Sherry Boschert

SAN FRANCISCO – Family physicians and pediatricians could polish their communication skills when talking to parents who are reluctant to immunize their children, judging by results of one of the first observational studies of these encounters in private practice.

A pilot study recruited seven pediatricians and two family physicians in Louisville, Ky., for a “field test” of using “standardized patients” in primary care practice settings, Dr. Kristina Bryant said at the annual meeting of the American Academy of Pediatrics. Standardized patients are actors or actresses who are trained to portray patients and are commonly used in medical schools to help teach and test students, explained Dr. Bryant of the University of Louisville (Ky.). Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

In presenting to the physicians, the actresses pretended to be pregnant women looking for a pediatrician. Each woman said that she didn't want to immunize her child because she believed the MMR vaccine causes autism and the varicella vaccine causes neurologic damage. She also said that too many vaccines overload the immune system, that the AAP and the Centers for Disease Control and Prevention are not truthful.

The standardized patients graded physicians after each encounter and four encounters were recorded. Among the four physicians who were recorded, only three discussed the risks and benefits of vaccines, and only two presented evidence to refute the mother's claims that MMR causes autism or that thimerosal is dangerous. Two referred mothers to the AAP and CDC Web sites for more information, and two offered to delay some vaccines–a strategy recommended by the AAP when dealing with reluctant parents. None explored cost as a potential barrier to immunization. Two physicians gave inaccurate information. One said he would have to contact Child Protective Services if the mother refused to vaccinate her child. The other said that the child could not attend public school unless immunized, but Kentucky allows religious exemptions.

“The plus side is that none of these physicians refused to care for this family if the mother refused immunizations, and [all] talked about its being addressed at future visits,” Dr. Bryant said.

To Do List When Shots Are Snubbed

As many as 70% of pediatricians each year may encounter patients who refuse one or more vaccinations for their children, a 2001 survey of pediatric fellows suggested. The AAP recommends the following steps in these encounters (Pediatrics 2005;115:1428-31):

▸ Listen to parents' concerns and try to understand them. Tell them the risks and benefits of immunizations, and correct parents' misconceptions.

▸ Take steps to reduce the pain of injection.

▸ Consider an alternative vaccination schedule that minimizes the number of injections at each visit, if that's a concern of parents.

▸ Explore cost as a barrier.

▸ Document vaccine refusal.

▸ If possible, avoid discharging vaccine refusers from your practice.

SAN FRANCISCO – Family physicians and pediatricians could polish their communication skills when talking to parents who are reluctant to immunize their children, judging by results of one of the first observational studies of these encounters in private practice.

A pilot study recruited seven pediatricians and two family physicians in Louisville, Ky., for a “field test” of using “standardized patients” in primary care practice settings, Dr. Kristina Bryant said at the annual meeting of the American Academy of Pediatrics. Standardized patients are actors or actresses who are trained to portray patients and are commonly used in medical schools to help teach and test students, explained Dr. Bryant of the University of Louisville (Ky.). Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

In presenting to the physicians, the actresses pretended to be pregnant women looking for a pediatrician. Each woman said that she didn't want to immunize her child because she believed the MMR vaccine causes autism and the varicella vaccine causes neurologic damage. She also said that too many vaccines overload the immune system, that the AAP and the Centers for Disease Control and Prevention are not truthful.

The standardized patients graded physicians after each encounter and four encounters were recorded. Among the four physicians who were recorded, only three discussed the risks and benefits of vaccines, and only two presented evidence to refute the mother's claims that MMR causes autism or that thimerosal is dangerous. Two referred mothers to the AAP and CDC Web sites for more information, and two offered to delay some vaccines–a strategy recommended by the AAP when dealing with reluctant parents. None explored cost as a potential barrier to immunization. Two physicians gave inaccurate information. One said he would have to contact Child Protective Services if the mother refused to vaccinate her child. The other said that the child could not attend public school unless immunized, but Kentucky allows religious exemptions.

“The plus side is that none of these physicians refused to care for this family if the mother refused immunizations, and [all] talked about its being addressed at future visits,” Dr. Bryant said.

To Do List When Shots Are Snubbed

As many as 70% of pediatricians each year may encounter patients who refuse one or more vaccinations for their children, a 2001 survey of pediatric fellows suggested. The AAP recommends the following steps in these encounters (Pediatrics 2005;115:1428-31):

▸ Listen to parents' concerns and try to understand them. Tell them the risks and benefits of immunizations, and correct parents' misconceptions.

▸ Take steps to reduce the pain of injection.

▸ Consider an alternative vaccination schedule that minimizes the number of injections at each visit, if that's a concern of parents.

▸ Explore cost as a barrier.

▸ Document vaccine refusal.

▸ If possible, avoid discharging vaccine refusers from your practice.

SAN FRANCISCO – Family physicians and pediatricians could polish their communication skills when talking to parents who are reluctant to immunize their children, judging by results of one of the first observational studies of these encounters in private practice.

A pilot study recruited seven pediatricians and two family physicians in Louisville, Ky., for a “field test” of using “standardized patients” in primary care practice settings, Dr. Kristina Bryant said at the annual meeting of the American Academy of Pediatrics. Standardized patients are actors or actresses who are trained to portray patients and are commonly used in medical schools to help teach and test students, explained Dr. Bryant of the University of Louisville (Ky.). Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.

In presenting to the physicians, the actresses pretended to be pregnant women looking for a pediatrician. Each woman said that she didn't want to immunize her child because she believed the MMR vaccine causes autism and the varicella vaccine causes neurologic damage. She also said that too many vaccines overload the immune system, that the AAP and the Centers for Disease Control and Prevention are not truthful.

The standardized patients graded physicians after each encounter and four encounters were recorded. Among the four physicians who were recorded, only three discussed the risks and benefits of vaccines, and only two presented evidence to refute the mother's claims that MMR causes autism or that thimerosal is dangerous. Two referred mothers to the AAP and CDC Web sites for more information, and two offered to delay some vaccines–a strategy recommended by the AAP when dealing with reluctant parents. None explored cost as a potential barrier to immunization. Two physicians gave inaccurate information. One said he would have to contact Child Protective Services if the mother refused to vaccinate her child. The other said that the child could not attend public school unless immunized, but Kentucky allows religious exemptions.

“The plus side is that none of these physicians refused to care for this family if the mother refused immunizations, and [all] talked about its being addressed at future visits,” Dr. Bryant said.

To Do List When Shots Are Snubbed

As many as 70% of pediatricians each year may encounter patients who refuse one or more vaccinations for their children, a 2001 survey of pediatric fellows suggested. The AAP recommends the following steps in these encounters (Pediatrics 2005;115:1428-31):

▸ Listen to parents' concerns and try to understand them. Tell them the risks and benefits of immunizations, and correct parents' misconceptions.

▸ Take steps to reduce the pain of injection.

▸ Consider an alternative vaccination schedule that minimizes the number of injections at each visit, if that's a concern of parents.

▸ Explore cost as a barrier.

▸ Document vaccine refusal.

