish and amphibians. "You can sometimes get a history of a fish tank, but you also can get this infection from swimming in pools and in natural bodies of water—any kind of significant water exposure," she said.

In rare cases, immunocompetent patients can develop disseminated M. marinum infection, affecting bones or joint tendon sheaths. "Particularly on the hand, it's a very worrisome diagnosis," Dr. Weintrub said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. S. schenckii resides in decaying vegetation, moss, soil, wood, and hay. It is more a disease of adults (typically farmers, gardeners, and forestry workers) than of children, with a history of skin trauma in 10%–60% of cases. A history of travel may suggest Leishmania, a parasite.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. "There aren't really good guidelines" on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients).

In general, 1–2 months of treatment may suffice, but 3 months of therapy was needed for the boy's lesions to clear completely. Localized infection is more likely to clear up than is deep infection. In rare cases, surgery may be needed to remove infected tissue.

This Mycobacterium marinum culture shows a colony of granular growth containing fine red pigment deposits. CDC/Dr. Charles C. Shepard

SAN FRANCISCO — A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as "fish tank granuloma," said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1–4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point clinicians toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank. M. marinum infects fish and amphibians. "You can sometimes get a history of a fish tank, but you also can get this infection from swimming in pools and in natural bodies of water—any kind of significant water exposure," she said.

In rare cases, immunocompetent patients can develop disseminated M. marinum infection, affecting bones or joint tendon sheaths. "Particularly on the hand, it's a very worrisome diagnosis," Dr. Weintrub said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. S. schenckii resides in decaying vegetation, moss, soil, wood, and hay. It is more a disease of adults (typically farmers, gardeners, and forestry workers) than of children, with a history of skin trauma in 10%–60% of cases. A history of travel may suggest Leishmania, a parasite.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. "There aren't really good guidelines" on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients).

In general, 1–2 months of treatment may suffice, but 3 months of therapy was needed for the boy's lesions to clear completely. Localized infection is more likely to clear up than is deep infection. In rare cases, surgery may be needed to remove infected tissue.

This Mycobacterium marinum culture shows a colony of granular growth containing fine red pigment deposits. CDC/Dr. Charles C. Shepard

SAN FRANCISCO — A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as "fish tank granuloma," said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1–4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point clinicians toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank. M. marinum infects fish and amphibians. "You can sometimes get a history of a fish tank, but you also can get this infection from swimming in pools and in natural bodies of water—any kind of significant water exposure," she said.

In rare cases, immunocompetent patients can develop disseminated M. marinum infection, affecting bones or joint tendon sheaths. "Particularly on the hand, it's a very worrisome diagnosis," Dr. Weintrub said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. S. schenckii resides in decaying vegetation, moss, soil, wood, and hay. It is more a disease of adults (typically farmers, gardeners, and forestry workers) than of children, with a history of skin trauma in 10%–60% of cases. A history of travel may suggest Leishmania, a parasite.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. "There aren't really good guidelines" on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients).

In general, 1–2 months of treatment may suffice, but 3 months of therapy was needed for the boy's lesions to clear completely. Localized infection is more likely to clear up than is deep infection. In rare cases, surgery may be needed to remove infected tissue.

This Mycobacterium marinum culture shows a colony of granular growth containing fine red pigment deposits. CDC/Dr. Charles C. Shepard

SAN FRANCISCO — Few patients will admit that they compulsively pull out their hair, but a hair biopsy can help make the diagnosis of trichotillomania, Dr. Pearl C. Kwong said at a meeting sponsored by Skin Disease Education Foundation.

Clinically, the missing hair may be barely noticeable or may show signs of regrowth, such as uneven hair lengths. In contrast, hairs lost from alopecia areata will be approximately the same length if they regrow. If a patient picks hair from a favored area of the scalp, a "Friar Tuck" sign can be a clue to trichotillomania, she said. Patients usually have no skin abnormalities elsewhere.

Both children and adults with this impulse control disorder typically deny hair-pulling, and parents may be unwilling to accept a possible diagnosis of trichotillomania, said Dr. Kwong, a dermatologist in Jacksonville, Fla.

