Sherry Boschert

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed an acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine.

“It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

In practical terms, however, physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI— other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were from two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

On the other hand, it's “refreshing” to hear skepticism about widespread use in the United States of stress tests, chest pain units, and prolonged cardiac monitoring, he added.

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed an acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine.

“It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

In practical terms, however, physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI— other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were from two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

On the other hand, it's “refreshing” to hear skepticism about widespread use in the United States of stress tests, chest pain units, and prolonged cardiac monitoring, he added.

SAN FRANCISCO — In some patients being evaluated for chest pain, stress tests might be avoided through the use of an algorithm designed to predict the probability of cardiac ischemia, David D. Moyer-Diener and his associates said at the annual meeting of the American College of Emergency Physicians.

In a prospective, observational cohort study of consecutive patients evaluated at a chest pain center, investigators obtained Acute Coronary Ischemia-Time Insensitive Predictive Instrument (ACI-TIPI) scores and conventional chest pain work-ups on 1,478 low- or intermediate-risk patients for whom acute myocardial ischemia had been ruled out. The treating physicians were blinded to the ACI-TIPI scores, and patients underwent conventional evaluations including serial enzyme tests and provocative cardiac testing.

Among 400 patients who had ACI-TIPI scores of 20 or less, 265 were men younger than aged 35 years or women younger than aged 45 years, and 217 underwent provocative cardiac testing. None of the 265 patients developed an acute coronary syndrome within 30 days, as determined by phone calls to patients and reviews of records and the Social Security Death Index.

If clinicians had used an ACI-TIPI score of 20 or less in these subsets of young patients to exclude provocative cardiac testing and had sent these patients home, 15% of all stress tests in the study cohort could have been avoided without causing any harm, said Mr. Moyer-Diener, a medical student at the University of Michigan, Ann Arbor, who conducted the study with Michael G. Mikhail, M.D., and associates at the university.

At the meeting, physicians on a separate panel discussing cutting-edge research both praised and criticized the study.

“There's been a lot of debate about just how useful” an ACI-TIPI score is, said Charles V. Pollack Jr., M.D., chair of emergency medicine at Pennsylvania Hospital, Philadelphia. Many emergency physicians would rather not have a quantitative number related to the risk of ischemia on a patient's chart, he said, because if the case sparks a lawsuit, they would rather defend their clinical impression that the patient didn't have ischemia.

The ACI-TIPI was designed to predict the probability of cardiac ischemia on a 0- to 100-point scale, to serve as support or a “second opinion” in clinical decision making. The way ACI-TIPI was used in the study to identify patients who don't need further tests “is not really the use for which it was designed,” but the idea is intriguing, Dr. Pollack said.

Jerome R. Hoffman, M.D., lauded the investigators for trying to identify a strategy to cut down on the many unnecessary tests performed for chest pain evaluation that are not backed by evidence-based medicine.

“It's very hard to get us out of that rut,” said Dr. Hoffman, professor of emergency medicine at the University of California, Los Angeles.

In practical terms, however, physicians are unlikely to adopt these criteria for avoiding stress tests. An ACI-TIPI score of 20 or less is associated with a 19% risk of acute myocardial ischemia, he explained. For medicolegal reasons, physicians will not feel comfortable sending patients home if that number appears on a patient's chart.

“That, more than anything, makes me question the value of an ACI-TIPI— other than as a research tool,” Dr. Hoffman said.

Previous studies have shown that physicians were from two to three times more likely to admit patients if given an ACI-TIPI score to include in the patient's chart, said Ian G. Stiell, M.D., of the University of Ottawa.

On the other hand, it's “refreshing” to hear skepticism about widespread use in the United States of stress tests, chest pain units, and prolonged cardiac monitoring, he added.

SAN DIEGO – Vigilantly monitor depressed children and adolescents during the first month of selective serotonin reuptake inhibitor therapy–especially during 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 during 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 during 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.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks into treatment and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, he warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. “Every time it has failed, I've undertreated,” Dr. Berger said. In appropriate doses, the combination therapy has never failed him.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks into treatment and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, he warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. “Every time it has failed, I've undertreated,” Dr. Berger said. In appropriate doses, the combination therapy has never failed him.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

KOHALA COAST, HAWAII — Attack hyperkeratotic scabies both topically and systemically or your treatment will fail, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

He divides patients with scabies into two categories to guide management—those with a low burden or a high burden of disease. For the typical patient with a low burden, two applications of permethrin 5% cream a week apart will cure 95% of cases.

But a double whammy usually is needed for patients with a high burden of disease—those with crusted or hyperkeratotic scabies, AIDS and scabies, or scabies acquired while in a long-term care facility or prison, said Dr. Berger of the University of California, San Francisco.

He prefers to use these two categories because patients with a high burden of disease may present with multiple papules instead of crusts, but need the combination therapy used for crusted scabies.

The combination treatment consists of weekly applications of permethrin 5% cream for 3–6 weeks plus ivermectin 200 mcg/kg every 2 weeks for two (or occasionally three) doses. The patient should show improvement by 3 weeks into treatment and continue to gradually improve.

