User login
Thrombocytopenia Ups Preeclampsia Risk in SLE
SAN FRANCISCO — The risk for preeclampsia in pregnant women with lupus tripled if they had thrombocytopenia at conception, according to a review of data from a 10-year period at one institution.
This previously unreported finding was highly statistically significant, but prospective studies will be needed to confirm the association, study investigator Maurice L. Druzin, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.
“We certainly are going to be looking at patients with thrombocytopenia very closely,” said Dr. Druzin, professor of ob.gyn. and chief of maternal and fetal medicine at Stanford (Calif.) University.
The review of all pregnancies complicated by systemic lupus erythematosus seen at the university from 1991 to 2001 covered 63 pregnancies in 48 patients with a mean maternal age of 30 years. Lupus had been present for a mean of 4 years in these patients, and the disease was active at conception in 63% of pregnancies. As a group, these were sicker patients than those usually seen by an ob.gyn.
Preeclampsia occurred in 22% of all pregnancies. Thrombocytopenia at conception predicted the development of preeclampsia, according to multivariate analyses to identify clinical predictors of prematurity and preeclampsia.
Gestational diabetes occurred in 5% of pregnancies, and 4% of the cohort developed hemolysis, elevated liver, low platelet (HELLP) syndrome.
Among the pregnancies with active maternal lupus at conception, treatments included prednisone in 48%, hydroxychloroquine in 21%, and antihypertensives in 13%.
Maternal antiphospholipid antibodies were detected in about half of all pregnancies. The cohort had a higher likelihood of having anti-Ro/SSA or anti-La/SSB antibodies than generally is seen in patients with lupus—38% vs. 25%—again emphasizing the select nature of this referral population. Maternal renal disease was present in 35% of pregnancies, and maternal CNS disease affected 10% of pregnancies.
Despite this, birth outcomes were “very good,” with 54 live births, Dr. Druzin said. “When a woman with lupus comes to you, you can tell her that she has a very good chance of having a live birth, which was not true 25 years ago.” The remaining pregnancies ended in first-trimester losses or therapeutic abortions.
As in other studies of pregnancy and lupus, premature delivery was the main fetal problem, occurring n 54% of pregnancies. However, 46% of these were delivered at 32–37 weeks' gestation. “In modern intensive care units, those babies tend to do very well,” he said. An additional 4% were born at 28–32 weeks, and 4% were delivered earlier than 28 weeks.
Lupus flares occurred in 68% of pregnancies. Of these, 71% were mild to moderate flares and were treated with 4–20 mg of additional prednisone. The risk for flare nearly doubled if lupus was active at conception. Prednisone use at conception predicted a 57% increased risk of flare, and a higher disease activity index score predicted a 56% increased risk for flare.
A severe flare was associated with nearly a doubling in risk for premature delivery. Maternal use of antihypertensives or prednisone at conception was associated with an 83% or 77% increase, respectively, in risk for premature birth.
Among 13 women on hydroxychloroquine at conception, severe flares occurred in 2 of 11 women who stopped taking the medication after conception but not in women who continued treatment or stopped before conception, he noted. This difference was not significant, but the finding plus other data suggest that hydroxychloroquine is safe to use in pregnancy.
The review will be published in the American Journal of Obstetrics and Gynecology. The lead author of the paper is Eliza F. Chakravarty, M.D., a rheumatology fellow at Stanford University.
SAN FRANCISCO — The risk for preeclampsia in pregnant women with lupus tripled if they had thrombocytopenia at conception, according to a review of data from a 10-year period at one institution.
This previously unreported finding was highly statistically significant, but prospective studies will be needed to confirm the association, study investigator Maurice L. Druzin, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.
“We certainly are going to be looking at patients with thrombocytopenia very closely,” said Dr. Druzin, professor of ob.gyn. and chief of maternal and fetal medicine at Stanford (Calif.) University.
The review of all pregnancies complicated by systemic lupus erythematosus seen at the university from 1991 to 2001 covered 63 pregnancies in 48 patients with a mean maternal age of 30 years. Lupus had been present for a mean of 4 years in these patients, and the disease was active at conception in 63% of pregnancies. As a group, these were sicker patients than those usually seen by an ob.gyn.
Preeclampsia occurred in 22% of all pregnancies. Thrombocytopenia at conception predicted the development of preeclampsia, according to multivariate analyses to identify clinical predictors of prematurity and preeclampsia.
Gestational diabetes occurred in 5% of pregnancies, and 4% of the cohort developed hemolysis, elevated liver, low platelet (HELLP) syndrome.
Among the pregnancies with active maternal lupus at conception, treatments included prednisone in 48%, hydroxychloroquine in 21%, and antihypertensives in 13%.
Maternal antiphospholipid antibodies were detected in about half of all pregnancies. The cohort had a higher likelihood of having anti-Ro/SSA or anti-La/SSB antibodies than generally is seen in patients with lupus—38% vs. 25%—again emphasizing the select nature of this referral population. Maternal renal disease was present in 35% of pregnancies, and maternal CNS disease affected 10% of pregnancies.
Despite this, birth outcomes were “very good,” with 54 live births, Dr. Druzin said. “When a woman with lupus comes to you, you can tell her that she has a very good chance of having a live birth, which was not true 25 years ago.” The remaining pregnancies ended in first-trimester losses or therapeutic abortions.
As in other studies of pregnancy and lupus, premature delivery was the main fetal problem, occurring n 54% of pregnancies. However, 46% of these were delivered at 32–37 weeks' gestation. “In modern intensive care units, those babies tend to do very well,” he said. An additional 4% were born at 28–32 weeks, and 4% were delivered earlier than 28 weeks.
Lupus flares occurred in 68% of pregnancies. Of these, 71% were mild to moderate flares and were treated with 4–20 mg of additional prednisone. The risk for flare nearly doubled if lupus was active at conception. Prednisone use at conception predicted a 57% increased risk of flare, and a higher disease activity index score predicted a 56% increased risk for flare.
A severe flare was associated with nearly a doubling in risk for premature delivery. Maternal use of antihypertensives or prednisone at conception was associated with an 83% or 77% increase, respectively, in risk for premature birth.
Among 13 women on hydroxychloroquine at conception, severe flares occurred in 2 of 11 women who stopped taking the medication after conception but not in women who continued treatment or stopped before conception, he noted. This difference was not significant, but the finding plus other data suggest that hydroxychloroquine is safe to use in pregnancy.
The review will be published in the American Journal of Obstetrics and Gynecology. The lead author of the paper is Eliza F. Chakravarty, M.D., a rheumatology fellow at Stanford University.
SAN FRANCISCO — The risk for preeclampsia in pregnant women with lupus tripled if they had thrombocytopenia at conception, according to a review of data from a 10-year period at one institution.
This previously unreported finding was highly statistically significant, but prospective studies will be needed to confirm the association, study investigator Maurice L. Druzin, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.