She recalled one girl who tried to hide her hair-pulling habit by eating the pulled hairs, which caused a bowel obstruction that required surgery. "To the end, the patient was denying that she ate her hair. The evidence was there in the bowel," Dr. Kwong said.

A hair biopsy can help with diagnosis. On histology, a high frequency of telogen hairs and a high frequency of noninflamed catagen hairs are typical of trichotillomania.

Accurate data on the prevalence of trichotillomania are hard to get because people hide the disorder, but it is estimated to affect 8 million people in the United States. The mean age of onset seems to be 8 years in boys and 12 years in girls, and 1%–2% of college students have experienced or currently have symptoms. Adults with trichotillomania often report that the disorder started at a young age, even as young as 1 year old, and it is more likely to be diagnosed in women than in men.

In infants or young children, pulling or twisting the hair usually is self-limited and is a benign form of trichotillomania. It may be a sign of psychosocial stress or an underlying psychological problem, however, and can become a chronic condition.

Adolescents and adults diagnosed with trichotillomania tend to have a poorer prognosis, with chronic remissions and exacerbations. Patients may avoid social situations or have GI complaints. "There's usually underlying psychopathology in that family," Dr. Kwong said.

Although scalp hair is the most common target, hair-pulling may focus on any hairy parts of the body, including eyelashes, eyebrows, or hair in pubic, perirectal, or armpit areas. "I see a lot of kids who pull their eyelashes. Eyebrows, not as much," she said.

In young children, treat trichotillomania as a short-term habit disorder by cutting the hair very short (like a crew cut in boys) and applying Vaseline to the hair. "They stop their habit right away because it's so slippery they can't pull," Dr. Kwong said.

Referral to psychiatry, psychology, or developmental and behavioral pediatrics should be considered, especially in patients older than young children. Trichotillomania has been associated with obsessive control disorder, personality disorders, body dysmorphic disorder, schizophrenia, and mental retardation.

Occasionally, people with trichotillomania compulsively pull hair from other people or pets, she added.

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

SAN FRANCISCO — Few patients will admit that they compulsively pull out their hair, but a hair biopsy can help make the diagnosis of trichotillomania, Dr. Pearl C. Kwong said at a meeting sponsored by Skin Disease Education Foundation.

Clinically, the missing hair may be barely noticeable or may show signs of regrowth, such as uneven hair lengths. In contrast, hairs lost from alopecia areata will be approximately the same length if they regrow. If a patient picks hair from a favored area of the scalp, a "Friar Tuck" sign can be a clue to trichotillomania, she said. Patients usually have no skin abnormalities elsewhere.

Both children and adults with this impulse control disorder typically deny hair-pulling, and parents may be unwilling to accept a possible diagnosis of trichotillomania, said Dr. Kwong, a dermatologist in Jacksonville, Fla.

She recalled one girl who tried to hide her hair-pulling habit by eating the pulled hairs, which caused a bowel obstruction that required surgery. "To the end, the patient was denying that she ate her hair. The evidence was there in the bowel," Dr. Kwong said.

A hair biopsy can help with diagnosis. On histology, a high frequency of telogen hairs and a high frequency of noninflamed catagen hairs are typical of trichotillomania.

Accurate data on the prevalence of trichotillomania are hard to get because people hide the disorder, but it is estimated to affect 8 million people in the United States. The mean age of onset seems to be 8 years in boys and 12 years in girls, and 1%–2% of college students have experienced or currently have symptoms. Adults with trichotillomania often report that the disorder started at a young age, even as young as 1 year old, and it is more likely to be diagnosed in women than in men.

In infants or young children, pulling or twisting the hair usually is self-limited and is a benign form of trichotillomania. It may be a sign of psychosocial stress or an underlying psychological problem, however, and can become a chronic condition.

Adolescents and adults diagnosed with trichotillomania tend to have a poorer prognosis, with chronic remissions and exacerbations. Patients may avoid social situations or have GI complaints. "There's usually underlying psychopathology in that family," Dr. Kwong said.

Although scalp hair is the most common target, hair-pulling may focus on any hairy parts of the body, including eyelashes, eyebrows, or hair in pubic, perirectal, or armpit areas. "I see a lot of kids who pull their eyelashes. Eyebrows, not as much," she said.