▸ If possible, avoid discharging vaccine refusers from your practice.

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

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

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

A positive hepatitis B surface antigen (HBsAg) test indicates that the patient is acutely or chronically infected and is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or immunity from recovering from an acute infection. False-positive cases are very rare.

The meaning of a positive hepatitis B core antibody (HBcAb) test depends on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus.

Dr. Tan suggested a three-step process for initial interpretation of the panel of tests:

▸ If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B.

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

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

A fourth test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have high concentrations of hepatitis B viral DNA and are at high risk of transmitting the infection. The tests may need to be repeated over time to assess the patient's status.

ELSEVIER GLOBAL MEDICAL NEWS

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

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

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

A positive hepatitis B surface antigen (HBsAg) test indicates that the patient is acutely or chronically infected and is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or immunity from recovering from an acute infection. False-positive cases are very rare.

The meaning of a positive hepatitis B core antibody (HBcAb) test depends on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus.

Dr. Tan suggested a three-step process for initial interpretation of the panel of tests:

▸ If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B.

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

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

A fourth test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have high concentrations of hepatitis B viral DNA and are at high risk of transmitting the infection. The tests may need to be repeated over time to assess the patient's status.

ELSEVIER GLOBAL MEDICAL NEWS

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

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

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

A positive hepatitis B surface antigen (HBsAg) test indicates that the patient is acutely or chronically infected and is immune to the hepatitis B virus or to infection with the virus, either because of vaccination or immunity from recovering from an acute infection. False-positive cases are very rare.

The meaning of a positive hepatitis B core antibody (HBcAb) test depends on the type of antibody. A patient who is IgM positive has recently been infected with the hepatitis B virus. Positivity to IgG antibody could indicate a past infection or a chronic infection with hepatitis B virus.

Dr. Tan suggested a three-step process for initial interpretation of the panel of tests:

▸ If the HBsAg is negative and the HBsAb is positive, then the patient is immune to hepatitis B.

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

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

A fourth test, for hepatitis B “e” antigen (HBeAg), is a marker of infectiousness. People with HBeAg have high concentrations of hepatitis B viral DNA and are at high risk of transmitting the infection. The tests may need to be repeated over time to assess the patient's status.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and they postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley said in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient … may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse [present].”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and “do not resuscitate” orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, noted Dr. Kelley and her associates. Overall, 21% expressed a preference for further medical treatments over deactivation of the ICD.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“I want [a patient or the family] to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked,” Dr. Kelley said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. Most (58%) said guidance from experts about managing patients with ICDs would be helpful in their practices. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of the 558 surveyed physicians would discuss ICD deactivation, advance directives, or do not resuscitate (DNR) orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical appointments and tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family has requested ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO – One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and they postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley said in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient … may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse [present].”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and “do not resuscitate” orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, noted Dr. Kelley and her associates. Overall, 21% expressed a preference for further medical treatments over deactivation of the ICD.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“I want [a patient or the family] to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked,” Dr. Kelley said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. Most (58%) said guidance from experts about managing patients with ICDs would be helpful in their practices. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of the 558 surveyed physicians would discuss ICD deactivation, advance directives, or do not resuscitate (DNR) orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical appointments and tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family has requested ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO – One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and they postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley said in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient … may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse [present].”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and “do not resuscitate” orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, noted Dr. Kelley and her associates. Overall, 21% expressed a preference for further medical treatments over deactivation of the ICD.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“I want [a patient or the family] to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked,” Dr. Kelley said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. Most (58%) said guidance from experts about managing patients with ICDs would be helpful in their practices. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of the 558 surveyed physicians would discuss ICD deactivation, advance directives, or do not resuscitate (DNR) orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical appointments and tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family has requested ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO — One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley reported in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient—internists and palliative care physicians—may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse.”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and do not resuscitate (DNR) orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, reported Dr. Kelley and her associates. Overall, 21% of the commenters expressed a preference for further medical treatments (including medications, devices, and procedures) over ICD deactivation.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“As a geriatrician and a primary care provider, if I'm ready to discuss other end-of-life topics with a patient or with the family, this would be on my list of things to discuss,” Dr. Kelley said. “I want them to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked.”

Data from a previous retrospective study that surveyed next of kin after a patient's death suggest that fewer than a fourth of ICDs get deactivated near the end of life, and then only after the patient suffered a painful shock from the device, she said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. A majority (58%) said that guidance from experts regarding management of patients with ICDs would be helpful. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

In two of the patient vignettes, physicians who said they had no religious affiliation were more likely to discuss ICD deactivation with patients.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of 558 surveyed physicians would discuss ICD deactivation, advance directives, or DNR orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family requests ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO — One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley reported in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient—internists and palliative care physicians—may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse.”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and do not resuscitate (DNR) orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, reported Dr. Kelley and her associates. Overall, 21% of the commenters expressed a preference for further medical treatments (including medications, devices, and procedures) over ICD deactivation.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“As a geriatrician and a primary care provider, if I'm ready to discuss other end-of-life topics with a patient or with the family, this would be on my list of things to discuss,” Dr. Kelley said. “I want them to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked.”

Data from a previous retrospective study that surveyed next of kin after a patient's death suggest that fewer than a fourth of ICDs get deactivated near the end of life, and then only after the patient suffered a painful shock from the device, she said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. A majority (58%) said that guidance from experts regarding management of patients with ICDs would be helpful. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

In two of the patient vignettes, physicians who said they had no religious affiliation were more likely to discuss ICD deactivation with patients.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of 558 surveyed physicians would discuss ICD deactivation, advance directives, or DNR orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family requests ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO — One reason that few implantable cardioverter defibrillators get shut off to prevent a painful, unnecessary shock near the end of a patient's life is that physicians disagree about who should begin the deactivation discussion, Dr. Amy S. Kelley said.

In addition, some physicians prefer further aggressive medical treatments and postpone discussing deactivation of implantable cardioverter defibrillators (ICDs), according to a survey mailed to 4,876 physicians and completed by 558. Inadequate knowledge about or awareness of ICDs also contributed to physicians' lack of attention to the issue, Dr. Kelley reported in a poster presentation at the annual meeting of the Gerontological Society of America.

“People at the bedside caring for a dying patient—internists and palliative care physicians—may not be familiar with how the ICD works, and the fact that they are very easy to deactivate,” said Dr. Kelley of the University of California, Los Angeles. “Even if it's functioning as a pacemaker, the shut-off function is entirely separate and could be deactivated in a moment's time at the bedside with a magnet and an electrophysiologist or even a nurse.”

The 96 general internists, 106 cardiologists, 163 geriatricians, and 193 electrophysiologists surveyed were asked if they would discuss ICD deactivation, advance directives, and do not resuscitate (DNR) orders with terminally ill patients described in five vignettes. (See box.) The survey also solicited comments, and investigators analyzed 310 comments provided by 177 physicians to identify recurrent themes.