“We certainly are going to be looking at patients with thrombocytopenia very closely,” said Dr. Druzin, professor of ob.gyn. and chief of maternal and fetal medicine at Stanford (Calif.) University.
The review of all pregnancies complicated by systemic lupus erythematosus seen at the university from 1991 to 2001 covered 63 pregnancies in 48 patients with a mean maternal age of 30 years. Lupus had been present for a mean of 4 years in these patients, and the disease was active at conception in 63% of pregnancies. As a group, these were sicker patients than those usually seen by an ob.gyn.
Preeclampsia occurred in 22% of all pregnancies. Thrombocytopenia at conception predicted the development of preeclampsia, according to multivariate analyses to identify clinical predictors of prematurity and preeclampsia.
Gestational diabetes occurred in 5% of pregnancies, and 4% of the cohort developed hemolysis, elevated liver, low platelet (HELLP) syndrome.
Among the pregnancies with active maternal lupus at conception, treatments included prednisone in 48%, hydroxychloroquine in 21%, and antihypertensives in 13%.
Maternal antiphospholipid antibodies were detected in about half of all pregnancies. The cohort had a higher likelihood of having anti-Ro/SSA or anti-La/SSB antibodies than generally is seen in patients with lupus—38% vs. 25%—again emphasizing the select nature of this referral population. Maternal renal disease was present in 35% of pregnancies, and maternal CNS disease affected 10% of pregnancies.
Despite this, birth outcomes were “very good,” with 54 live births, Dr. Druzin said. “When a woman with lupus comes to you, you can tell her that she has a very good chance of having a live birth, which was not true 25 years ago.” The remaining pregnancies ended in first-trimester losses or therapeutic abortions.
As in other studies of pregnancy and lupus, premature delivery was the main fetal problem, occurring n 54% of pregnancies. However, 46% of these were delivered at 32–37 weeks' gestation. “In modern intensive care units, those babies tend to do very well,” he said. An additional 4% were born at 28–32 weeks, and 4% were delivered earlier than 28 weeks.
Lupus flares occurred in 68% of pregnancies. Of these, 71% were mild to moderate flares and were treated with 4–20 mg of additional prednisone. The risk for flare nearly doubled if lupus was active at conception. Prednisone use at conception predicted a 57% increased risk of flare, and a higher disease activity index score predicted a 56% increased risk for flare.
A severe flare was associated with nearly a doubling in risk for premature delivery. Maternal use of antihypertensives or prednisone at conception was associated with an 83% or 77% increase, respectively, in risk for premature birth.
Among 13 women on hydroxychloroquine at conception, severe flares occurred in 2 of 11 women who stopped taking the medication after conception but not in women who continued treatment or stopped before conception, he noted. This difference was not significant, but the finding plus other data suggest that hydroxychloroquine is safe to use in pregnancy.
The review will be published in the American Journal of Obstetrics and Gynecology. The lead author of the paper is Eliza F. Chakravarty, M.D., a rheumatology fellow at Stanford University.
Adherence Better With Home BP Monitoring
SAN FRANCISCO — New data for the first time support the assumption that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.
Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.
The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks.
Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.
At baseline, 47% of patients in the home monitoring group and 65% of those in the usual care group reported being adherent to therapy, a difference that was not statistically significant.
In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.
At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.
In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.
Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with those in the usual care group (18%). The rest of the patients did not change adherence patterns.
The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.
SAN FRANCISCO — New data for the first time support the assumption that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.
Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.
The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks.
Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.
At baseline, 47% of patients in the home monitoring group and 65% of those in the usual care group reported being adherent to therapy, a difference that was not statistically significant.
In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.
At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.
In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.
Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with those in the usual care group (18%). The rest of the patients did not change adherence patterns.
The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.
SAN FRANCISCO — New data for the first time support the assumption that home monitoring improves blood pressure control because of better adherence to antihypertensive therapy, Gbenga Ogedegbe, M.D., said at the annual meeting of the American Society of Hypertension.
Previous reports showed better control in hypertensive patients performing home blood pressure monitoring, compared with patients monitored in physicians' offices, and clinicians assumed this was due to better adherence to therapy with home monitoring.
The current data—part of a larger and longer study—came from patients with uncontrolled blood pressure on one or more antihypertensive medications who were randomized to home blood pressure monitoring (118 patients) or usual care in offices (60 patients) for 12 weeks.
Investigators assessed adherence to therapy using the well-validated Morisky questionnaire, said Dr. Ogedegbe of Columbia University, New York.
At baseline, 47% of patients in the home monitoring group and 65% of those in the usual care group reported being adherent to therapy, a difference that was not statistically significant.
In the home monitoring group, patients took their blood pressure three times per week on average, usually at different times of the day, using a “life-link” monitoring system that gave them immediate feedback on their blood pressure control (or lack of it) and electronically sent a report to their physicians.
At follow-up 12 weeks later, patients were asked four questions that have been shown to predict the likelihood of blood pressure control: In the past 4 weeks, have you been careless about taking your blood pressure medication? In the past 4 weeks, have you forgotten to take your blood pressure medication? Do you stop taking the medication when you feel better? Do you stop taking the medication when you feel worse, from side effects? Patients who answered “yes” to any of the questions were considered nonadherent to therapy.
In the home monitoring group, 31% went from being nonadherent at baseline to adherent with therapy at 12 weeks, compared with 12% of patients in the usual care group, a significant difference.
Patients in the home monitoring group were less likely to move from adherent to nonadherent (12%), compared with those in the usual care group (18%). The rest of the patients did not change adherence patterns.
The study was not large enough to detect any significant changes in blood pressure, Dr. Ogedegbe said.
Combination Lipid/BP Treatment Reduces Events : Lower event rates with calcium channel blocker and statin are attributed to improved arterial elasticity.
SAN FRANCISCO — Combining a calcium channel blocker and a lipid-lowering drug to treat 847 patients with both hypertension and hyperlipidemia reduced cardiovascular events more than either drug alone or placebo because of improvements in small artery elasticity, said Jay N. Cohn, M.D.
Preliminary results previously reported from the Efficacy and Safety of Atorvastatin Plus Amlodipine Versus Either Agent Alone in Patients with Concomitant Dyslipidemia and Hypertension (AVALON) trial showed a significantly lower rate of cardiovascular events with the combination therapy than with monotherapy or placebo, he said at the annual meeting of the American Society of Hypertension.
New data provide an explanation for the additive effects of the combined therapy. A nested substudy of 667 patients within the AVALON trial sequentially measured arterial wall compliance during treatment and found physiologic changes consistent with significantly greater improvements in small-artery compliance and better endothelial function in the combination therapy group, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Prevention of Cardiovascular Disease at the University of Minnesota, Minneapolis.