In young children, treat trichotillomania as a short-term habit disorder by cutting the hair very short (like a crew cut in boys) and applying Vaseline to the hair. "They stop their habit right away because it's so slippery they can't pull," Dr. Kwong said.

Referral to psychiatry, psychology, or developmental and behavioral pediatrics should be considered, especially in patients older than young children. Trichotillomania has been associated with obsessive control disorder, personality disorders, body dysmorphic disorder, schizophrenia, and mental retardation.

Occasionally, people with trichotillomania compulsively pull hair from other people or pets, she added.

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

SAN FRANCISCO — Few patients will admit that they compulsively pull out their hair, but a hair biopsy can help make the diagnosis of trichotillomania, Dr. Pearl C. Kwong said at a meeting sponsored by Skin Disease Education Foundation.

Clinically, the missing hair may be barely noticeable or may show signs of regrowth, such as uneven hair lengths. In contrast, hairs lost from alopecia areata will be approximately the same length if they regrow. If a patient picks hair from a favored area of the scalp, a "Friar Tuck" sign can be a clue to trichotillomania, she said. Patients usually have no skin abnormalities elsewhere.

Both children and adults with this impulse control disorder typically deny hair-pulling, and parents may be unwilling to accept a possible diagnosis of trichotillomania, said Dr. Kwong, a dermatologist in Jacksonville, Fla.

She recalled one girl who tried to hide her hair-pulling habit by eating the pulled hairs, which caused a bowel obstruction that required surgery. "To the end, the patient was denying that she ate her hair. The evidence was there in the bowel," Dr. Kwong said.

A hair biopsy can help with diagnosis. On histology, a high frequency of telogen hairs and a high frequency of noninflamed catagen hairs are typical of trichotillomania.

Accurate data on the prevalence of trichotillomania are hard to get because people hide the disorder, but it is estimated to affect 8 million people in the United States. The mean age of onset seems to be 8 years in boys and 12 years in girls, and 1%–2% of college students have experienced or currently have symptoms. Adults with trichotillomania often report that the disorder started at a young age, even as young as 1 year old, and it is more likely to be diagnosed in women than in men.

In infants or young children, pulling or twisting the hair usually is self-limited and is a benign form of trichotillomania. It may be a sign of psychosocial stress or an underlying psychological problem, however, and can become a chronic condition.

Adolescents and adults diagnosed with trichotillomania tend to have a poorer prognosis, with chronic remissions and exacerbations. Patients may avoid social situations or have GI complaints. "There's usually underlying psychopathology in that family," Dr. Kwong said.

Although scalp hair is the most common target, hair-pulling may focus on any hairy parts of the body, including eyelashes, eyebrows, or hair in pubic, perirectal, or armpit areas. "I see a lot of kids who pull their eyelashes. Eyebrows, not as much," she said.

In young children, treat trichotillomania as a short-term habit disorder by cutting the hair very short (like a crew cut in boys) and applying Vaseline to the hair. "They stop their habit right away because it's so slippery they can't pull," Dr. Kwong said.

Referral to psychiatry, psychology, or developmental and behavioral pediatrics should be considered, especially in patients older than young children. Trichotillomania has been associated with obsessive control disorder, personality disorders, body dysmorphic disorder, schizophrenia, and mental retardation.

Occasionally, people with trichotillomania compulsively pull hair from other people or pets, she added.

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

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, advises Dr. Jeffrey L. Brown of the Cornell University Medical School in New York.

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, Dr. 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 also 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 to ask whether you 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.

Or, physicians may want to look into the Academy's partnership with Medem (www.medem.com

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.” Other versions of disclaimers should be available from your attorney.

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.”

Rx for Security: E-Mail Don'ts

Dr. Brown has the following trouble-avoiding tips:

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

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

▸ 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 indiscrete topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line.” 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.”

▸ 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, advises Dr. Jeffrey L. Brown of the Cornell University Medical School in New York.

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, Dr. 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 also 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 to ask whether you 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.

Or, physicians may want to look into the Academy's partnership with Medem (www.medem.com

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.” Other versions of disclaimers should be available from your attorney.

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.”

Rx for Security: E-Mail Don'ts

Dr. Brown has the following trouble-avoiding tips:

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

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

▸ 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 indiscrete topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line.” 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.”