Of the 177 who commented, 6% said they had never thought about deactivating an ICD, 2% were unaware of the separate pacer and defibrillator functions, and 1% declared a lack of knowledge about defibrillators, reported Dr. Kelley and her associates. Overall, 21% of the commenters expressed a preference for further medical treatments (including medications, devices, and procedures) over ICD deactivation.

Of the 177, 13% accepted primary responsibility for initiating discussions about deactivating pacemakers, 10% said another specialist should start the discussion, and 7% said the patient or family should bring it up first.

“As a geriatrician and a primary care provider, if I'm ready to discuss other end-of-life topics with a patient or with the family, this would be on my list of things to discuss,” Dr. Kelley said. “I want them to know they have the option to possibly pass quietly from arrhythmia versus the possibility of being shocked.”

Data from a previous retrospective study that surveyed next of kin after a patient's death suggest that fewer than a fourth of ICDs get deactivated near the end of life, and then only after the patient suffered a painful shock from the device, she said.

Informed consent for ICD implantation should include information about deactivation options, 77% of physicians in the current survey agreed. A majority (58%) said that guidance from experts regarding management of patients with ICDs would be helpful. There are no guidelines for managing the deactivation of ICDs.

The study has been accepted for publication in the American Journal of Geriatric Cardiology, Dr. Kelley said.

In two of the patient vignettes, physicians who said they had no religious affiliation were more likely to discuss ICD deactivation with patients.

Most Physicians Willing to Talk

In the following scenarios, the percentages indicate how many of 558 surveyed physicians would discuss ICD deactivation, advance directives, or DNR orders with patients.

▸ A man with severe chronic obstructive pulmonary disease who reports a poor quality of life:

ICD deactivation: 56%

Advance directives: 88%

DNR: 82%

▸ A man with advanced dementia who is agitated by medical tests:

ICD deactivation: 71%

Advance directives: 84%

DNR: 84%

▸ A woman with stage IV ovarian cancer who requests palliative care:

ICD deactivation: 79%

Advance directives: 94%

DNR: 93%

▸ A man with end-stage renal failure who declines dialysis:

ICD deactivation: 76%

Advance directives: 90%

DNR: 90%

▸ A woman with a massive stroke whose family requests ventilator withdrawal:

ICD deactivation: 83%

Advance directives: 80%

DNR: 83%

SAN FRANCISCO — A surprisingly high 85% of older adults with hypertension, hyperglycemia, or hyperlipidemia reported engaging in lifestyle modifications, such as diet change or exercise, in a longitudinal study of 666 people, Eleanor M. Simonsick, Ph.D., said at the annual meeting of the Gerontological Society of America.

Patients who reported voluntary lifestyle modification generally weighed less, had less obesity, and exercised more than patients who denied lifestyle modification. The two groups did not differ, however, in measures of disease such as blood pressure, hemoglobin A_1c values, and cholesterol levels, with the possible exception of triglyceride levels, reported Dr. Simonsick, an epidemiologist at the National Institute on Aging, Baltimore, and her associates.

Data from previous intervention studies suggest that people with these chronic diseases improve disease parameters through lifestyle modifications, “but these interventions are often very comprehensive and quite rigorous,” she said. Little is known about what people do on their own or how effective the changes may be.

“In terms of their specific conditions, it would appear that additional guidance is required” for voluntary lifestyle modification to improve health, she added.

On the plus side, the results refute the common notion that patients aren't interested in lifestyle modification, a misconception that dissuades many physicians from bringing up the subject, some surveys suggest. “I think that we should have more confidence in the patient population, that they may actually be receptive to lifestyle modification,” Dr. Simonsick said. Sociodemographic factors did not affect participation rates in lifestyle modification.

The study analyzed data from the Baltimore Longitudinal Study of Aging (BLSA), which performs 3-day examinations and surveys of participants every 1–4 years, depending on their age. Participants make the trip to Baltimore for these visits, so the study is skewed toward healthier, more highly educated adults, she acknowledged. The study's results are not representative of the general population, and probably represent the most positive outcomes one might expect to see in terms of effects from lifestyle modification, she said.

Patients in this analysis of visits during 2004 to 2007 had a mean age of 68 years. Half were women, 29% were black, and a majority had more than a college education.

Overall, 47% of participants reported being diagnosed with hypertension, 19% said they had been told they had either diabetes or high glucose levels, 56% said they had been diagnosed with hyperglycemia, and 23% had none of the above.

Among those with hypertension, 83% reported voluntary lifestyle modification, “which is a much higher number than we had expected,” Dr. Simonsick said. Of those who made lifestyle modifications, 90% were taking antihypertensive medication, compared with 91% who did not change their lifestyle.

The obesity rate in hypertensive patients was 31% with lifestyle modification and 65% without, a significant difference. There were no major differences between these groups in systolic or diastolic blood pressures—126/67 mm Hg in the lifestyle modification group, compared with 127/69 mm Hg in the others.

Among participants with hyperglycemia, 85% reported lifestyle modification, and these patients were significantly more likely to be on medication (48% vs. 22% of non-lifestyle modifiers). Fasting glucose levels were slightly higher in the lifestyle modification group than in other patients, but hemoglobin A_1c values were 6% in both groups.

The higher medication use and higher fasting glucose levels in the lifestyle modification group may be caused by a higher rate of diabetes rather than just hyperglycemia, compared with the non-lifestyle modification group, but the data couldn't show that explicitly, Dr. Simonsick said.

Among those with hyperlipidemia, 85% reported lifestyle modification, and 62% of these people were taking medication, compared with 54% of non-lifestyle modifiers (a nonsignificant difference).

Obesity rates were 26% in the lifestyle modifiers and 50% in non-lifestyle. Triglyceride levels also were significantly different between groups—though “not remarkably so,” she said—measuring 116 mg/dL in patients who pursued lifestyle modification, compared with 133 mg/dL in those who didn't.

SAN FRANCISCO — A surprisingly high 85% of older adults with hypertension, hyperglycemia, or hyperlipidemia reported engaging in lifestyle modifications, such as diet change or exercise, in a longitudinal study of 666 people, Eleanor M. Simonsick, Ph.D., said at the annual meeting of the Gerontological Society of America.

Patients who reported voluntary lifestyle modification generally weighed less, had less obesity, and exercised more than patients who denied lifestyle modification. The two groups did not differ, however, in measures of disease such as blood pressure, hemoglobin A_1c values, and cholesterol levels, with the possible exception of triglyceride levels, reported Dr. Simonsick, an epidemiologist at the National Institute on Aging, Baltimore, and her associates.

Data from previous intervention studies suggest that people with these chronic diseases improve disease parameters through lifestyle modifications, “but these interventions are often very comprehensive and quite rigorous,” she said. Little is known about what people do on their own or how effective the changes may be.

“In terms of their specific conditions, it would appear that additional guidance is required” for voluntary lifestyle modification to improve health, she added.