Pfizer Inc., which makes both amlodipine and atorvastatin, funded the study. Two of the investigators were Pfizer employees. Dr. Cohn is a consultant to and holds stock in Hypertension Diagnostics Inc., which makes the CV Profiler device that measured arterial compliance.
The CV Profiler uses a transducer placed over the radial artery of a patient at rest to measure pulse waves. A computer analysis of the waveforms assesses arterial stiffness. Separate short-term epidemiologic data suggest that lower small-artery elasticity increases the risk of heart attack, stroke, and other cardiovascular events, he said.
Dr. Cohn extrapolated from the current and previous data to suggest that reduced nitric oxide activity causes small-artery stiffness and that the combination of amlodipine and atorvastatin improves nitric oxide bioactivity. “I'm a firm believer that it's more than blood pressure which is playing a role in arterial health,” he said.
The results add to findings from a 10,000-patient substudy within the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) showing that amlodipine plus atorvastatin therapy in older hypertensive patients with normal lipid levels reduced the rate of cardiovascular events, compared with monotherapy or placebo (Drugs 2004;2[64 suppl. 2]:43-60).
SAN FRANCISCO — Combining a calcium channel blocker and a lipid-lowering drug to treat 847 patients with both hypertension and hyperlipidemia reduced cardiovascular events more than either drug alone or placebo because of improvements in small artery elasticity, said Jay N. Cohn, M.D.
Preliminary results previously reported from the Efficacy and Safety of Atorvastatin Plus Amlodipine Versus Either Agent Alone in Patients with Concomitant Dyslipidemia and Hypertension (AVALON) trial showed a significantly lower rate of cardiovascular events with the combination therapy than with monotherapy or placebo, he said at the annual meeting of the American Society of Hypertension.
New data provide an explanation for the additive effects of the combined therapy. A nested substudy of 667 patients within the AVALON trial sequentially measured arterial wall compliance during treatment and found physiologic changes consistent with significantly greater improvements in small-artery compliance and better endothelial function in the combination therapy group, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Prevention of Cardiovascular Disease at the University of Minnesota, Minneapolis.
Pfizer Inc., which makes both amlodipine and atorvastatin, funded the study. Two of the investigators were Pfizer employees. Dr. Cohn is a consultant to and holds stock in Hypertension Diagnostics Inc., which makes the CV Profiler device that measured arterial compliance.
The CV Profiler uses a transducer placed over the radial artery of a patient at rest to measure pulse waves. A computer analysis of the waveforms assesses arterial stiffness. Separate short-term epidemiologic data suggest that lower small-artery elasticity increases the risk of heart attack, stroke, and other cardiovascular events, he said.
Dr. Cohn extrapolated from the current and previous data to suggest that reduced nitric oxide activity causes small-artery stiffness and that the combination of amlodipine and atorvastatin improves nitric oxide bioactivity. “I'm a firm believer that it's more than blood pressure which is playing a role in arterial health,” he said.
The results add to findings from a 10,000-patient substudy within the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) showing that amlodipine plus atorvastatin therapy in older hypertensive patients with normal lipid levels reduced the rate of cardiovascular events, compared with monotherapy or placebo (Drugs 2004;2[64 suppl. 2]:43-60).
SAN FRANCISCO — Combining a calcium channel blocker and a lipid-lowering drug to treat 847 patients with both hypertension and hyperlipidemia reduced cardiovascular events more than either drug alone or placebo because of improvements in small artery elasticity, said Jay N. Cohn, M.D.
Preliminary results previously reported from the Efficacy and Safety of Atorvastatin Plus Amlodipine Versus Either Agent Alone in Patients with Concomitant Dyslipidemia and Hypertension (AVALON) trial showed a significantly lower rate of cardiovascular events with the combination therapy than with monotherapy or placebo, he said at the annual meeting of the American Society of Hypertension.
New data provide an explanation for the additive effects of the combined therapy. A nested substudy of 667 patients within the AVALON trial sequentially measured arterial wall compliance during treatment and found physiologic changes consistent with significantly greater improvements in small-artery compliance and better endothelial function in the combination therapy group, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Prevention of Cardiovascular Disease at the University of Minnesota, Minneapolis.
Pfizer Inc., which makes both amlodipine and atorvastatin, funded the study. Two of the investigators were Pfizer employees. Dr. Cohn is a consultant to and holds stock in Hypertension Diagnostics Inc., which makes the CV Profiler device that measured arterial compliance.
The CV Profiler uses a transducer placed over the radial artery of a patient at rest to measure pulse waves. A computer analysis of the waveforms assesses arterial stiffness. Separate short-term epidemiologic data suggest that lower small-artery elasticity increases the risk of heart attack, stroke, and other cardiovascular events, he said.
Dr. Cohn extrapolated from the current and previous data to suggest that reduced nitric oxide activity causes small-artery stiffness and that the combination of amlodipine and atorvastatin improves nitric oxide bioactivity. “I'm a firm believer that it's more than blood pressure which is playing a role in arterial health,” he said.
The results add to findings from a 10,000-patient substudy within the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) showing that amlodipine plus atorvastatin therapy in older hypertensive patients with normal lipid levels reduced the rate of cardiovascular events, compared with monotherapy or placebo (Drugs 2004;2[64 suppl. 2]:43-60).
Evaluating Attorney Part of the Lawsuit Process
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
Ask whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf.
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
Ask whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf.
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of past disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful, failed to communicate, or failed to represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advised, think about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
Ask whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either. The lawyer should be able to listen to the client and think about the case without being distracted by calls, e-mails, or an overload of other cases.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, document reviews, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
Ask whether legal interns will bill at the same rate as senior lawyers in the firm, and be sure that you'll get access to all legal work generated on your behalf.
Evaluating Attorney Part of the Lawsuit Process : Be knowledgeable and prepared when selecting and working with lawyers on malpractice lawsuits.
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful or failed to communicate or represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advise thinking about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful or failed to communicate or represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advise thinking about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice suit is doing a good job?
When a physician gets sued, the malpractice insurer assigns the case to a legal defense firm. According to Annette Friend, M.D., a psychiatrist, physicians should expect five basic things from a competent lawyer: a plan of action; clear communication; ongoing communications; management of your expectations; and clear explanations of billing policies.
A review of disciplinary actions against lawyers suggests that more than half stemmed from clients' complaints that the lawyers were neglectful or failed to communicate or represent clients diligently or competently. Another complaint—that failure to communicate billing policies led to fee disputes—is an increasing cause of disciplinary dockets, Dr. Friend, who also is a lawyer, said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.
“We want to satisfy you, but you have to insist on being satisfied,” Dennis J. Sinclitico, J.D., a defense lawyer, said in a separate presentation at a conference in Cabo San Lucas, Mexico, on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
Get a copy of the malpractice insurance company's guidelines on expectations of lawyers to know what the insurer expects for your case, said Mr. Sinclitico of Long Beach, Calif.