Don't try to save a buck by skimping on the ivermectin, he warned. Don't round down the dose but, rather, give the full dose of ivermectin (usually 12–18 mg), and allow plenty of time to treat. “Every time it has failed, I've undertreated,” Dr. Berger said. In appropriate doses, the combination therapy has never failed him.

Don't be dissuaded from suspecting scabies just because a patient has failed permethrin treatment or family members seem unaffected, Dr. Berger advised.

Treat the whole family, but not necessarily immediately. Family members who are affected get immediate treatment, but otherwise Dr. Berger waits to treat the family until the primary patient has been treated, so that the patient is no longer infectious.

High-burden cases often involve the scalp, so instruct patients to apply permethrin to the scalp too, he advised. Ivermectin won't help scabies involving the nail plate, so consider more aggressive treatments for nail scabies.

Ivermectin is secreted in sebum, he noted, which is one reason monotherapy may not work in the elderly, children, malnourished patients, or people with Down syndrome, all of whom make less sebum.

Immunosuppression plus neural disease puts patients at risk for crusted scabies, one reason that people with AIDS or Down syndrome are at higher risk for crusted scabies, he said.

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of ?-tocopherol and ?-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of ?-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of ?-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation, he added.

Micronutrients in fruits and vegetables have antioxidant and immunomodulatory effects that may counter HPV infection. James Reinaker

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of ?-tocopherol and ?-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of ?-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of ?-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation, he added.

Micronutrients in fruits and vegetables have antioxidant and immunomodulatory effects that may counter HPV infection. James Reinaker

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of ?-tocopherol and ?-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of ?-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of ?-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation, he added.

Micronutrients in fruits and vegetables have antioxidant and immunomodulatory effects that may counter HPV infection. James Reinaker

OAKLAND, CALIF. — The medical model of assessing diarrhea gauges severity based on the frequency of bowel movements, but that is not what's most distressing to many patients being treated for HIV infection, Lisa Capaldini, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

In many cases, the urgency of bowel movements affects patients' lives more than the number of diarrheal episodes. Ask the right questions to get a good functional assessment of the problem and to guide management, advised Dr. Capaldini, who practices internal medicine in San Francisco.

Among antiretroviral medications used to treat HIV, protease inhibitors are the most likely to cause variable degrees of gas, distension, and loose stools. But don't automatically assume that the protease inhibitor is causing the diarrhea. Rule out parasitic infection, and consider other drugs the patient is taking, she suggested.

Ask patients specifically about side effects instead of waiting for them to bring them up. “If it's anything that's potentially shaming or embarrassing, patients are less likely to report it,” she said. Asking them about it sends the message that other people have the same problem.

Ask patients not just whether they're having diarrhea, and how often, but at what time of day, she suggested. Ask how this affects them. Are they staying home because of it? Are they giving up activities that they like? Have they had any “accidents” when they couldn't get to a bathroom in time?

“One episode of losing control of your bowel in a public place for most people is worth 100 or 1,000 episodes of being in your own home and dealing with diarrhea,” she said at the conference, cosponsored by the Pacific AIDS Education and Training Center.

If a patient is doing well on HIV therapy except for loose stools just in the morning, neither the patient nor the clinician may want to change drug regimens. That's no excuse for complacency though, Dr. Capaldini said. “There's a tendency to put up with it and assume there's nothing we can do about it.”

Getting up an hour earlier each day to get the diarrhea out of the way before starting the rest of the day may help the patient cope. Taking an antidiarrheal agent such as diphenoxylate/atropine (Lomotil) at night may change the morning episodes from five bowel movements to one.

Dr. Capaldini is a speaker for all the companies that make antiretroviral medications. One of them, Pfizer, also makes Lomotil.

If these interventions don't work, try other management strategies that work in some patients but not others, for reasons unknown, she said. Most patients with diarrhea associated with the protease inhibitor nelfinavir who respond to pancreatic enzyme therapy do not have clinically apparent pancreatic dysfunction. “We don't know why they work, but sometimes they do,” Dr. Capaldini said.

High-dose oral calcium without magnesium may help some patients with HIV and diarrhea. Use calcium formulations without magnesium because magnesium exacerbates diarrhea.

Other options can be found on HIV Insite, a Web site run by the University of California, San Francisco, in a section on symptom management authored by Dr. Capaldini (http://hivinsite.ucsf.edu/InSite?page=kb-03-01-06

Dietary modifications such as limiting consumption of dairy products, sugar, or wheat may help, even if it does not seem like the modifications should help. Many patients who improve after eliminating wheat do not show evidence of gluten enteropathy or wheat allergy, for example.

Most patients try several strategies for managing diarrhea before they find the most helpful approach.

OAKLAND, CALIF. — The medical model of assessing diarrhea gauges severity based on the frequency of bowel movements, but that is not what's most distressing to many patients being treated for HIV infection, Lisa Capaldini, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

In many cases, the urgency of bowel movements affects patients' lives more than the number of diarrheal episodes. Ask the right questions to get a good functional assessment of the problem and to guide management, advised Dr. Capaldini, who practices internal medicine in San Francisco.

Among antiretroviral medications used to treat HIV, protease inhibitors are the most likely to cause variable degrees of gas, distension, and loose stools. But don't automatically assume that the protease inhibitor is causing the diarrhea. Rule out parasitic infection, and consider other drugs the patient is taking, she suggested.