On the plus side, the results refute the common notion that patients aren't interested in lifestyle modification, a misconception that dissuades many physicians from bringing up the subject, some surveys suggest. “I think that we should have more confidence in the patient population, that they may actually be receptive to lifestyle modification,” Dr. Simonsick said. Sociodemographic factors did not affect participation rates in lifestyle modification.

The study analyzed data from the Baltimore Longitudinal Study of Aging (BLSA), which performs 3-day examinations and surveys of participants every 1–4 years, depending on their age. Participants make the trip to Baltimore for these visits, so the study is skewed toward healthier, more highly educated adults, she acknowledged. The study's results are not representative of the general population, and probably represent the most positive outcomes one might expect to see in terms of effects from lifestyle modification, she said.

Patients in this analysis of visits during 2004 to 2007 had a mean age of 68 years. Half were women, 29% were black, and a majority had more than a college education.

Overall, 47% of participants reported being diagnosed with hypertension, 19% said they had been told they had either diabetes or high glucose levels, 56% said they had been diagnosed with hyperglycemia, and 23% had none of the above.

Among those with hypertension, 83% reported voluntary lifestyle modification, “which is a much higher number than we had expected,” Dr. Simonsick said. Of those who made lifestyle modifications, 90% were taking antihypertensive medication, compared with 91% who did not change their lifestyle.

The obesity rate in hypertensive patients was 31% with lifestyle modification and 65% without, a significant difference. There were no major differences between these groups in systolic or diastolic blood pressures—126/67 mm Hg in the lifestyle modification group, compared with 127/69 mm Hg in the others.

Among participants with hyperglycemia, 85% reported lifestyle modification, and these patients were significantly more likely to be on medication (48% vs. 22% of non-lifestyle modifiers). Fasting glucose levels were slightly higher in the lifestyle modification group than in other patients, but hemoglobin A_1c values were 6% in both groups.

The higher medication use and higher fasting glucose levels in the lifestyle modification group may be caused by a higher rate of diabetes rather than just hyperglycemia, compared with the non-lifestyle modification group, but the data couldn't show that explicitly, Dr. Simonsick said.

Among those with hyperlipidemia, 85% reported lifestyle modification, and 62% of these people were taking medication, compared with 54% of non-lifestyle modifiers (a nonsignificant difference).

Obesity rates were 26% in the lifestyle modifiers and 50% in non-lifestyle. Triglyceride levels also were significantly different between groups—though “not remarkably so,” she said—measuring 116 mg/dL in patients who pursued lifestyle modification, compared with 133 mg/dL in those who didn't.

SAN FRANCISCO — A surprisingly high 85% of older adults with hypertension, hyperglycemia, or hyperlipidemia reported engaging in lifestyle modifications, such as diet change or exercise, in a longitudinal study of 666 people, Eleanor M. Simonsick, Ph.D., said at the annual meeting of the Gerontological Society of America.

Patients who reported voluntary lifestyle modification generally weighed less, had less obesity, and exercised more than patients who denied lifestyle modification. The two groups did not differ, however, in measures of disease such as blood pressure, hemoglobin A_1c values, and cholesterol levels, with the possible exception of triglyceride levels, reported Dr. Simonsick, an epidemiologist at the National Institute on Aging, Baltimore, and her associates.

Data from previous intervention studies suggest that people with these chronic diseases improve disease parameters through lifestyle modifications, “but these interventions are often very comprehensive and quite rigorous,” she said. Little is known about what people do on their own or how effective the changes may be.

“In terms of their specific conditions, it would appear that additional guidance is required” for voluntary lifestyle modification to improve health, she added.

On the plus side, the results refute the common notion that patients aren't interested in lifestyle modification, a misconception that dissuades many physicians from bringing up the subject, some surveys suggest. “I think that we should have more confidence in the patient population, that they may actually be receptive to lifestyle modification,” Dr. Simonsick said. Sociodemographic factors did not affect participation rates in lifestyle modification.

The study analyzed data from the Baltimore Longitudinal Study of Aging (BLSA), which performs 3-day examinations and surveys of participants every 1–4 years, depending on their age. Participants make the trip to Baltimore for these visits, so the study is skewed toward healthier, more highly educated adults, she acknowledged. The study's results are not representative of the general population, and probably represent the most positive outcomes one might expect to see in terms of effects from lifestyle modification, she said.

Patients in this analysis of visits during 2004 to 2007 had a mean age of 68 years. Half were women, 29% were black, and a majority had more than a college education.

Overall, 47% of participants reported being diagnosed with hypertension, 19% said they had been told they had either diabetes or high glucose levels, 56% said they had been diagnosed with hyperglycemia, and 23% had none of the above.

Among those with hypertension, 83% reported voluntary lifestyle modification, “which is a much higher number than we had expected,” Dr. Simonsick said. Of those who made lifestyle modifications, 90% were taking antihypertensive medication, compared with 91% who did not change their lifestyle.

The obesity rate in hypertensive patients was 31% with lifestyle modification and 65% without, a significant difference. There were no major differences between these groups in systolic or diastolic blood pressures—126/67 mm Hg in the lifestyle modification group, compared with 127/69 mm Hg in the others.

Among participants with hyperglycemia, 85% reported lifestyle modification, and these patients were significantly more likely to be on medication (48% vs. 22% of non-lifestyle modifiers). Fasting glucose levels were slightly higher in the lifestyle modification group than in other patients, but hemoglobin A_1c values were 6% in both groups.

The higher medication use and higher fasting glucose levels in the lifestyle modification group may be caused by a higher rate of diabetes rather than just hyperglycemia, compared with the non-lifestyle modification group, but the data couldn't show that explicitly, Dr. Simonsick said.

Among those with hyperlipidemia, 85% reported lifestyle modification, and 62% of these people were taking medication, compared with 54% of non-lifestyle modifiers (a nonsignificant difference).

Obesity rates were 26% in the lifestyle modifiers and 50% in non-lifestyle. Triglyceride levels also were significantly different between groups—though “not remarkably so,” she said—measuring 116 mg/dL in patients who pursued lifestyle modification, compared with 133 mg/dL in those who didn't.

SAN FRANCISCO — Girls may present with vulvovaginal skin problems that are seldom or never seen in women, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

Vulvovaginal aphthae, pseudowarts, and infantile labial agglutination are nearly unique to girls, she said.

Aphthae (canker sores) are extremely common painful lesions in the mouths of adults but seldom appear on adult genitalia. Vulvar aphthae are very common in girls aged 10–18 years, however, whether or not they have oral aphthae.

“This is something that once you recognize it, you see it quite often,” said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Vulvar aphthae can be large or small, and typically are 5–20 mm in diameter, larger than oral aphthae that average 1–5 mm in diameter. Vulvar aphthae are well demarcated and red, usually with a white fibrin base. Typically, they are surrounded by significant inflammation, are very painful, and can scar. They usually appear on modified mucous membranes, and sometimes appear on keratinized skin.

Often vulvar aphthae are misdiagnosed as a sexually transmitted disease. They differ from herpes lesions by being deeper ulcerations rather than erosions, and usually are fewer in number than herpes lesions. Individual aphthae typically are much larger than the tiny round erosions of herpes. Aphthae differ from chancres (another sexually transmitted disease to consider) by the painful nature of aphthae and their lack of induration, Dr. Edwards said.