To get your lawyer to do the best job for you, Dr. Friend and Mr. Sinclitico advise thinking about the following factors:
▸ Plan. The physician and lawyer jointly plan a course of action. The lawyer should explain what is involved in the case, what needs to be done, what may happen next, and various means of resolving the case. The client makes the final decision about how to resolve the legal matter, said Dr. Friend of Fort Lauderdale, Fla.
She suggested asking whether the lawyer has ever handled this type of case before, and if there is some other way to settle the matter other than going to trial. Your bill for an inexperienced lawyer may be higher as more hours are needed to learn the matter.
▸ Communicate. Expect plain speaking, clear writing, and good listening skills from your lawyer. When a complex legal issue can be explained in a way that one's grandmother might understand, that's clear speaking, she said. If you don't understand something your lawyer wrote, chances are the judge and others won't understand it, either.
If your lawyer isn't communicating well and regularly or you just don't get along, demand a new lawyer from the firm's associates or from the insurer's panel of lawyers, Mr. Sinclitico said.
Communication is a two-way street, he added. If you see an article in the medical literature that's pertinent to your case, send it to the lawyer. Insist on participating in selecting the medical experts whom your attorney will rely on.
▸ Communicate some more. The legal process can drag on for years, so expect ongoing communication from your legal team, preferably from your lawyer personally, Dr. Friend said.
Request regular, periodic status reports from the lawyer, Mr. Sinclitico advised. If the flow of paper stops, or if you call three or four times without a response from the lawyer, that's a red flag that something's wrong.
▸ Manage expectations. As the lawyer continually analyzes and updates you on the pros and cons of the legal proceedings, options should be articulated in a commonsense way without exaggerating the probable success of the case and without painting an overly bleak outcome.
▸ Explain billing. Demand an up-front, detailed accounting of billing policies. Law firms may bill for face time with the client, phone calls, conversations between firm members, time spent reviewing documents, legal research, preparation of forms or documents, revisions, travel time and expenses, and many other services.
If the lawyer in charge of the case changes while the case is in progress, the client should not have to pay for the firm to bring a new lawyer up to speed on the case, Dr. Friend said.
Pediatric SSRI Use Calls for Intense Monitoring
SAN DIEGO — Vigilantly monitor depressed children and adolescents during the first month of selective serotonin reuptake inhibitor therapy—especially in the first 10 days, David Sack, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
See the patient face-to-face at least weekly during that first month, and make sure that someone is monitoring the patient between visits. “It isn't enough to begin monitoring them when they show up at the office” for follow-up, said Dr. Sack of White Plains, N.Y.
Selective serotonin reuptake inhibitors (SSRIs) lack consistent data showing effectiveness in treating depression in children and adolescents, and metaanalyses of pediatric SSRI use show a slight but consistently significant increased risk of suicidal behavior with the drugs. The Food and Drug Administration's recent addition of a black box warning to labeling for SSRIs notes the risks of antidepressants in children.
An informal poll of several hundred physicians at the meeting showed that about half routinely schedule 1-week follow-ups after starting SSRIs in depressed children and adolescents. The first and second weeks “are very high-risk periods. If we're going to treat children with SSRIs, then we're going to have to modify the way we follow them up,” he said.
Studies of depressed adults treated with SSRIs suggest that the risk of suicidal behavior is four times higher in the first 7 days, compared with other times in the first 90 days. In the first month of treatment, the risk of suicidal behavior is three times higher than in the following 60 days.
Vigilant monitoring during these high-risk periods is a challenge for most medical practices. “As hard as it is for a psychiatrist to maintain contact in the first week, it's even more difficult for many pediatric practices,” Dr. Sack noted. Front-office nurses or other personnel may not have the knowledge to assess over the phone whether a patient has had a change in behavior. “We have a lot of work to do in terms of our training and understanding to make this a reality in practice,” he said.
Patients with a history of prior suicide attempt or previous antidepressant therapy failure are at increased risk for suicidal behavior on SSRIs.
Before starting SSRI therapy in a child or adolescent, rule out bipolar disorder as much as possible.
Give verbal and written information to families about the lack of consistent benefit with SSRIs in depressed pediatric patients and the apparent increase in risk of suicidal ideation. Respect a family's decision if they refuse SSRI therapy for the patient, Dr. Sack instructed.
Families should be told to contact the physician's office if they see changes suggesting suicidal thinking or behavior. “They need to know that changes in hopelessness or suicidal ideation are an emergency,” he said.
The need to change dosages or drugs should be a sentinel for increased risk, he added. Pay special attention about 3–4 weeks after starting therapy, which is when most switches occur.
Use the weekly visits and monitoring in between to look for and respond to signs of suicidality, and to avoid a lawsuit in the event that something goes wrong, write down everything done to monitor the patient, Dr. Sack said.
None of the pediatric trials individually showed an increased risk of suicidality. Only when the data were pooled did that risk emerge. Pooled estimates suggest up to a doubling of risk for suicidal ideation in children on SSRIs, compared with placebo.
Only one out of five placebo-controlled studies of SSRIs in children and adolescents showed efficacy in treating depression, but that may be attributable to the studies' designs, Dr. Sack said. A separate 2004 study suggested that every 1% increase in adolescent use of SSRIs for major depression decreases the suicide rate by 0.23 per 100,000 adolescents.
SAN DIEGO — Vigilantly monitor depressed children and adolescents during the first month of selective serotonin reuptake inhibitor therapy—especially in the first 10 days, David Sack, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
See the patient face-to-face at least weekly during that first month, and make sure that someone is monitoring the patient between visits. “It isn't enough to begin monitoring them when they show up at the office” for follow-up, said Dr. Sack of White Plains, N.Y.
Selective serotonin reuptake inhibitors (SSRIs) lack consistent data showing effectiveness in treating depression in children and adolescents, and metaanalyses of pediatric SSRI use show a slight but consistently significant increased risk of suicidal behavior with the drugs. The Food and Drug Administration's recent addition of a black box warning to labeling for SSRIs notes the risks of antidepressants in children.
An informal poll of several hundred physicians at the meeting showed that about half routinely schedule 1-week follow-ups after starting SSRIs in depressed children and adolescents. The first and second weeks “are very high-risk periods. If we're going to treat children with SSRIs, then we're going to have to modify the way we follow them up,” he said.
Studies of depressed adults treated with SSRIs suggest that the risk of suicidal behavior is four times higher in the first 7 days, compared with other times in the first 90 days. In the first month of treatment, the risk of suicidal behavior is three times higher than in the following 60 days.
Vigilant monitoring during these high-risk periods is a challenge for most medical practices. “As hard as it is for a psychiatrist to maintain contact in the first week, it's even more difficult for many pediatric practices,” Dr. Sack noted. Front-office nurses or other personnel may not have the knowledge to assess over the phone whether a patient has had a change in behavior. “We have a lot of work to do in terms of our training and understanding to make this a reality in practice,” he said.