Ask patients specifically about side effects instead of waiting for them to bring them up. “If it's anything that's potentially shaming or embarrassing, patients are less likely to report it,” she said. Asking them about it sends the message that other people have the same problem.

Ask patients not just whether they're having diarrhea, and how often, but at what time of day, she suggested. Ask how this affects them. Are they staying home because of it? Are they giving up activities that they like? Have they had any “accidents” when they couldn't get to a bathroom in time?

“One episode of losing control of your bowel in a public place for most people is worth 100 or 1,000 episodes of being in your own home and dealing with diarrhea,” she said at the conference, cosponsored by the Pacific AIDS Education and Training Center.

If a patient is doing well on HIV therapy except for loose stools just in the morning, neither the patient nor the clinician may want to change drug regimens. That's no excuse for complacency though, Dr. Capaldini said. “There's a tendency to put up with it and assume there's nothing we can do about it.”

Getting up an hour earlier each day to get the diarrhea out of the way before starting the rest of the day may help the patient cope. Taking an antidiarrheal agent such as diphenoxylate/atropine (Lomotil) at night may change the morning episodes from five bowel movements to one.

Dr. Capaldini is a speaker for all the companies that make antiretroviral medications. One of them, Pfizer, also makes Lomotil.

If these interventions don't work, try other management strategies that work in some patients but not others, for reasons unknown, she said. Most patients with diarrhea associated with the protease inhibitor nelfinavir who respond to pancreatic enzyme therapy do not have clinically apparent pancreatic dysfunction. “We don't know why they work, but sometimes they do,” Dr. Capaldini said.

High-dose oral calcium without magnesium may help some patients with HIV and diarrhea. Use calcium formulations without magnesium because magnesium exacerbates diarrhea.

Other options can be found on HIV Insite, a Web site run by the University of California, San Francisco, in a section on symptom management authored by Dr. Capaldini (http://hivinsite.ucsf.edu/InSite?page=kb-03-01-06

Dietary modifications such as limiting consumption of dairy products, sugar, or wheat may help, even if it does not seem like the modifications should help. Many patients who improve after eliminating wheat do not show evidence of gluten enteropathy or wheat allergy, for example.

Most patients try several strategies for managing diarrhea before they find the most helpful approach.

OAKLAND, CALIF. — The medical model of assessing diarrhea gauges severity based on the frequency of bowel movements, but that is not what's most distressing to many patients being treated for HIV infection, Lisa Capaldini, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

In many cases, the urgency of bowel movements affects patients' lives more than the number of diarrheal episodes. Ask the right questions to get a good functional assessment of the problem and to guide management, advised Dr. Capaldini, who practices internal medicine in San Francisco.

Among antiretroviral medications used to treat HIV, protease inhibitors are the most likely to cause variable degrees of gas, distension, and loose stools. But don't automatically assume that the protease inhibitor is causing the diarrhea. Rule out parasitic infection, and consider other drugs the patient is taking, she suggested.

Ask patients specifically about side effects instead of waiting for them to bring them up. “If it's anything that's potentially shaming or embarrassing, patients are less likely to report it,” she said. Asking them about it sends the message that other people have the same problem.

Ask patients not just whether they're having diarrhea, and how often, but at what time of day, she suggested. Ask how this affects them. Are they staying home because of it? Are they giving up activities that they like? Have they had any “accidents” when they couldn't get to a bathroom in time?

“One episode of losing control of your bowel in a public place for most people is worth 100 or 1,000 episodes of being in your own home and dealing with diarrhea,” she said at the conference, cosponsored by the Pacific AIDS Education and Training Center.

If a patient is doing well on HIV therapy except for loose stools just in the morning, neither the patient nor the clinician may want to change drug regimens. That's no excuse for complacency though, Dr. Capaldini said. “There's a tendency to put up with it and assume there's nothing we can do about it.”

Getting up an hour earlier each day to get the diarrhea out of the way before starting the rest of the day may help the patient cope. Taking an antidiarrheal agent such as diphenoxylate/atropine (Lomotil) at night may change the morning episodes from five bowel movements to one.

Dr. Capaldini is a speaker for all the companies that make antiretroviral medications. One of them, Pfizer, also makes Lomotil.

If these interventions don't work, try other management strategies that work in some patients but not others, for reasons unknown, she said. Most patients with diarrhea associated with the protease inhibitor nelfinavir who respond to pancreatic enzyme therapy do not have clinically apparent pancreatic dysfunction. “We don't know why they work, but sometimes they do,” Dr. Capaldini said.

High-dose oral calcium without magnesium may help some patients with HIV and diarrhea. Use calcium formulations without magnesium because magnesium exacerbates diarrhea.

Other options can be found on HIV Insite, a Web site run by the University of California, San Francisco, in a section on symptom management authored by Dr. Capaldini (http://hivinsite.ucsf.edu/InSite?page=kb-03-01-06

Dietary modifications such as limiting consumption of dairy products, sugar, or wheat may help, even if it does not seem like the modifications should help. Many patients who improve after eliminating wheat do not show evidence of gluten enteropathy or wheat allergy, for example.