Aphthae often are preceded by fever, malaise, and sore throat, followed quickly by vulvar pain and ulcerations, suggesting that the aphthae are precipitated by a viral syndrome. Epstein-Barr virus may be one of many viral triggers of vulvar aphthae, she said.

The prodrome plus vulvar aphthae “doesn't make it Behçet's disease,” which is a chronic, systemic disease, she added. “Only if they have clinically objective eye, joint, or neurologic disease is it a symptom of Behçet's.”

Prescribe oral prednisone at a dose of 40 mg each morning for vulvar aphthae until pain ceases. If there are occasional, future episodes, parents can be ready to give a short burst of prednisone. Girls with frequent or ongoing vulvar aphthae will need suppressive anti-inflammatory therapy, starting with dapsone and moving to other agents if needed.

Pseudowarts—a unique nodular reaction to chronic irritation of anogenital skin—is also found by far more often in girls rather than women.

Usually caused by chronic incontinence (especially diarrhea), pseudowarts are bilaterally symmetrical, monomorphous, well-demarcated, flat-topped papules. They can be nearly skin colored or red with an eroded surface, Dr. Edwards said.

Also called Jacquet's diaper dermatitis or granuloma gluteale infantum, pseudowarts are diagnosed by appearance and setting. A biopsy in difficult cases will show squamous hyperplasia, spongiosis, hyperkeratosis, and sometimes erosion with associated acute and chronic inflammation.

Treat by removing the irritants, which can be challenging in a patient with chronic diarrhea or incontinence, she said. Don't use corticosteroids, which may cause irritation that contributes to formation of pseudowarts.

Infantile labial agglutination, not an uncommon finding in young girls, usually resolves before puberty as fragile, thin skin matures, Dr. Edwards said.

“It's not the labial minora agglutination we see with adults, where they're absorbed into the labia majora, but it's more midline,” and often more like adhesions than agglutination, she said. Occasionally, this can interfere with urine flow and cause dribbling, which may be misdiagnosed as incontinence.

If the parent insists on treatment, minimize irritants and massage the area with topical estrogen. If that doesn't work, use clobetasol, she said.

The cause of infantile labial agglutination is unknown. “I think it can be from irritation from anything. It's very often from very mild, unrecognized lichen sclerosus,” she said.

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

SAN FRANCISCO — Girls may present with vulvovaginal skin problems that are seldom or never seen in women, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

Vulvovaginal aphthae, pseudowarts, and infantile labial agglutination are nearly unique to girls, she said.

Aphthae (canker sores) are extremely common painful lesions in the mouths of adults but seldom appear on adult genitalia. Vulvar aphthae are very common in girls aged 10–18 years, however, whether or not they have oral aphthae.

“This is something that once you recognize it, you see it quite often,” said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Vulvar aphthae can be large or small, and typically are 5–20 mm in diameter, larger than oral aphthae that average 1–5 mm in diameter. Vulvar aphthae are well demarcated and red, usually with a white fibrin base. Typically, they are surrounded by significant inflammation, are very painful, and can scar. They usually appear on modified mucous membranes, and sometimes appear on keratinized skin.

Often vulvar aphthae are misdiagnosed as a sexually transmitted disease. They differ from herpes lesions by being deeper ulcerations rather than erosions, and usually are fewer in number than herpes lesions. Individual aphthae typically are much larger than the tiny round erosions of herpes. Aphthae differ from chancres (another sexually transmitted disease to consider) by the painful nature of aphthae and their lack of induration, Dr. Edwards said.

Aphthae often are preceded by fever, malaise, and sore throat, followed quickly by vulvar pain and ulcerations, suggesting that the aphthae are precipitated by a viral syndrome. Epstein-Barr virus may be one of many viral triggers of vulvar aphthae, she said.

The prodrome plus vulvar aphthae “doesn't make it Behçet's disease,” which is a chronic, systemic disease, she added. “Only if they have clinically objective eye, joint, or neurologic disease is it a symptom of Behçet's.”

Prescribe oral prednisone at a dose of 40 mg each morning for vulvar aphthae until pain ceases. If there are occasional, future episodes, parents can be ready to give a short burst of prednisone. Girls with frequent or ongoing vulvar aphthae will need suppressive anti-inflammatory therapy, starting with dapsone and moving to other agents if needed.

Pseudowarts—a unique nodular reaction to chronic irritation of anogenital skin—is also found by far more often in girls rather than women.

Usually caused by chronic incontinence (especially diarrhea), pseudowarts are bilaterally symmetrical, monomorphous, well-demarcated, flat-topped papules. They can be nearly skin colored or red with an eroded surface, Dr. Edwards said.

Also called Jacquet's diaper dermatitis or granuloma gluteale infantum, pseudowarts are diagnosed by appearance and setting. A biopsy in difficult cases will show squamous hyperplasia, spongiosis, hyperkeratosis, and sometimes erosion with associated acute and chronic inflammation.

Treat by removing the irritants, which can be challenging in a patient with chronic diarrhea or incontinence, she said. Don't use corticosteroids, which may cause irritation that contributes to formation of pseudowarts.

Infantile labial agglutination, not an uncommon finding in young girls, usually resolves before puberty as fragile, thin skin matures, Dr. Edwards said.

“It's not the labial minora agglutination we see with adults, where they're absorbed into the labia majora, but it's more midline,” and often more like adhesions than agglutination, she said. Occasionally, this can interfere with urine flow and cause dribbling, which may be misdiagnosed as incontinence.

If the parent insists on treatment, minimize irritants and massage the area with topical estrogen. If that doesn't work, use clobetasol, she said.

The cause of infantile labial agglutination is unknown. “I think it can be from irritation from anything. It's very often from very mild, unrecognized lichen sclerosus,” she said.

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

SAN FRANCISCO — Girls may present with vulvovaginal skin problems that are seldom or never seen in women, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

Vulvovaginal aphthae, pseudowarts, and infantile labial agglutination are nearly unique to girls, she said.

Aphthae (canker sores) are extremely common painful lesions in the mouths of adults but seldom appear on adult genitalia. Vulvar aphthae are very common in girls aged 10–18 years, however, whether or not they have oral aphthae.

“This is something that once you recognize it, you see it quite often,” said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Vulvar aphthae can be large or small, and typically are 5–20 mm in diameter, larger than oral aphthae that average 1–5 mm in diameter. Vulvar aphthae are well demarcated and red, usually with a white fibrin base. Typically, they are surrounded by significant inflammation, are very painful, and can scar. They usually appear on modified mucous membranes, and sometimes appear on keratinized skin.

Often vulvar aphthae are misdiagnosed as a sexually transmitted disease. They differ from herpes lesions by being deeper ulcerations rather than erosions, and usually are fewer in number than herpes lesions. Individual aphthae typically are much larger than the tiny round erosions of herpes. Aphthae differ from chancres (another sexually transmitted disease to consider) by the painful nature of aphthae and their lack of induration, Dr. Edwards said.