▸ 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, advises Dr. Jeffrey L. Brown of the Cornell University Medical School in New York.

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, Dr. 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 also 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 to ask whether you 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.

Or, physicians may want to look into the Academy's partnership with Medem (www.medem.com

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.” Other versions of disclaimers should be available from your attorney.

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.”

Rx for Security: E-Mail Don'ts

Dr. Brown has the following trouble-avoiding tips:

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

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

▸ 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 indiscrete topic in the heading of your response. “Don't write, 'Your pregnancy test is positive' in the subject line.” 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.”

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

Source: Dr. Jeffrey L. Brown

SAN FRANCISCO — There's a product niche waiting to be filled, one that might save a life during postpartum hemorrhage.

Health care providers consistently underestimate the amount of postpartum blood loss, and adding calibrations to vaginal delivery drapes could improve blood loss estimates, results of a randomized crossover study suggest.

Participants who viewed calibrated delivery drapes and then were asked to estimate the amount of blood in uncalibrated drapes reduced the error in their estimates from more than 30% to less than 10% for the highest volumes of blood, Robert J. McCarthy, Pharm.D., said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

There are no vaginal delivery drapes on the market calibrated to indicate the amount of blood loss, added Dr. McCarthy of Northwestern University, Chicago. “It's time consuming to go through and set these up [individually],” he said. If such a product became available, it “could prevent delay in diagnosis and treatment of postpartum hemorrhage.”

The investigators asked 42 obstetricians, 21 nurses, and 43 anesthesiologists to estimate blood loss at eight mock vaginal delivery stations, four with uncalibrated delivery drapes and four with drapes that were marked at 500-mL increments up to 2,500 mL.

Each set of delivery drapes contained expired packed red blood cells diluted to a hematocrit of 33%, in volumes of 300, 500, 1,000, or 2,000 mL, plus 100 mL of urine and 5, 10, or 15 surgical sponges.

Subjects were randomized to view the calibrated or uncalibrated drapes first, then crossed over to the other group of stations.

Viewing the uncalibrated drapes first produced greater underestimates of blood loss that worsened with larger volumes of blood loss, reported Dr. McCarthy, lead investigator Dr. Paloma Toledo, and their associates. All the authors are from Northwestern University.

Errors by those who first viewed uncalibrated drapes ranged from a 16% underestimate of the 300-mL blood volume to a 41% underestimate of the 2000-mL volume.

Subjects who first viewed the calibrated drapes underestimated volumes in the uncalibrated drapes by less than 15%.

The results did not differ by the type of health care provider, the level of training, or number of years of experience.

A previous study reported that estimates of postpartum blood loss based on visual assessment underestimated blood loss by 33%–50% compared with photospectrometry, “which is the gold standard for this,” Dr. McCarthy said (Int. J. Gynecol. Obstet. 2006;93:220–4).

“They used smaller amounts of blood loss—300 mL as their top volume—while we used volumes that were more likely to be clinically important and need some kind of intervention.”

Another previous study reported that estimates of blood loss worsen with increasing volumes of blood loss (Int. J. Gynecol. Obstet. 2000;71:69–70).

Blood loss greater than 500 mL after vaginal delivery (postpartum hemorrhage) is a major cause of maternal morbidity and mortality.

SAN FRANCISCO — There's a product niche waiting to be filled, one that might save a life during postpartum hemorrhage.

Health care providers consistently underestimate the amount of postpartum blood loss, and adding calibrations to vaginal delivery drapes could improve blood loss estimates, results of a randomized crossover study suggest.

Participants who viewed calibrated delivery drapes and then were asked to estimate the amount of blood in uncalibrated drapes reduced the error in their estimates from more than 30% to less than 10% for the highest volumes of blood, Robert J. McCarthy, Pharm.D., said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

There are no vaginal delivery drapes on the market calibrated to indicate the amount of blood loss, added Dr. McCarthy of Northwestern University, Chicago. “It's time consuming to go through and set these up [individually],” he said. If such a product became available, it “could prevent delay in diagnosis and treatment of postpartum hemorrhage.”

The investigators asked 42 obstetricians, 21 nurses, and 43 anesthesiologists to estimate blood loss at eight mock vaginal delivery stations, four with uncalibrated delivery drapes and four with drapes that were marked at 500-mL increments up to 2,500 mL.