Most patients try several strategies for managing diarrhea before they find the most helpful approach.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice lawsuit 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 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 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.

She suggested asking whether the lawyer has ever handled this type of case, and if there is a way to settle the matter without 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, or you don't get along, demand a new lawyer from the firm's associates or 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 several times without a response from the lawyer, that's a red flag 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 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, and be sure that you'll get access to all legal work generated on your behalf, she added.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice lawsuit 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 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 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.

She suggested asking whether the lawyer has ever handled this type of case, and if there is a way to settle the matter without 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, or you don't get along, demand a new lawyer from the firm's associates or 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 several times without a response from the lawyer, that's a red flag 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 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, and be sure that you'll get access to all legal work generated on your behalf, she added.

KOHALA COAST, HAWAII — You're a physician, not a lawyer. How do you know that the lawyer defending you in a malpractice lawsuit 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 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 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.

She suggested asking whether the lawyer has ever handled this type of case, and if there is a way to settle the matter without 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, or you don't get along, demand a new lawyer from the firm's associates or 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 several times without a response from the lawyer, that's a red flag 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 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, and be sure that you'll get access to all legal work generated on your behalf, she added.

RANCHO MIRAGE, CALIF. — The face of ob.gyns. is changing, and so are practices and training methods in the specialty, several speakers said at the annual meeting of the Society of Gynecologic Surgeons.

“Our specialty is currently in crisis,” said Joseph Schaffer, M.D., who moderated a session on the future of the specialty. Problems with changing attitudes toward work among younger physicians, increasing subspecialization, reimbursement, and malpractice insurance premiums, and shorter hours for residents pose challenges that will alter the lives of many ob.gyns., said Dr. Schaffer of the University of Texas Southwestern Medical Center, Dallas.

Many younger physicians value their free time highly and prefer to limit practice hours, even if it means staying out of the operating room or delivery room, Stanley Zinberg, M.D., said, adding that he sees this as a generational issue. “To many of our young graduates, medicine is not a calling or a commitment, it's a job,” said Dr. Zinberg, vice president for practice activities for the American College of Obstetricians and Gynecologists (ACOG).

At the same time, the gender balance in ACOG is changing rapidly. ACOG leaders are pleased that the college is expected to have an equal number of male and female members by 2010, earlier than the previous estimate of 2014, Dr. Zinberg noted. Of ACOG's 47,322 members, 42% are women, but among its 9,600 “junior fellows” (in residency or early practice) 71% are women.

For many years, only about 2% of ob.gyns. were subspecialists, but this too will change, he predicted. In the near future, perhaps half of ob.gyns. will follow the conventional generalist model of practice and the rest will practice maternal-fetal medicine, gynecologic oncology, pelvic reconstructive surgery, or reproductive endocrinology. Fellowship slots in these subspecialties today tend to be full, which wasn't the case a few years ago.

Governmental actions portend other changes. Medicare reimbursements will be reduced by 31% over the next 5 years, while physicians' costs will increase by 15%, not counting changes in the cost of liability insurance, Dr. Zinberg said. “Ob.gyns. may decide to accept fewer Medicare patients.”

Congressional leaders have said they will not consider adjustments to Medicare payment rates unless these changes include reforms to base pay on measures of physician performance, called “pay for performance.” Despite a lack of validated, evidence-based measures of physician performance, “pay for performance is on a fast track, whether we're ready or not,” he said.

Separately, a key turf battle looms over physicians' right to perform ultrasound imaging. “Radiologists' top legislative priority is to make sure that nonradiologists do not perform imaging procedures,” Dr. Zinberg said. No legislation has been introduced, but there is talk of requiring accreditation for ultrasound imaging, which ACOG opposes.

Another shift is seen in gynecologic surgery training in response to 80-hour limits on residents' workweeks, technological innovations, and other factors, Dee Fenner, M.D., said in a separate presentation during the session.

No longer will surgical training rely predominantly on the apprenticeship model, which teaches through the example of skilled mentors and repetition of a high number of procedures, said Dr. Fenner, director of gynecology of the University of Michigan, Ann Arbor.

“The apprentice system will never go away. It will always be a major part of our surgical education, but we need to modify it,” she said. The adoption of formal curricula is a key move toward creating reliable, valid criteria for assessing surgical competency and away from the subjective assessments used in the apprenticeship model.

With shorter hours, residents today experience a smaller volume of surgeries. Many residents now train at four hospitals rather than at a single institution, an obstacle to developing mentor relationships. Pressures on faculty to produce revenue or meet other goals interfere with teaching, altering the one-to-one ratio of residents to faculty that once was the norm.

Ethical and cost considerations also hinder the apprenticeship model. Time in the operating room (OR) is expensive. Patients may demand a faculty surgeon rather than a resident for their operation.

Increasingly, surgery will be learned and practiced outside of the OR using simulators, models, and patient substitutes. “There are no data to say that you can't use a watermelon for a C-section” as effectively as a more expensive manufactured model, but an increasing number of models will be available, Dr. Fenner said.