Aphthae often are preceded by fever, malaise, and sore throat, followed quickly by vulvar pain and ulcerations, suggesting that the aphthae are precipitated by a viral syndrome. Epstein-Barr virus may be one of many viral triggers of vulvar aphthae, she said.

The prodrome plus vulvar aphthae “doesn't make it Behçet's disease,” which is a chronic, systemic disease, she added. “Only if they have clinically objective eye, joint, or neurologic disease is it a symptom of Behçet's.”

Prescribe oral prednisone at a dose of 40 mg each morning for vulvar aphthae until pain ceases. If there are occasional, future episodes, parents can be ready to give a short burst of prednisone. Girls with frequent or ongoing vulvar aphthae will need suppressive anti-inflammatory therapy, starting with dapsone and moving to other agents if needed.

Pseudowarts—a unique nodular reaction to chronic irritation of anogenital skin—is also found by far more often in girls rather than women.

Usually caused by chronic incontinence (especially diarrhea), pseudowarts are bilaterally symmetrical, monomorphous, well-demarcated, flat-topped papules. They can be nearly skin colored or red with an eroded surface, Dr. Edwards said.

Also called Jacquet's diaper dermatitis or granuloma gluteale infantum, pseudowarts are diagnosed by appearance and setting. A biopsy in difficult cases will show squamous hyperplasia, spongiosis, hyperkeratosis, and sometimes erosion with associated acute and chronic inflammation.

Treat by removing the irritants, which can be challenging in a patient with chronic diarrhea or incontinence, she said. Don't use corticosteroids, which may cause irritation that contributes to formation of pseudowarts.

Infantile labial agglutination, not an uncommon finding in young girls, usually resolves before puberty as fragile, thin skin matures, Dr. Edwards said.

“It's not the labial minora agglutination we see with adults, where they're absorbed into the labia majora, but it's more midline,” and often more like adhesions than agglutination, she said. Occasionally, this can interfere with urine flow and cause dribbling, which may be misdiagnosed as incontinence.

If the parent insists on treatment, minimize irritants and massage the area with topical estrogen. If that doesn't work, use clobetasol, she said.

The cause of infantile labial agglutination is unknown. “I think it can be from irritation from anything. It's very often from very mild, unrecognized lichen sclerosus,” she said.

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

SAN FRANCISCO — The first and most important thing to look for in a fetal heart rate pattern is variability, Michael D. Fox, R.N., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Pattern recognition is the key. Is the heart rate pattern jagged and unpredictable? That's a sign of moderate variability, which nearly guarantees that the fetus is sufficiently oxygenated. Is the pattern smooth, round, blunted, and flat? That loss of variability, when combined with recurrent heart rate decelerations, flags a baby who may be getting asphyxiated, said Mr. Fox, director of the perinatal resource group at the university.

The conventional method of assessing fetal heart rate-monitoring strips starts with drawing an arbitrary line that the clinician designates as the baseline heart rate, so that everything above it is considered accelerations and everything below it is thought to be decelerations. “I would argue that [the conventional method] is fraught with peril” because it employs the wrong interpretive construct and the wrong cues, he said.

Clinicians get into trouble by focusing too much on various methods to measure the height of the variability complexes on the fetal heart rate-monitoring strip. “It's not just the height of the variability complexes that are important, but the way they look,” he added.

A jagged and unpredictable pattern on the heart rate-monitoring strip is good: It's a visual representation of an intact neurologic pathway in the fetus. A progressively smooth, round, blunted and flat pattern is bad: This is a pattern that every baby who dies of asphyxia develops, even if the height of the heart rate oscillations meets previous definitions for moderate variability. A common mistake is to consider smooth, round, blunted oscillations to be moderate variability if they have enough height in the pattern.

Because heart rate accelerations usually occur in association with moderate variability, they are typically jagged and unpredictable in both appearance and timing. Rarely are accelerations regular, rhythmic, or occurring with each contraction.

Recurrent decelerations that get deeper and deeper as labor progresses are no cause for immediate delivery, so long as moderate variability remains present. “These are tracings that we traditionally called nonreassuring,” yet 98% of fetuses with this pattern will be free of asphyxia and 99% will have no morbidities, he noted.

That doesn't mean clinicians needn't be alert. If you see recurrent decelerations in the presence of moderate variability, then be sure a physician or nurse-midwife is managing the patient at the bedside, prepare the patient for delivery, and notify the rest of the obstetric and neonatal team. “Once you have the capacity to rescue this fetus, these are tracings that can continue to be observed,” he said.

The timing of decelerations in relation to uterine activity may tell the clinician something about the underlying physiology “but it does not tell you what to do in most circumstances,” Mr. Fox added. “Variability always trumps timing.”

He teaches a four-step process of evaluating a fetal heart rate strip. First, ask if variability is absent, minimal, moderate, or marked. Second, look for decelerations. Third, consider the baseline fetal heart rate. Finally, sum up the evolution of the tracing. Babies with asphyxia don't regain variability; they continue to lose it over time in association with deeper decelerations.

Video Teaches Pattern Recognition

A free video that teaches recognition of variability and other signs of fetal health on heart rate-monitoring tracings is available to clinicians who “commit to interdisciplinary education”—meaning it will be used to train doctors, nurses, midwives, and anyone else involved in monitoring fetal heart rates, Mr. Fox said.

Funded by Kaiser Permanente, the video “Situational Awareness in Fetal Heart Rate Monitoring” features four 27-minute segments with cases and tracings presented by Mr. Fox, Dr. Julian (“Bill”) Parer, professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and other faculty members.

A small shipping and handling fee is charged for each order. Mr. Fox is the distributor. To request a copy, contact him at

perinatal@consultant.com

SAN FRANCISCO — The first and most important thing to look for in a fetal heart rate pattern is variability, Michael D. Fox, R.N., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Pattern recognition is the key. Is the heart rate pattern jagged and unpredictable? That's a sign of moderate variability, which nearly guarantees that the fetus is sufficiently oxygenated. Is the pattern smooth, round, blunted, and flat? That loss of variability, when combined with recurrent heart rate decelerations, flags a baby who may be getting asphyxiated, said Mr. Fox, director of the perinatal resource group at the university.

The conventional method of assessing fetal heart rate-monitoring strips starts with drawing an arbitrary line that the clinician designates as the baseline heart rate, so that everything above it is considered accelerations and everything below it is thought to be decelerations. “I would argue that [the conventional method] is fraught with peril” because it employs the wrong interpretive construct and the wrong cues, he said.

Clinicians get into trouble by focusing too much on various methods to measure the height of the variability complexes on the fetal heart rate-monitoring strip. “It's not just the height of the variability complexes that are important, but the way they look,” he added.