Patients with a history of prior suicide attempt or previous antidepressant therapy failure are at increased risk for suicidal behavior on SSRIs.
Before starting SSRI therapy in a child or adolescent, rule out bipolar disorder as much as possible.
Give verbal and written information to families about the lack of consistent benefit with SSRIs in depressed pediatric patients and the apparent increase in risk of suicidal ideation. Respect a family's decision if they refuse SSRI therapy for the patient, Dr. Sack instructed.
Families should be told to contact the physician's office if they see changes suggesting suicidal thinking or behavior. “They need to know that changes in hopelessness or suicidal ideation are an emergency,” he said.
The need to change dosages or drugs should be a sentinel for increased risk, he added. Pay special attention about 3–4 weeks after starting therapy, which is when most switches occur.
Use the weekly visits and monitoring in between to look for and respond to signs of suicidality, and to avoid a lawsuit in the event that something goes wrong, write down everything done to monitor the patient, Dr. Sack said.
None of the pediatric trials individually showed an increased risk of suicidality. Only when the data were pooled did that risk emerge. Pooled estimates suggest up to a doubling of risk for suicidal ideation in children on SSRIs, compared with placebo.
Only one out of five placebo-controlled studies of SSRIs in children and adolescents showed efficacy in treating depression, but that may be attributable to the studies' designs, Dr. Sack said. A separate 2004 study suggested that every 1% increase in adolescent use of SSRIs for major depression decreases the suicide rate by 0.23 per 100,000 adolescents.
SAN DIEGO — Vigilantly monitor depressed children and adolescents during the first month of selective serotonin reuptake inhibitor therapy—especially in the first 10 days, David Sack, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
See the patient face-to-face at least weekly during that first month, and make sure that someone is monitoring the patient between visits. “It isn't enough to begin monitoring them when they show up at the office” for follow-up, said Dr. Sack of White Plains, N.Y.
Selective serotonin reuptake inhibitors (SSRIs) lack consistent data showing effectiveness in treating depression in children and adolescents, and metaanalyses of pediatric SSRI use show a slight but consistently significant increased risk of suicidal behavior with the drugs. The Food and Drug Administration's recent addition of a black box warning to labeling for SSRIs notes the risks of antidepressants in children.
An informal poll of several hundred physicians at the meeting showed that about half routinely schedule 1-week follow-ups after starting SSRIs in depressed children and adolescents. The first and second weeks “are very high-risk periods. If we're going to treat children with SSRIs, then we're going to have to modify the way we follow them up,” he said.
Studies of depressed adults treated with SSRIs suggest that the risk of suicidal behavior is four times higher in the first 7 days, compared with other times in the first 90 days. In the first month of treatment, the risk of suicidal behavior is three times higher than in the following 60 days.
Vigilant monitoring during these high-risk periods is a challenge for most medical practices. “As hard as it is for a psychiatrist to maintain contact in the first week, it's even more difficult for many pediatric practices,” Dr. Sack noted. Front-office nurses or other personnel may not have the knowledge to assess over the phone whether a patient has had a change in behavior. “We have a lot of work to do in terms of our training and understanding to make this a reality in practice,” he said.
Patients with a history of prior suicide attempt or previous antidepressant therapy failure are at increased risk for suicidal behavior on SSRIs.
Before starting SSRI therapy in a child or adolescent, rule out bipolar disorder as much as possible.
Give verbal and written information to families about the lack of consistent benefit with SSRIs in depressed pediatric patients and the apparent increase in risk of suicidal ideation. Respect a family's decision if they refuse SSRI therapy for the patient, Dr. Sack instructed.
Families should be told to contact the physician's office if they see changes suggesting suicidal thinking or behavior. “They need to know that changes in hopelessness or suicidal ideation are an emergency,” he said.
The need to change dosages or drugs should be a sentinel for increased risk, he added. Pay special attention about 3–4 weeks after starting therapy, which is when most switches occur.
Use the weekly visits and monitoring in between to look for and respond to signs of suicidality, and to avoid a lawsuit in the event that something goes wrong, write down everything done to monitor the patient, Dr. Sack said.
None of the pediatric trials individually showed an increased risk of suicidality. Only when the data were pooled did that risk emerge. Pooled estimates suggest up to a doubling of risk for suicidal ideation in children on SSRIs, compared with placebo.
Only one out of five placebo-controlled studies of SSRIs in children and adolescents showed efficacy in treating depression, but that may be attributable to the studies' designs, Dr. Sack said. A separate 2004 study suggested that every 1% increase in adolescent use of SSRIs for major depression decreases the suicide rate by 0.23 per 100,000 adolescents.
Question the Right People For Bipolar Dx
SAN FRANCISCO — Diagnosing bipolar disorder requires not just asking the right questions but the right people, Michael J. Gitlin, M.D., said.
More than a third of 600 bipolar disorder patients sought help within a year of becoming symptomatic, but 69% were misdiagnosed (usually as having major depression). In addition, patients saw a mean of four physicians before being correctly diagnosed, a 2003 survey found.
“My quarrel with these data that get published over and over is that the implication is that the physicians” erred, said Dr. Gitlin, professor of clinical psychiatry at the University of California, Los Angeles. “I think it's more complex than that.”
Even physicians who ask the right questions often fail to get the whole story from bipolar disorder patients. “You need corroborative evidence” obtained by getting the patient's permission to talk with significant others—a spouse, boyfriend or girlfriend, sibling, or parents, he said.
The same survey of 600 bipolar disorder patients found that they reported manic symptoms far less often than they reported depressive symptoms to physicians when seeking help (J. Clin. Psychiatry 2003;64:161–74).
That's not surprising, he noted, because depression feels bad and brings people into treatment. Patients reported manic symptoms other than erratic sleep only 43% of the time or less. Only 37% of patients, for example, told physicians of feeling elated at times.
“That is much more the issue than the idea that we're not probing correctly,” he said.
Bipolar disorder patients may not recognize manic or hypomanic symptoms as abnormal, or remember having them. When they're depressed, they're dominated by depressive thoughts and symptoms, and when they're hypomanic they may not remember the depressive symptoms.
Ask significant others as well as the patient about any hypomanic symptoms immediately before or after depressed periods. The highs and lows of bipolar disorder are temporarily related, usually with mania preceding depression, but less commonly in reverse order, Dr. Gitlin said.
Don't just focus on mood, but ask about overactivity, which may be a core feature of hypomania. “The data are not entirely convincing for this, but I think it's something we really ought to be thinking about,” he said.
Ask about a family history of mood disorders, and ask whether the patient or family members have ever shown signs of antidepressant-induced hypomania. If you decide to start an antidepressant, educate the patient and significant others to watch for signs of induced hypomania.