The rapidly growing field of haptics (the science of touch) infuses simulators with a lifelike feel when you poke with an instrument or grab with a grasper. Newer mannequins can be programmed for codes—give one epinephrine and it will exhibit tachycardia, for example. Virtual-reality technology is being used to develop training models for such procedures as obstetrical deliveries and ultrasound, as well as for handling forceps and all types of scopes. A virtual OR provides practice in surgical skills and also can help train teams or team leaders.

“This is where we'll be training our residents and our faculty in the very, very near future,” she said.

Telementoring will begin to play a role, with surgical mentors outside the OR sometimes guiding trainees in real surgery through audiovisual connections.

All this new technology isn't inexpensive, but hospitals probably will cover much of the cost if certifying physicians' surgical skills can help reduce malpractice risks, Dr. Fenner said.

Ob.gyn. residents should have a bit more time for surgical rotations after July 2005, when primary care requirements will be trimmed. No mandatory rotations in primary care clinics and fewer continuity clinics will mean more time for subjects that are more integral to ob.gyns.—a prediction applauded by physicians at the meeting.

RANCHO MIRAGE, CALIF. — The face of ob.gyns. is changing, and so are practices and training methods in the specialty, several speakers said at the annual meeting of the Society of Gynecologic Surgeons.

“Our specialty is currently in crisis,” said Joseph Schaffer, M.D., who moderated a session on the future of the specialty. Problems with changing attitudes toward work among younger physicians, increasing subspecialization, reimbursement, and malpractice insurance premiums, and shorter hours for residents pose challenges that will alter the lives of many ob.gyns., said Dr. Schaffer of the University of Texas Southwestern Medical Center, Dallas.

Many younger physicians value their free time highly and prefer to limit practice hours, even if it means staying out of the operating room or delivery room, Stanley Zinberg, M.D., said, adding that he sees this as a generational issue. “To many of our young graduates, medicine is not a calling or a commitment, it's a job,” said Dr. Zinberg, vice president for practice activities for the American College of Obstetricians and Gynecologists (ACOG).

At the same time, the gender balance in ACOG is changing rapidly. ACOG leaders are pleased that the college is expected to have an equal number of male and female members by 2010, earlier than the previous estimate of 2014, Dr. Zinberg noted. Of ACOG's 47,322 members, 42% are women, but among its 9,600 “junior fellows” (in residency or early practice) 71% are women.

For many years, only about 2% of ob.gyns. were subspecialists, but this too will change, he predicted. In the near future, perhaps half of ob.gyns. will follow the conventional generalist model of practice and the rest will practice maternal-fetal medicine, gynecologic oncology, pelvic reconstructive surgery, or reproductive endocrinology. Fellowship slots in these subspecialties today tend to be full, which wasn't the case a few years ago.

Governmental actions portend other changes. Medicare reimbursements will be reduced by 31% over the next 5 years, while physicians' costs will increase by 15%, not counting changes in the cost of liability insurance, Dr. Zinberg said. “Ob.gyns. may decide to accept fewer Medicare patients.”

Congressional leaders have said they will not consider adjustments to Medicare payment rates unless these changes include reforms to base pay on measures of physician performance, called “pay for performance.” Despite a lack of validated, evidence-based measures of physician performance, “pay for performance is on a fast track, whether we're ready or not,” he said.

Separately, a key turf battle looms over physicians' right to perform ultrasound imaging. “Radiologists' top legislative priority is to make sure that nonradiologists do not perform imaging procedures,” Dr. Zinberg said. No legislation has been introduced, but there is talk of requiring accreditation for ultrasound imaging, which ACOG opposes.

Another shift is seen in gynecologic surgery training in response to 80-hour limits on residents' workweeks, technological innovations, and other factors, Dee Fenner, M.D., said in a separate presentation during the session.

No longer will surgical training rely predominantly on the apprenticeship model, which teaches through the example of skilled mentors and repetition of a high number of procedures, said Dr. Fenner, director of gynecology of the University of Michigan, Ann Arbor.

“The apprentice system will never go away. It will always be a major part of our surgical education, but we need to modify it,” she said. The adoption of formal curricula is a key move toward creating reliable, valid criteria for assessing surgical competency and away from the subjective assessments used in the apprenticeship model.

With shorter hours, residents today experience a smaller volume of surgeries. Many residents now train at four hospitals rather than at a single institution, an obstacle to developing mentor relationships. Pressures on faculty to produce revenue or meet other goals interfere with teaching, altering the one-to-one ratio of residents to faculty that once was the norm.

Ethical and cost considerations also hinder the apprenticeship model. Time in the operating room (OR) is expensive. Patients may demand a faculty surgeon rather than a resident for their operation.

Increasingly, surgery will be learned and practiced outside of the OR using simulators, models, and patient substitutes. “There are no data to say that you can't use a watermelon for a C-section” as effectively as a more expensive manufactured model, but an increasing number of models will be available, Dr. Fenner said.

The rapidly growing field of haptics (the science of touch) infuses simulators with a lifelike feel when you poke with an instrument or grab with a grasper. Newer mannequins can be programmed for codes—give one epinephrine and it will exhibit tachycardia, for example. Virtual-reality technology is being used to develop training models for such procedures as obstetrical deliveries and ultrasound, as well as for handling forceps and all types of scopes. A virtual OR provides practice in surgical skills and also can help train teams or team leaders.