A jagged and unpredictable pattern on the heart rate-monitoring strip is good: It's a visual representation of an intact neurologic pathway in the fetus. A progressively smooth, round, blunted and flat pattern is bad: This is a pattern that every baby who dies of asphyxia develops, even if the height of the heart rate oscillations meets previous definitions for moderate variability. A common mistake is to consider smooth, round, blunted oscillations to be moderate variability if they have enough height in the pattern.

Because heart rate accelerations usually occur in association with moderate variability, they are typically jagged and unpredictable in both appearance and timing. Rarely are accelerations regular, rhythmic, or occurring with each contraction.

Recurrent decelerations that get deeper and deeper as labor progresses are no cause for immediate delivery, so long as moderate variability remains present. “These are tracings that we traditionally called nonreassuring,” yet 98% of fetuses with this pattern will be free of asphyxia and 99% will have no morbidities, he noted.

That doesn't mean clinicians needn't be alert. If you see recurrent decelerations in the presence of moderate variability, then be sure a physician or nurse-midwife is managing the patient at the bedside, prepare the patient for delivery, and notify the rest of the obstetric and neonatal team. “Once you have the capacity to rescue this fetus, these are tracings that can continue to be observed,” he said.

The timing of decelerations in relation to uterine activity may tell the clinician something about the underlying physiology “but it does not tell you what to do in most circumstances,” Mr. Fox added. “Variability always trumps timing.”

He teaches a four-step process of evaluating a fetal heart rate strip. First, ask if variability is absent, minimal, moderate, or marked. Second, look for decelerations. Third, consider the baseline fetal heart rate. Finally, sum up the evolution of the tracing. Babies with asphyxia don't regain variability; they continue to lose it over time in association with deeper decelerations.

Video Teaches Pattern Recognition

A free video that teaches recognition of variability and other signs of fetal health on heart rate-monitoring tracings is available to clinicians who “commit to interdisciplinary education”—meaning it will be used to train doctors, nurses, midwives, and anyone else involved in monitoring fetal heart rates, Mr. Fox said.

Funded by Kaiser Permanente, the video “Situational Awareness in Fetal Heart Rate Monitoring” features four 27-minute segments with cases and tracings presented by Mr. Fox, Dr. Julian (“Bill”) Parer, professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and other faculty members.

A small shipping and handling fee is charged for each order. Mr. Fox is the distributor. To request a copy, contact him at

perinatal@consultant.com

SAN FRANCISCO — The first and most important thing to look for in a fetal heart rate pattern is variability, Michael D. Fox, R.N., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Pattern recognition is the key. Is the heart rate pattern jagged and unpredictable? That's a sign of moderate variability, which nearly guarantees that the fetus is sufficiently oxygenated. Is the pattern smooth, round, blunted, and flat? That loss of variability, when combined with recurrent heart rate decelerations, flags a baby who may be getting asphyxiated, said Mr. Fox, director of the perinatal resource group at the university.

The conventional method of assessing fetal heart rate-monitoring strips starts with drawing an arbitrary line that the clinician designates as the baseline heart rate, so that everything above it is considered accelerations and everything below it is thought to be decelerations. “I would argue that [the conventional method] is fraught with peril” because it employs the wrong interpretive construct and the wrong cues, he said.

Clinicians get into trouble by focusing too much on various methods to measure the height of the variability complexes on the fetal heart rate-monitoring strip. “It's not just the height of the variability complexes that are important, but the way they look,” he added.

A jagged and unpredictable pattern on the heart rate-monitoring strip is good: It's a visual representation of an intact neurologic pathway in the fetus. A progressively smooth, round, blunted and flat pattern is bad: This is a pattern that every baby who dies of asphyxia develops, even if the height of the heart rate oscillations meets previous definitions for moderate variability. A common mistake is to consider smooth, round, blunted oscillations to be moderate variability if they have enough height in the pattern.

Because heart rate accelerations usually occur in association with moderate variability, they are typically jagged and unpredictable in both appearance and timing. Rarely are accelerations regular, rhythmic, or occurring with each contraction.

Recurrent decelerations that get deeper and deeper as labor progresses are no cause for immediate delivery, so long as moderate variability remains present. “These are tracings that we traditionally called nonreassuring,” yet 98% of fetuses with this pattern will be free of asphyxia and 99% will have no morbidities, he noted.

That doesn't mean clinicians needn't be alert. If you see recurrent decelerations in the presence of moderate variability, then be sure a physician or nurse-midwife is managing the patient at the bedside, prepare the patient for delivery, and notify the rest of the obstetric and neonatal team. “Once you have the capacity to rescue this fetus, these are tracings that can continue to be observed,” he said.

The timing of decelerations in relation to uterine activity may tell the clinician something about the underlying physiology “but it does not tell you what to do in most circumstances,” Mr. Fox added. “Variability always trumps timing.”

He teaches a four-step process of evaluating a fetal heart rate strip. First, ask if variability is absent, minimal, moderate, or marked. Second, look for decelerations. Third, consider the baseline fetal heart rate. Finally, sum up the evolution of the tracing. Babies with asphyxia don't regain variability; they continue to lose it over time in association with deeper decelerations.

Video Teaches Pattern Recognition

A free video that teaches recognition of variability and other signs of fetal health on heart rate-monitoring tracings is available to clinicians who “commit to interdisciplinary education”—meaning it will be used to train doctors, nurses, midwives, and anyone else involved in monitoring fetal heart rates, Mr. Fox said.

Funded by Kaiser Permanente, the video “Situational Awareness in Fetal Heart Rate Monitoring” features four 27-minute segments with cases and tracings presented by Mr. Fox, Dr. Julian (“Bill”) Parer, professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and other faculty members.

A small shipping and handling fee is charged for each order. Mr. Fox is the distributor. To request a copy, contact him at

perinatal@consultant.com

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis.

The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif.

The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures.

The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Dissemination is more likely in males, Filipinos, African Americans, and people with deficient cell-mediated immunity.

Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases. Itraconazole or amphotericin has been used as an alternative to fluconazole in some cases.

“This is a very, very difficult disease to treat,” Dr. Azimi said. Meningitis is fatal without treatment.

SAN FRANCISCO — Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis.

The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif.

The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures.

The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Dissemination is more likely in males, Filipinos, African Americans, and people with deficient cell-mediated immunity.

Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases. Itraconazole or amphotericin has been used as an alternative to fluconazole in some cases.

“This is a very, very difficult disease to treat,” Dr. Azimi said. Meningitis is fatal without treatment.

SAN FRANCISCO — Hydrocephalus is an easy clue to potential Coccidioides immitis meningitis, but a subacute course of the disease can make it much more difficult to pin down the diagnosis, Dr. Parvin Azimi said at the annual meeting of the American Academy of Pediatrics.

She described two cases of chronic meningitis that illustrate different manifestations of C. immitis.

The first patient, a 16-year-old African American boy, had a history of exposure to soil in endemic areas, the likely source of his fungal infection, said Dr. Azimi, director of infectious diseases at Children's Hospital and Research Center, Oakland, Calif.

The patient presented with a 5-week history of headache, vomiting, and decreased energy, with no response to treatment with oral amoxicillin. He had a fever higher than 100° F with a stiff neck, flat affect, and lethargy.