Each set of delivery drapes contained expired packed red blood cells diluted to a hematocrit of 33%, in volumes of 300, 500, 1,000, or 2,000 mL, plus 100 mL of urine and 5, 10, or 15 surgical sponges.

Subjects were randomized to view the calibrated or uncalibrated drapes first, then crossed over to the other group of stations.

Viewing the uncalibrated drapes first produced greater underestimates of blood loss that worsened with larger volumes of blood loss, reported Dr. McCarthy, lead investigator Dr. Paloma Toledo, and their associates. All the authors are from Northwestern University.

Errors by those who first viewed uncalibrated drapes ranged from a 16% underestimate of the 300-mL blood volume to a 41% underestimate of the 2000-mL volume.

Subjects who first viewed the calibrated drapes underestimated volumes in the uncalibrated drapes by less than 15%.

The results did not differ by the type of health care provider, the level of training, or number of years of experience.

A previous study reported that estimates of postpartum blood loss based on visual assessment underestimated blood loss by 33%–50% compared with photospectrometry, “which is the gold standard for this,” Dr. McCarthy said (Int. J. Gynecol. Obstet. 2006;93:220–4).

“They used smaller amounts of blood loss—300 mL as their top volume—while we used volumes that were more likely to be clinically important and need some kind of intervention.”

Another previous study reported that estimates of blood loss worsen with increasing volumes of blood loss (Int. J. Gynecol. Obstet. 2000;71:69–70).

Blood loss greater than 500 mL after vaginal delivery (postpartum hemorrhage) is a major cause of maternal morbidity and mortality.

SAN FRANCISCO — There's a product niche waiting to be filled, one that might save a life during postpartum hemorrhage.

Health care providers consistently underestimate the amount of postpartum blood loss, and adding calibrations to vaginal delivery drapes could improve blood loss estimates, results of a randomized crossover study suggest.

Participants who viewed calibrated delivery drapes and then were asked to estimate the amount of blood in uncalibrated drapes reduced the error in their estimates from more than 30% to less than 10% for the highest volumes of blood, Robert J. McCarthy, Pharm.D., said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

There are no vaginal delivery drapes on the market calibrated to indicate the amount of blood loss, added Dr. McCarthy of Northwestern University, Chicago. “It's time consuming to go through and set these up [individually],” he said. If such a product became available, it “could prevent delay in diagnosis and treatment of postpartum hemorrhage.”

The investigators asked 42 obstetricians, 21 nurses, and 43 anesthesiologists to estimate blood loss at eight mock vaginal delivery stations, four with uncalibrated delivery drapes and four with drapes that were marked at 500-mL increments up to 2,500 mL.

Each set of delivery drapes contained expired packed red blood cells diluted to a hematocrit of 33%, in volumes of 300, 500, 1,000, or 2,000 mL, plus 100 mL of urine and 5, 10, or 15 surgical sponges.

Subjects were randomized to view the calibrated or uncalibrated drapes first, then crossed over to the other group of stations.

Viewing the uncalibrated drapes first produced greater underestimates of blood loss that worsened with larger volumes of blood loss, reported Dr. McCarthy, lead investigator Dr. Paloma Toledo, and their associates. All the authors are from Northwestern University.

Errors by those who first viewed uncalibrated drapes ranged from a 16% underestimate of the 300-mL blood volume to a 41% underestimate of the 2000-mL volume.

Subjects who first viewed the calibrated drapes underestimated volumes in the uncalibrated drapes by less than 15%.

The results did not differ by the type of health care provider, the level of training, or number of years of experience.

A previous study reported that estimates of postpartum blood loss based on visual assessment underestimated blood loss by 33%–50% compared with photospectrometry, “which is the gold standard for this,” Dr. McCarthy said (Int. J. Gynecol. Obstet. 2006;93:220–4).

“They used smaller amounts of blood loss—300 mL as their top volume—while we used volumes that were more likely to be clinically important and need some kind of intervention.”

Another previous study reported that estimates of blood loss worsen with increasing volumes of blood loss (Int. J. Gynecol. Obstet. 2000;71:69–70).