“This is where we'll be training our residents and our faculty in the very, very near future,” she said.

Telementoring will begin to play a role, with surgical mentors outside the OR sometimes guiding trainees in real surgery through audiovisual connections.

All this new technology isn't inexpensive, but hospitals probably will cover much of the cost if certifying physicians' surgical skills can help reduce malpractice risks, Dr. Fenner said.

Ob.gyn. residents should have a bit more time for surgical rotations after July 2005, when primary care requirements will be trimmed. No mandatory rotations in primary care clinics and fewer continuity clinics will mean more time for subjects that are more integral to ob.gyns.—a prediction applauded by physicians at the meeting.

RANCHO MIRAGE, CALIF. — The face of ob.gyns. is changing, and so are practices and training methods in the specialty, several speakers said at the annual meeting of the Society of Gynecologic Surgeons.

“Our specialty is currently in crisis,” said Joseph Schaffer, M.D., who moderated a session on the future of the specialty. Problems with changing attitudes toward work among younger physicians, increasing subspecialization, reimbursement, and malpractice insurance premiums, and shorter hours for residents pose challenges that will alter the lives of many ob.gyns., said Dr. Schaffer of the University of Texas Southwestern Medical Center, Dallas.

Many younger physicians value their free time highly and prefer to limit practice hours, even if it means staying out of the operating room or delivery room, Stanley Zinberg, M.D., said, adding that he sees this as a generational issue. “To many of our young graduates, medicine is not a calling or a commitment, it's a job,” said Dr. Zinberg, vice president for practice activities for the American College of Obstetricians and Gynecologists (ACOG).

At the same time, the gender balance in ACOG is changing rapidly. ACOG leaders are pleased that the college is expected to have an equal number of male and female members by 2010, earlier than the previous estimate of 2014, Dr. Zinberg noted. Of ACOG's 47,322 members, 42% are women, but among its 9,600 “junior fellows” (in residency or early practice) 71% are women.

For many years, only about 2% of ob.gyns. were subspecialists, but this too will change, he predicted. In the near future, perhaps half of ob.gyns. will follow the conventional generalist model of practice and the rest will practice maternal-fetal medicine, gynecologic oncology, pelvic reconstructive surgery, or reproductive endocrinology. Fellowship slots in these subspecialties today tend to be full, which wasn't the case a few years ago.

Governmental actions portend other changes. Medicare reimbursements will be reduced by 31% over the next 5 years, while physicians' costs will increase by 15%, not counting changes in the cost of liability insurance, Dr. Zinberg said. “Ob.gyns. may decide to accept fewer Medicare patients.”

Congressional leaders have said they will not consider adjustments to Medicare payment rates unless these changes include reforms to base pay on measures of physician performance, called “pay for performance.” Despite a lack of validated, evidence-based measures of physician performance, “pay for performance is on a fast track, whether we're ready or not,” he said.

Separately, a key turf battle looms over physicians' right to perform ultrasound imaging. “Radiologists' top legislative priority is to make sure that nonradiologists do not perform imaging procedures,” Dr. Zinberg said. No legislation has been introduced, but there is talk of requiring accreditation for ultrasound imaging, which ACOG opposes.

Another shift is seen in gynecologic surgery training in response to 80-hour limits on residents' workweeks, technological innovations, and other factors, Dee Fenner, M.D., said in a separate presentation during the session.

No longer will surgical training rely predominantly on the apprenticeship model, which teaches through the example of skilled mentors and repetition of a high number of procedures, said Dr. Fenner, director of gynecology of the University of Michigan, Ann Arbor.

“The apprentice system will never go away. It will always be a major part of our surgical education, but we need to modify it,” she said. The adoption of formal curricula is a key move toward creating reliable, valid criteria for assessing surgical competency and away from the subjective assessments used in the apprenticeship model.

With shorter hours, residents today experience a smaller volume of surgeries. Many residents now train at four hospitals rather than at a single institution, an obstacle to developing mentor relationships. Pressures on faculty to produce revenue or meet other goals interfere with teaching, altering the one-to-one ratio of residents to faculty that once was the norm.

Ethical and cost considerations also hinder the apprenticeship model. Time in the operating room (OR) is expensive. Patients may demand a faculty surgeon rather than a resident for their operation.

Increasingly, surgery will be learned and practiced outside of the OR using simulators, models, and patient substitutes. “There are no data to say that you can't use a watermelon for a C-section” as effectively as a more expensive manufactured model, but an increasing number of models will be available, Dr. Fenner said.

The rapidly growing field of haptics (the science of touch) infuses simulators with a lifelike feel when you poke with an instrument or grab with a grasper. Newer mannequins can be programmed for codes—give one epinephrine and it will exhibit tachycardia, for example. Virtual-reality technology is being used to develop training models for such procedures as obstetrical deliveries and ultrasound, as well as for handling forceps and all types of scopes. A virtual OR provides practice in surgical skills and also can help train teams or team leaders.

“This is where we'll be training our residents and our faculty in the very, very near future,” she said.

Telementoring will begin to play a role, with surgical mentors outside the OR sometimes guiding trainees in real surgery through audiovisual connections.