A spinal tap showed that the cerebral spinal fluid (CSF) had a high protein level (148 mg/dL) and a low glucose level (15 mg/dL). The RBC count was 3/mcL and the WBC count was 380/mcL with 25% polymorphonuclear leukocytes (PMNs), 66% lymphocytes, and 9% monocytes. Gram stain and culture were negative for bacteria.

“Obviously, the spinal fluid findings look very much like TB,” so clinicians did a work-up for tuberculosis, she said. A purified protein derivative (PPD) skin test for tuberculosis produced no induration, although “that doesn't mean the patient doesn't have TB,” she acknowledged. Chest x-ray, cranial CT scan, and EEG were all normal.

The teenager had been traveling to Corpus Christi, Tex., where he collected insects and played with his pet tarantula and puppy during his visit. He sought help for his symptoms at a Texas hospital and was sent home to California with a diagnosis of viral meningitis.

The headaches and vomiting continued. A repeat spinal tap 3 weeks after the first one showed that the CSF protein level had increased (176 mg/dL) and the glucose level decreased (9 mg/dL). The RBC was 1/mcL and the WBC was 737/mcL with 33% PMNs, 51% lymphocytes, 15% monocytes, and 1% macrocytes.

Infectious disease consultants were called in at this point. They ordered fungal, parasitic, and acid-fast bacilli studies and started the patient on empiric therapy for presumed TB meningitis pending results of cultures.

The CSF was negative for cryptococcal antigen and amebic trophozoites, ruling these out of the differential diagnosis, Dr. Azimi said. An HIV test was negative.

Finally, the CSF and sera were found to be reactive to C. immitis antibodies.

In the second case described by Dr. Azimi, a 19-month-old Filipino-Latino boy from Antioch, Calif., presented with a 6-month history of decreased activity, clinging behavior, and poor growth. In the past 6 days, he'd had lethargy, frequent falls, and difficulty walking. On physical exam, he was mildly feverish and irritable, and refused to stand or walk.

A head CT scan showed hydrocephalus “that was significant enough that it prompted surgeons to place a shunt quickly” to provide decompression, she said. Hydrocephalus is a well-known complication of Coccidioides meningitis.

The patient's CSF showed highly elevated protein (319 mg/dL) and low glucose (25 mg/dL). The RBC was 340/mcL and the WBC was 117/mcL with 65% lymphocytes and 4% PMNs, among other findings. CSF Gram stain and cultures were negative, as were a chest x-ray and PPD skin test for TB.

As in the first patient with subacute disease, this patient's CSF and sera were reactive for C. immitis antibodies.

Fewer than 1% of cases of Coccidioides infection become disseminated, but half of disseminated cases have CNS involvement, Dr. Azimi said. Dissemination is more likely in males, Filipinos, African Americans, and people with deficient cell-mediated immunity.

Oral fluconazole is the treatment of choice, continued for life. Stopping therapy risks a recurrence in 35% of cases. Itraconazole or amphotericin has been used as an alternative to fluconazole in some cases.

“This is a very, very difficult disease to treat,” Dr. Azimi said. Meningitis is fatal without treatment.

SAN FRANCISCO — Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, reported Michael V. Vitiello, Ph.D, and his associates in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in controls. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (higher scores indicate less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as assessed by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive cognitive-behavioral therapy for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

Cognitive-behavioral therapy for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said. The cognitive-behavioral intervention consisted of a fairly standard series of behavioral manipulations such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“We always think of sleep disturbance as a symptom, as secondary,” Dr. Vitiello said. “What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom.”

SAN FRANCISCO — Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, reported Michael V. Vitiello, Ph.D, and his associates in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in controls. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (higher scores indicate less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as assessed by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive cognitive-behavioral therapy for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

Cognitive-behavioral therapy for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said. The cognitive-behavioral intervention consisted of a fairly standard series of behavioral manipulations such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“We always think of sleep disturbance as a symptom, as secondary,” Dr. Vitiello said. “What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom.”

SAN FRANCISCO — Cognitive-behavioral therapy for comorbid insomnia in patients with osteoarthritis not only improved sleep but also reduced self-reported pain in a randomized, controlled pilot study of 51 patients.

The improvements in both sleep and pain levels persisted at 1-year follow-up. This is the first study to demonstrate such a duration of benefit from cognitive-behavioral therapy for insomnia in patients with comorbid chronic medical illness of any kind, reported Michael V. Vitiello, Ph.D, and his associates in a poster presentation at the annual meeting of the Gerontological Society of America.

This preliminary study suggests that improving sleep can be “analgesic” in patients with osteoarthritis, said Dr. Vitiello, professor of psychiatry and behavioral sciences at the University of Washington, Seattle. “Techniques to improve sleep should be considered for addition to treatment programs for pain management in osteoarthritis and possibly other pain states,” he added.

More than half of older adults develop osteoarthritis, and a majority of these develop significant sleep disturbance. The pain initiates and exacerbates the sleep disturbance, and the disturbed sleep then seems to maintain and exacerbate pain by lowering pain thresholds and amplifying transmission of pain signals, he said.

The study randomized 23 patients (18 women and 5 men) to cognitive-behavioral therapy for insomnia and 28 patients (27 women, 1 man) to a control group that received an intervention focused on attention control, stress management, and wellness. Neither group specifically addressed pain control. Each group met 2 hours per week for 8 weeks for the intervention.

Several measures of insomnia improved significantly in the treatment group but not in controls. Sleep latency (the time it takes to fall asleep) decreased from a mean of 40 minutes to 24 minutes, and nighttime wakefulness decreased from 62 to 25 minutes. Sleep efficiency (the proportion of time in bed spent asleep) improved from 71% to 84%.

Self-reported pain on the Short Form-36 pain scale improved from a score of 56 before cognitive-behavioral therapy to 66 afterward (higher scores indicate less pain), but did not change significantly in the control group. There was a nonsignificant trend toward reduced pain in the treatment group as assessed by the McGill Pain Questionnaire.

After posttreatment results were assessed, 10 patients in the control group crossed over to receive cognitive-behavioral therapy for insomnia. Results of 1-year follow-up in 19 patients from the original cognitive-behavioral therapy group plus the 10 crossovers were nearly identical to the results of the after-treatment assessments, showing duration of the improvements over time, Dr. Vitiello said.

Cognitive-behavioral therapy for insomnia is “not the kind of thing that a physician can do in an office visit, but it can be done by trained health care professionals in relatively quick fashion in group settings,” he said. The cognitive-behavioral intervention consisted of a fairly standard series of behavioral manipulations such as sleep restriction (teaching patients to somewhat curtail their time in bed), stimulus control (telling them not to go to bed unless sleepy), sleep hygiene (teaching them how to nap appropriately), and other techniques.

“We always think of sleep disturbance as a symptom, as secondary,” Dr. Vitiello said. “What we're learning, really, is that sleep is interactive with illness, and it is not simply a symptom.”