SAN FRANCISCO — Diagnosing bipolar disorder requires not just asking the right questions but the right people, Michael J. Gitlin, M.D., said.
More than a third of 600 bipolar disorder patients sought help within a year of becoming symptomatic, but 69% were misdiagnosed (usually as having major depression). In addition, patients saw a mean of four physicians before being correctly diagnosed, a 2003 survey found.
“My quarrel with these data that get published over and over is that the implication is that the physicians” erred, said Dr. Gitlin, professor of clinical psychiatry at the University of California, Los Angeles. “I think it's more complex than that.”
Even physicians who ask the right questions often fail to get the whole story from bipolar disorder patients. “You need corroborative evidence” obtained by getting the patient's permission to talk with significant others—a spouse, boyfriend or girlfriend, sibling, or parents, he said.
The same survey of 600 bipolar disorder patients found that they reported manic symptoms far less often than they reported depressive symptoms to physicians when seeking help (J. Clin. Psychiatry 2003;64:161–74).
That's not surprising, he noted, because depression feels bad and brings people into treatment. Patients reported manic symptoms other than erratic sleep only 43% of the time or less. Only 37% of patients, for example, told physicians of feeling elated at times.
“That is much more the issue than the idea that we're not probing correctly,” he said.
Bipolar disorder patients may not recognize manic or hypomanic symptoms as abnormal, or remember having them. When they're depressed, they're dominated by depressive thoughts and symptoms, and when they're hypomanic they may not remember the depressive symptoms.
Ask significant others as well as the patient about any hypomanic symptoms immediately before or after depressed periods. The highs and lows of bipolar disorder are temporarily related, usually with mania preceding depression, but less commonly in reverse order, Dr. Gitlin said.
Don't just focus on mood, but ask about overactivity, which may be a core feature of hypomania. “The data are not entirely convincing for this, but I think it's something we really ought to be thinking about,” he said.
Ask about a family history of mood disorders, and ask whether the patient or family members have ever shown signs of antidepressant-induced hypomania. If you decide to start an antidepressant, educate the patient and significant others to watch for signs of induced hypomania.
SAN FRANCISCO — Diagnosing bipolar disorder requires not just asking the right questions but the right people, Michael J. Gitlin, M.D., said.
More than a third of 600 bipolar disorder patients sought help within a year of becoming symptomatic, but 69% were misdiagnosed (usually as having major depression). In addition, patients saw a mean of four physicians before being correctly diagnosed, a 2003 survey found.
“My quarrel with these data that get published over and over is that the implication is that the physicians” erred, said Dr. Gitlin, professor of clinical psychiatry at the University of California, Los Angeles. “I think it's more complex than that.”
Even physicians who ask the right questions often fail to get the whole story from bipolar disorder patients. “You need corroborative evidence” obtained by getting the patient's permission to talk with significant others—a spouse, boyfriend or girlfriend, sibling, or parents, he said.
The same survey of 600 bipolar disorder patients found that they reported manic symptoms far less often than they reported depressive symptoms to physicians when seeking help (J. Clin. Psychiatry 2003;64:161–74).
That's not surprising, he noted, because depression feels bad and brings people into treatment. Patients reported manic symptoms other than erratic sleep only 43% of the time or less. Only 37% of patients, for example, told physicians of feeling elated at times.
“That is much more the issue than the idea that we're not probing correctly,” he said.
Bipolar disorder patients may not recognize manic or hypomanic symptoms as abnormal, or remember having them. When they're depressed, they're dominated by depressive thoughts and symptoms, and when they're hypomanic they may not remember the depressive symptoms.
Ask significant others as well as the patient about any hypomanic symptoms immediately before or after depressed periods. The highs and lows of bipolar disorder are temporarily related, usually with mania preceding depression, but less commonly in reverse order, Dr. Gitlin said.
Don't just focus on mood, but ask about overactivity, which may be a core feature of hypomania. “The data are not entirely convincing for this, but I think it's something we really ought to be thinking about,” he said.
Ask about a family history of mood disorders, and ask whether the patient or family members have ever shown signs of antidepressant-induced hypomania. If you decide to start an antidepressant, educate the patient and significant others to watch for signs of induced hypomania.
Botox Reduced Excessive Sweating in 1-Year Trial
KOHALA COAST, HAWAII — Underarm injections of botulinum toxin type A reduced underarm sweating by at least 75% in 80%–84% of patients for a median of 7 months in a yearlong study of 322 patients with primary hyperhidrosis, said Dee Anna Glaser, M.D.
Gravimetric measurements of sweat production showed that sweating was reduced by at least 75% in only 21% of patients treated with placebo in the multicenter, double-blind, randomized, controlled trial, she said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc. Dr. Glaser previously reported the results at the 2004 meeting of the American Academy of Neurology.
The study included patients with scores of 3 or 4 on the 4-point Hyperhidrosis Disease Severity Scale (HDSS), meaning they reported intolerable or barely tolerable axillary sweating that always or frequently interfered with activities. They were randomized to treatment with injections of 50 or 75 units of botulinum toxin type A (Botox) or placebo in each armpit, and could be reinjected 8 or more weeks after the injections. The patients were followed at 4-week intervals.
In the 50-unit and 75-unit Botox groups, a first treatment improved HDSS scores by at least 2 points (to tolerable or unnoticeable) in 75% of patients, compared with a 2-point improvement in 25% of the placebo group, said Dr. Glaser of St. Louis University. The HDSS score improvements in the Botox groups lasted a median of 7 months after the first treatment.
After a second treatment, 85% in the 50-unit Botox group, 74% in the 75-unit Botox group, and 26% in the placebo group improved HDSS scores by at least 2 points. The improvements lasted a median of about 5 months in the 50-unit Botox group and 6 months in the 75-unit Botox group.
Dr. Glaser is a consultant for and has received research funding from Allergan Inc. which markets Botox, and her family owns stock in the company.
More than half of patients at baseline in each group reported feeling dissatisfied with their ability to perform work activities because of hyperhidrosis. These percentages fell significantly in the Botox groups, to 10% or less, but declined only slightly in the placebo group.
Despite receiving multiple injections in their armpits, 84%–85% of patients in the Botox groups and 20% in the placebo group said that they felt much more satisfied with the results of this therapy, compared with any previous treatments.
The main side effects were some pain or bleeding at the injection site in 3%–12% of patients. Between 4% and 10% of patients thought their hands or feet were sweating a little more after the armpit injections, “but in truth I think that maybe they just started noticing it,” Dr. Glaser said.
Treating Axilla With Botox
To treat the axilla with Botox, Dr. Glaser first delineates the treatment area by Minors starch/iodine test. She dries the armpit, swabs it with Betadine a couple of centimeters beyond what appears to be the axillary border, and applies a light dusting of starch powder.
She uses a makeup brush to apply the powder, but other gentle techniques work as well, such as using a powdered sugar sifter, she said.