All this new technology isn't inexpensive, but hospitals probably will cover much of the cost if certifying physicians' surgical skills can help reduce malpractice risks, Dr. Fenner said.

Ob.gyn. residents should have a bit more time for surgical rotations after July 2005, when primary care requirements will be trimmed. No mandatory rotations in primary care clinics and fewer continuity clinics will mean more time for subjects that are more integral to ob.gyns.—a prediction applauded by physicians at the meeting.

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of β-tocopherol and α-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of β-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of α-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation.

Carotenoids—found in green, leafy vegetables, tropical fruits, and nectarines—may help clear HPV infection. James Reinaker

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of β-tocopherol and α-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of β-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of α-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation.

Carotenoids—found in green, leafy vegetables, tropical fruits, and nectarines—may help clear HPV infection. James Reinaker

VANCOUVER, B.C. — Women who eat their vegetables and take vitamins may have a better chance of avoiding or clearing human papillomavirus infection, Marc T. Goodman, Ph.D., said at the 22nd International Papillomavirus Conference.

Low serum levels of tocopherol (vitamin E) or retinol (vitamin A) may increase the risk for acquiring human papillomavirus (HPV) infection, according to preliminary data from a controlled study of micronutrients and HPV.

High serum levels of carotenoids may enhance clearance of HPV infection and avoid persistent infection, said Dr. Goodman of the University of Hawaii, Manoa.

The investigators analyzed data on 242 women who had complete records from at least four clinical visits, part of a larger longitudinal study at three clinics and two university-based health services. They categorized serum micronutrient levels as either low or high.

Women with low serum levels of vitamins E or A were twice as likely to develop incident HPV infection, compared with women with high levels of these nutrients, he said at the meeting, sponsored by the University of California, San Francisco.

A new HPV infection was found in 18% of women with low serum levels of β-tocopherol and α-tocopherol combined, compared with 9% of women with high levels of these nutrients. HPV test results went from negative to positive from one visit to the next in 19% of women with low levels of retinol and 10% of those with high serum levels.

Incident HPV infection at one visit persisted in a positive HPV test at the next clinical visit in 20% of women with high serum levels of lutein or zeaxanthin, carotenoids that are abundant in green, leafy vegetables. HPV persisted in 31% of women with low levels of these carotenoids, a 60% increased risk with low serum levels.

HPV persisted in 22% of women with high levels of β-cryptoxanthin (a carotenoid found in a variety of tropical fruits and nectarines), compared with 38% of women with low levels of this nutrient, who had a 70% increased risk for persistence.

The risk for HPV persistence doubled with low levels of α-carotene and was 60% higher with low levels of lycopene, compared with having high levels of these nutrients.

Dr. Goodman speculated that the differences might be related to the antioxidant functions of these nutrients, or to the interface between cytokine levels and local levels of antibodies. “We know that the micronutrient levels do enhance the immune response,” he said.

Intracellular signaling might play a role. A variety of nutrients affect the genes associated with transcription. It's also possible that antioxidants could directly affect HPV viral load and cell proliferation.

Carotenoids—found in green, leafy vegetables, tropical fruits, and nectarines—may help clear HPV infection. James Reinaker

RANCHO MIRAGE, CALIF. — Preoperative characteristics may help identify patients more or less likely to need catheterization for urinary retention immediately after minimally invasive sling surgery, said Abraham Morse, M.D.

Outpatients treated for urinary incontinence with the tension-free vaginal tape (TVT) system were studied retrospectively. Of the 119 cases, those who had a parity of at least three, were very anxious in the preoperative holding area, or had a normal Valsalva leak point pressure were less likely to require postoperative catheterization, Dr. Morse said at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Morse of the University of Massachusetts, Worcester, and his associates hope to use these parameters to develop a scoring system for likelihood of postoperative voiding to better counsel patients before the TVT procedure.

“For [many] patients, the idea of going home on a catheter is a big issue …. If we could better predict who will be able to immediately void postoperatively, we [could] more effectively manage patient expectations and concerns, and identify those most likely to benefit from preoperative teaching of self-catheterization,” said Dr. Morse, who disclaimed any financial interest in Gynecare, which markets the TVT system.

A review of TVT cases over a 3.5-year period focused on 119 outpatient procedures and excluded outpatients with cystotomies, because they were discharged with Foley catheters in place. Nurses in the preoperative holding area asked patients to rate their anxiety on a 10-point scale, with 1 being the least anxious.

Overall, 39% failed an immediate postoperative voiding trial and needed some kind of catheterization to be discharged. Of the total, 28% were discharged with a Foley catheter, and 11% went home using intermittent self-catheterization. Eventually, two patients (2%) needed mesh sectioning to treat persistent urinary retention lasting longer than 2 weeks. These rates are similar to those in other reports in the literature, Dr. Morse said.

Patients with a parity of at least three were five times more likely to pass the postoperative voiding trial, compared with patients who had a lower parity, a logistic regression analysis showed. A normal Valsalva leak point pressure conferred a sevenfold greater likelihood of not needing catheterization, compared with those with abnormal pressures. Patients with high preoperative anxiety were six times more likely to pass the voiding trial, compared with less anxious patients, he said.

Immediate postoperative urinary retention is common after incontinence surgery. Two previous series of TVT procedures found that 45%–49% of patients required some catheterization at discharge, he said.