Blood loss greater than 500 mL after vaginal delivery (postpartum hemorrhage) is a major cause of maternal morbidity and mortality.

SAN FRANCISCO – While scanning the acquired moles on the skin of a child, consider whether individual moles look like they are part of a pack or if there is one that stands out–“the ugly duckling,” Dr. Lawrence F. Eichenfield advised.

Mild variations in nevi are okay if several nevi look the same, but when there are many mildly atypical nevi, look for an atypically atypical lesion, Dr. Eichenfield said at a conference on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

In children, the asymmetry (A) and border irregularity (B) tend to be the most useful of the ABCDEs in identifying worrisome changes in nevi. “That makes sense because what you're looking for is uncontrolled growth–looking for one part of the mole doing something different from the other part,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego.

Remember the other ABCDEs of worrisome changes in nevi as well–color irregularity (C), diameter larger than 5 mm (D), and elevation (E). Teens can develop symmetric, two-toned moles that are no cause for alarm but simply a sign of evolution. Dysplastic nevi can be found in sun-exposed areas, but also on the scalp, buttocks, or other sun-protected sites.

Frequently, atypical nevi have a macular component, which gives them a pebbly or fried-egg appearance, he noted. Benign scalp nevi, too, often look like fried eggs.

Finding a truly atypical nevus necessitates specialist review. Be alert for children with atypical moles and two immediate family members with a history of melanoma. Ten percent of these children will develop melanoma before age 20, and 80%-90% will develop melanoma in their lifetimes. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO – While scanning the acquired moles on the skin of a child, consider whether individual moles look like they are part of a pack or if there is one that stands out–“the ugly duckling,” Dr. Lawrence F. Eichenfield advised.

Mild variations in nevi are okay if several nevi look the same, but when there are many mildly atypical nevi, look for an atypically atypical lesion, Dr. Eichenfield said at a conference on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

In children, the asymmetry (A) and border irregularity (B) tend to be the most useful of the ABCDEs in identifying worrisome changes in nevi. “That makes sense because what you're looking for is uncontrolled growth–looking for one part of the mole doing something different from the other part,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego.

Remember the other ABCDEs of worrisome changes in nevi as well–color irregularity (C), diameter larger than 5 mm (D), and elevation (E). Teens can develop symmetric, two-toned moles that are no cause for alarm but simply a sign of evolution. Dysplastic nevi can be found in sun-exposed areas, but also on the scalp, buttocks, or other sun-protected sites.

Frequently, atypical nevi have a macular component, which gives them a pebbly or fried-egg appearance, he noted. Benign scalp nevi, too, often look like fried eggs.

Finding a truly atypical nevus necessitates specialist review. Be alert for children with atypical moles and two immediate family members with a history of melanoma. Ten percent of these children will develop melanoma before age 20, and 80%-90% will develop melanoma in their lifetimes. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO – While scanning the acquired moles on the skin of a child, consider whether individual moles look like they are part of a pack or if there is one that stands out–“the ugly duckling,” Dr. Lawrence F. Eichenfield advised.

Mild variations in nevi are okay if several nevi look the same, but when there are many mildly atypical nevi, look for an atypically atypical lesion, Dr. Eichenfield said at a conference on women's and pediatric dermatology sponsored by Skin Disease Education Foundation.

In children, the asymmetry (A) and border irregularity (B) tend to be the most useful of the ABCDEs in identifying worrisome changes in nevi. “That makes sense because what you're looking for is uncontrolled growth–looking for one part of the mole doing something different from the other part,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at the University of California, San Diego.

Remember the other ABCDEs of worrisome changes in nevi as well–color irregularity (C), diameter larger than 5 mm (D), and elevation (E). Teens can develop symmetric, two-toned moles that are no cause for alarm but simply a sign of evolution. Dysplastic nevi can be found in sun-exposed areas, but also on the scalp, buttocks, or other sun-protected sites.

Frequently, atypical nevi have a macular component, which gives them a pebbly or fried-egg appearance, he noted. Benign scalp nevi, too, often look like fried eggs.

Finding a truly atypical nevus necessitates specialist review. Be alert for children with atypical moles and two immediate family members with a history of melanoma. Ten percent of these children will develop melanoma before age 20, and 80%-90% will develop melanoma in their lifetimes. SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO – A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as “fish tank granuloma,” said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1-4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank.