The combination of Betadine and powder turns blue-black in the presence of sweat glands, and in 20%–25% of cases identifies little ectopic foci of the axillae that might be missed if the target area is estimated without the powder dusting.
Dr. Glaser marks the perimeter of the axillae and draws points for injection targets every 1.5–2 cm, which is 10–15 injection sites for an average-sized underarm. She reconstitutes 50 units of Botox in 4 cc of saline per underarm and divides the amount by the number of injection sites. Using a 30-gauge needle and a 1-cc syringe, she administers the calculated amount per site in deep dermal or intradermal injections, which should start to produce a wheal.
KOHALA COAST, HAWAII — Underarm injections of botulinum toxin type A reduced underarm sweating by at least 75% in 80%–84% of patients for a median of 7 months in a yearlong study of 322 patients with primary hyperhidrosis, said Dee Anna Glaser, M.D.
Gravimetric measurements of sweat production showed that sweating was reduced by at least 75% in only 21% of patients treated with placebo in the multicenter, double-blind, randomized, controlled trial, she said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc. Dr. Glaser previously reported the results at the 2004 meeting of the American Academy of Neurology.
The study included patients with scores of 3 or 4 on the 4-point Hyperhidrosis Disease Severity Scale (HDSS), meaning they reported intolerable or barely tolerable axillary sweating that always or frequently interfered with activities. They were randomized to treatment with injections of 50 or 75 units of botulinum toxin type A (Botox) or placebo in each armpit, and could be reinjected 8 or more weeks after the injections. The patients were followed at 4-week intervals.
In the 50-unit and 75-unit Botox groups, a first treatment improved HDSS scores by at least 2 points (to tolerable or unnoticeable) in 75% of patients, compared with a 2-point improvement in 25% of the placebo group, said Dr. Glaser of St. Louis University. The HDSS score improvements in the Botox groups lasted a median of 7 months after the first treatment.
After a second treatment, 85% in the 50-unit Botox group, 74% in the 75-unit Botox group, and 26% in the placebo group improved HDSS scores by at least 2 points. The improvements lasted a median of about 5 months in the 50-unit Botox group and 6 months in the 75-unit Botox group.
Dr. Glaser is a consultant for and has received research funding from Allergan Inc. which markets Botox, and her family owns stock in the company.
More than half of patients at baseline in each group reported feeling dissatisfied with their ability to perform work activities because of hyperhidrosis. These percentages fell significantly in the Botox groups, to 10% or less, but declined only slightly in the placebo group.
Despite receiving multiple injections in their armpits, 84%–85% of patients in the Botox groups and 20% in the placebo group said that they felt much more satisfied with the results of this therapy, compared with any previous treatments.
The main side effects were some pain or bleeding at the injection site in 3%–12% of patients. Between 4% and 10% of patients thought their hands or feet were sweating a little more after the armpit injections, “but in truth I think that maybe they just started noticing it,” Dr. Glaser said.
Treating Axilla With Botox
To treat the axilla with Botox, Dr. Glaser first delineates the treatment area by Minors starch/iodine test. She dries the armpit, swabs it with Betadine a couple of centimeters beyond what appears to be the axillary border, and applies a light dusting of starch powder.
She uses a makeup brush to apply the powder, but other gentle techniques work as well, such as using a powdered sugar sifter, she said.
The combination of Betadine and powder turns blue-black in the presence of sweat glands, and in 20%–25% of cases identifies little ectopic foci of the axillae that might be missed if the target area is estimated without the powder dusting.
Dr. Glaser marks the perimeter of the axillae and draws points for injection targets every 1.5–2 cm, which is 10–15 injection sites for an average-sized underarm. She reconstitutes 50 units of Botox in 4 cc of saline per underarm and divides the amount by the number of injection sites. Using a 30-gauge needle and a 1-cc syringe, she administers the calculated amount per site in deep dermal or intradermal injections, which should start to produce a wheal.
KOHALA COAST, HAWAII — Underarm injections of botulinum toxin type A reduced underarm sweating by at least 75% in 80%–84% of patients for a median of 7 months in a yearlong study of 322 patients with primary hyperhidrosis, said Dee Anna Glaser, M.D.
Gravimetric measurements of sweat production showed that sweating was reduced by at least 75% in only 21% of patients treated with placebo in the multicenter, double-blind, randomized, controlled trial, she said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc. Dr. Glaser previously reported the results at the 2004 meeting of the American Academy of Neurology.
The study included patients with scores of 3 or 4 on the 4-point Hyperhidrosis Disease Severity Scale (HDSS), meaning they reported intolerable or barely tolerable axillary sweating that always or frequently interfered with activities. They were randomized to treatment with injections of 50 or 75 units of botulinum toxin type A (Botox) or placebo in each armpit, and could be reinjected 8 or more weeks after the injections. The patients were followed at 4-week intervals.
In the 50-unit and 75-unit Botox groups, a first treatment improved HDSS scores by at least 2 points (to tolerable or unnoticeable) in 75% of patients, compared with a 2-point improvement in 25% of the placebo group, said Dr. Glaser of St. Louis University. The HDSS score improvements in the Botox groups lasted a median of 7 months after the first treatment.
After a second treatment, 85% in the 50-unit Botox group, 74% in the 75-unit Botox group, and 26% in the placebo group improved HDSS scores by at least 2 points. The improvements lasted a median of about 5 months in the 50-unit Botox group and 6 months in the 75-unit Botox group.
Dr. Glaser is a consultant for and has received research funding from Allergan Inc. which markets Botox, and her family owns stock in the company.
More than half of patients at baseline in each group reported feeling dissatisfied with their ability to perform work activities because of hyperhidrosis. These percentages fell significantly in the Botox groups, to 10% or less, but declined only slightly in the placebo group.
Despite receiving multiple injections in their armpits, 84%–85% of patients in the Botox groups and 20% in the placebo group said that they felt much more satisfied with the results of this therapy, compared with any previous treatments.
The main side effects were some pain or bleeding at the injection site in 3%–12% of patients. Between 4% and 10% of patients thought their hands or feet were sweating a little more after the armpit injections, “but in truth I think that maybe they just started noticing it,” Dr. Glaser said.
Treating Axilla With Botox
To treat the axilla with Botox, Dr. Glaser first delineates the treatment area by Minors starch/iodine test. She dries the armpit, swabs it with Betadine a couple of centimeters beyond what appears to be the axillary border, and applies a light dusting of starch powder.
She uses a makeup brush to apply the powder, but other gentle techniques work as well, such as using a powdered sugar sifter, she said.
The combination of Betadine and powder turns blue-black in the presence of sweat glands, and in 20%–25% of cases identifies little ectopic foci of the axillae that might be missed if the target area is estimated without the powder dusting.
Dr. Glaser marks the perimeter of the axillae and draws points for injection targets every 1.5–2 cm, which is 10–15 injection sites for an average-sized underarm. She reconstitutes 50 units of Botox in 4 cc of saline per underarm and divides the amount by the number of injection sites. Using a 30-gauge needle and a 1-cc syringe, she administers the calculated amount per site in deep dermal or intradermal injections, which should start to produce a wheal.
Survey Finds Gaps in Physicians' HPV Knowledge
VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.
Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.
Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC.
Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.
Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).
A higher proportion of ob.gyns. (67%) knew that HPV infections may clear without medical intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).
Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).
A second analysis of results related to HPV testing practices found that 35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians use HPV tests, Nidhi Jain, M.D., of the CDC in Atlanta reported at the conference, sponsored by the University of California, San Francisco.
By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.
Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASC-US), and 98% of the 2,980 respondents use it for that purpose.
The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.
The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.
A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.
Ob.gyns. and nurse-midwives were the most likely to do an HPV test following an ASC-US Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported.
Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. Nearly half (48%) said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the HPV test as it relates to the Pap smear.
VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.
Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.
Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC.
Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.
Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).
A higher proportion of ob.gyns. (67%) knew that HPV infections may clear without medical intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).
Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).
A second analysis of results related to HPV testing practices found that 35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians use HPV tests, Nidhi Jain, M.D., of the CDC in Atlanta reported at the conference, sponsored by the University of California, San Francisco.
By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.
Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASC-US), and 98% of the 2,980 respondents use it for that purpose.
The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.
The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.
A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.
Ob.gyns. and nurse-midwives were the most likely to do an HPV test following an ASC-US Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported.
Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. Nearly half (48%) said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the HPV test as it relates to the Pap smear.
VANCOUVER, B.C. — A large survey of U.S. clinicians in nine specialties identified clinically important gaps in their knowledge of human papillomavirus and found that many don't test for HPV in the recommended ways.
Several analyses of the survey results by investigators at the Centers for Disease Control and Prevention were reported in separate poster presentations at the 22nd International Papillomavirus Conference.
Only 35% of 4,305 clinicians surveyed were aware that recent scientific evidence shows that most HPV infections clear without medical intervention, reported Crystal M. Freeman, Ph.D., of Battelle Centers for Public Health Research and Evaluation of Seattle, which conducted the survey studies with the CDC.
Knowledge of anogenital warts also appeared to be inadequate. Only 38% of respondents knew that anogenital warts do not increase the risk of cancer at the same sites where the warts are located, and only 47% knew that genital HPV types usually associated with external anogenital warts are not the same HPV types associated with cervical dysplasia and cancer.
Respondents included 464 ob.gyns., 1,107 primary care physicians (family or general physicians, internists, or adolescent medicine physicians), 966 specialists (dermatologists or urologists), 624 certified nurse-midwives, and 1,144 midlevel providers (nurse-practitioners or physician assistants).
A higher proportion of ob.gyns. (67%) knew that HPV infections may clear without medical intervention, compared with primary care physicians (31%), specialists (14%), midlevel providers (30%), or nurse-midwives (43%).
Nearly all respondents knew, however, that HPV infection is common (89%), that most people with HPV lack signs or symptoms of infection (95%), and that HPV infection increases the risk of cervical cancer (98%). They also showed high rates of knowledge that HPV infection causes anogenital warts (90%) and that treating warts or cervical dysplasia does not eliminate HPV infection (91%).
A second analysis of results related to HPV testing practices found that 35% of general internists, 33% of adolescent medicine physicians, and 57% of family or general physicians use HPV tests, Nidhi Jain, M.D., of the CDC in Atlanta reported at the conference, sponsored by the University of California, San Francisco.
By comparison, 93% of ob.gyns. said they use HPV tests, as did 89% of certified nurse-midwives, 63% of nurse-practitioners, 56% of physician assistants, 10% of urologists, and 5% of dermatologists.
Among the 2,980 clinicians who use HPV tests, many test in ways not recommended by national guidelines, the survey found. The HPV test is approved to help manage patients with Pap results showing atypical squamous cells of undetermined significance (ASC-US), and 98% of the 2,980 respondents use it for that purpose.
The HPV test also is used by 91% of clinicians in patients with higher-grade Pap abnormalities, which is an off-label use of the test.
The second approved use of the HPV test is as an adjunct to Pap testing for cervical screening in women older than 30. Clinicians were equally likely to use HPV testing in women older or younger than 30 years, regardless of the guidelines.
A significant minority of clinicians also tested for HPV in men, patients with other sexually transmitted diseases, and patients with anogenital warts—all indications outside current guidelines.
Ob.gyns. and nurse-midwives were the most likely to do an HPV test following an ASC-US Pap result, compared with other clinicians, Kathleen Irwin, M.D., of the CDC reported.
Only 28% usually sought patient consent when doing an HPV test after an abnormal Pap result. Nearly half (48%) said they tell patients they are ordering an HPV test, and 58% usually explain the purpose of the HPV test as it relates to the Pap smear.
No Simple Markers of HPV Risk in Older Women
VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.
Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.
“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.
All the women completed a detailed medical and sexual history form and underwent a pelvic exam. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years.
More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of lifetime sexual partners, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.
Pap results did not correlate with risk for infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman.
VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.
Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.
“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.
All the women completed a detailed medical and sexual history form and underwent a pelvic exam. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years.
More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of lifetime sexual partners, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.
Pap results did not correlate with risk for infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman.
VANCOUVER, B.C. — There's no easy way to identify older women whose risk for human papillomavirus infection is low, so physicians should continue cervical screening unless the woman has tested negative consistently for the virus, Concepcion Diaz-Arrastia, M.D., and her associates advised in a poster presentation at the 22nd International Papillomavirus Conference.
Nineteen (11%) of 176 women older than 55 years tested positive for infection with high-risk or intermediate-risk types of the human papillomavirus (HPV) in a prospective, longitudinal study, they reported at the conference, sponsored by the University of California, San Francisco.
“High-risk HPV infection is not restricted to young women,” said Dr. Diaz-Arrastia of the University of Texas, Galveston, and her associates.
All the women completed a detailed medical and sexual history form and underwent a pelvic exam. The study found no clear social markers of risk for HPV infection in this group of older women, whose mean age was 67 years.
More than a third of the HPV-positive women said they had been sexually inactive for more than the past 5 years. There were no significant differences between the HPV-positive and negative women in terms of the traditional social risk factors for cervical neoplasia, including a history of first sexual activity before age 16, number of lifetime sexual partners, presence of other sexually transmitted disease, history of sexual abuse, or smoking habits.
Pap results did not correlate with risk for infection. In the HPV-positive group, two women had atypical squamous cells of undetermined significance (ASC-US), and one woman had low-grade squamous intraepithelial lesions (LSIL). In the HPV-negative group, Pap results showed ASC-US in five women and LSIL in one woman.