“Apparently, this was his favorite job, so he had done it multiple times in the weeks before he broke out in these lesions,” giving M. marinum an inoculation pathway through the boy's eczematous lesions.

M. marinum infects fish and amphibians. “You also can get this infection from swimming in pools and in natural bodies of water,” she said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. It is more a disease of adults (typically farmers and gardeners) than of children, with a history of skin trauma in 10%-60% of cases. A history of travel may suggest Leishmania, a parasite.

Providers also should consider Staphylococcus aureus infection, which most commonly causes pustular, draining lesions but rarely can cause granulomatous disease that looks like M. marinum.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. “There aren't really good guidelines” on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients). One to two months of treatment may suffice. In rare cases, surgery may be needed to remove infected tissue.

SAN FRANCISCO – A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as “fish tank granuloma,” said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1-4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank.

“Apparently, this was his favorite job, so he had done it multiple times in the weeks before he broke out in these lesions,” giving M. marinum an inoculation pathway through the boy's eczematous lesions.

M. marinum infects fish and amphibians. “You also can get this infection from swimming in pools and in natural bodies of water,” she said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. It is more a disease of adults (typically farmers and gardeners) than of children, with a history of skin trauma in 10%-60% of cases. A history of travel may suggest Leishmania, a parasite.

Providers also should consider Staphylococcus aureus infection, which most commonly causes pustular, draining lesions but rarely can cause granulomatous disease that looks like M. marinum.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. “There aren't really good guidelines” on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients). One to two months of treatment may suffice. In rare cases, surgery may be needed to remove infected tissue.

SAN FRANCISCO – A water-borne mycobacterium that infects humans through breaks in the skin causes lesions that easily are mistaken for staphylococcal infection, Dr. Peggy Weintrub said at the annual meeting of the American Academy of Pediatrics.

Mycobacterium marinum infection causes what's commonly known as “fish tank granuloma,” said Dr. Weintrub, chief of pediatric infectious diseases at the University of California, San Francisco. Lesions typically appear 1-4 weeks after exposure and start out as little papules and nodules that can be misdiagnosed as a staph infection. Later, however, they become verrucous, plaquelike lesions that start spreading up the skin along lymphatic tracts.

She described a case in a 3-year-old boy who presented with mild eczema and some other long-standing, crusting lesions on his hand and arm that were spreading up the arm lymphocutaneously. The lesions had not responded to previous treatment with cephalexin. A previous culture from the lesions did grow some staphylococcal organisms, but two additional courses of antibiotics did not affect the lesions.

The boy was afebrile and systemically well, and had an infant sibling at home with no lesions.

The patient's history helped point toward M. marinum. The boy liked to be helpful, assisting his mother with the baby and helping his father with anything and everything, including gardening and cleaning the family's fish tank.

“Apparently, this was his favorite job, so he had done it multiple times in the weeks before he broke out in these lesions,” giving M. marinum an inoculation pathway through the boy's eczematous lesions.

M. marinum infects fish and amphibians. “You also can get this infection from swimming in pools and in natural bodies of water,” she said.

If a lesion is oozing, the secretions can be cultured for M. marinum. A skin biopsy from the boy grew the organism. Histopathology will show granulomas. Patients with the infection often are purified protein derivative (PPD) positive.

Patient history also can help sort through the differential diagnoses. A history of gardening raises the possibility of Sporothrix schenckii infection, which produces lesions that look very similar to M. marinum lesions, with a lymphocutaneous spread. It is more a disease of adults (typically farmers and gardeners) than of children, with a history of skin trauma in 10%-60% of cases. A history of travel may suggest Leishmania, a parasite.

Providers also should consider Staphylococcus aureus infection, which most commonly causes pustular, draining lesions but rarely can cause granulomatous disease that looks like M. marinum.

Usually two or three drugs are used to treat M. marinum infection, although no controlled studies back these strategies. “There aren't really good guidelines” on which drugs to use or for how long, she said. Regimens may include clarithromycin or azithromycin, ethambutol, rifampin, and/or minocycline or doxycycline (for older patients). One to two months of treatment may suffice. In rare cases, surgery may be needed to remove infected tissue.