Patients in the current study had a mean age of 53 and a median parity of two. A majority of the women were menopausal. Preoperatively, 55% of patients had stress urinary incontinence only, 45% had mixed incontinence, 11% had detrusor instability, and 87% had urethral hypermobility. Six percent had undergone previous surgery for pelvic organ prolapse, and 12% had undergone surgery for incontinence. The procedures lasted a median of 42 minutes each.

The lead investigator in the study was Kim I. Barron, a medical student at the university.

RANCHO MIRAGE, CALIF. — Preoperative characteristics may help identify patients more or less likely to need catheterization for urinary retention immediately after minimally invasive sling surgery, said Abraham Morse, M.D.

Outpatients treated for urinary incontinence with the tension-free vaginal tape (TVT) system were studied retrospectively. Of the 119 cases, those who had a parity of at least three, were very anxious in the preoperative holding area, or had a normal Valsalva leak point pressure were less likely to require postoperative catheterization, Dr. Morse said at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Morse of the University of Massachusetts, Worcester, and his associates hope to use these parameters to develop a scoring system for likelihood of postoperative voiding to better counsel patients before the TVT procedure.

“For [many] patients, the idea of going home on a catheter is a big issue …. If we could better predict who will be able to immediately void postoperatively, we [could] more effectively manage patient expectations and concerns, and identify those most likely to benefit from preoperative teaching of self-catheterization,” said Dr. Morse, who disclaimed any financial interest in Gynecare, which markets the TVT system.

A review of TVT cases over a 3.5-year period focused on 119 outpatient procedures and excluded outpatients with cystotomies, because they were discharged with Foley catheters in place. Nurses in the preoperative holding area asked patients to rate their anxiety on a 10-point scale, with 1 being the least anxious.

Overall, 39% failed an immediate postoperative voiding trial and needed some kind of catheterization to be discharged. Of the total, 28% were discharged with a Foley catheter, and 11% went home using intermittent self-catheterization. Eventually, two patients (2%) needed mesh sectioning to treat persistent urinary retention lasting longer than 2 weeks. These rates are similar to those in other reports in the literature, Dr. Morse said.

Patients with a parity of at least three were five times more likely to pass the postoperative voiding trial, compared with patients who had a lower parity, a logistic regression analysis showed. A normal Valsalva leak point pressure conferred a sevenfold greater likelihood of not needing catheterization, compared with those with abnormal pressures. Patients with high preoperative anxiety were six times more likely to pass the voiding trial, compared with less anxious patients, he said.

Immediate postoperative urinary retention is common after incontinence surgery. Two previous series of TVT procedures found that 45%–49% of patients required some catheterization at discharge, he said.

Patients in the current study had a mean age of 53 and a median parity of two. A majority of the women were menopausal. Preoperatively, 55% of patients had stress urinary incontinence only, 45% had mixed incontinence, 11% had detrusor instability, and 87% had urethral hypermobility. Six percent had undergone previous surgery for pelvic organ prolapse, and 12% had undergone surgery for incontinence. The procedures lasted a median of 42 minutes each.

The lead investigator in the study was Kim I. Barron, a medical student at the university.

RANCHO MIRAGE, CALIF. — Preoperative characteristics may help identify patients more or less likely to need catheterization for urinary retention immediately after minimally invasive sling surgery, said Abraham Morse, M.D.

Outpatients treated for urinary incontinence with the tension-free vaginal tape (TVT) system were studied retrospectively. Of the 119 cases, those who had a parity of at least three, were very anxious in the preoperative holding area, or had a normal Valsalva leak point pressure were less likely to require postoperative catheterization, Dr. Morse said at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Morse of the University of Massachusetts, Worcester, and his associates hope to use these parameters to develop a scoring system for likelihood of postoperative voiding to better counsel patients before the TVT procedure.

“For [many] patients, the idea of going home on a catheter is a big issue …. If we could better predict who will be able to immediately void postoperatively, we [could] more effectively manage patient expectations and concerns, and identify those most likely to benefit from preoperative teaching of self-catheterization,” said Dr. Morse, who disclaimed any financial interest in Gynecare, which markets the TVT system.

A review of TVT cases over a 3.5-year period focused on 119 outpatient procedures and excluded outpatients with cystotomies, because they were discharged with Foley catheters in place. Nurses in the preoperative holding area asked patients to rate their anxiety on a 10-point scale, with 1 being the least anxious.

Overall, 39% failed an immediate postoperative voiding trial and needed some kind of catheterization to be discharged. Of the total, 28% were discharged with a Foley catheter, and 11% went home using intermittent self-catheterization. Eventually, two patients (2%) needed mesh sectioning to treat persistent urinary retention lasting longer than 2 weeks. These rates are similar to those in other reports in the literature, Dr. Morse said.

Patients with a parity of at least three were five times more likely to pass the postoperative voiding trial, compared with patients who had a lower parity, a logistic regression analysis showed. A normal Valsalva leak point pressure conferred a sevenfold greater likelihood of not needing catheterization, compared with those with abnormal pressures. Patients with high preoperative anxiety were six times more likely to pass the voiding trial, compared with less anxious patients, he said.

Immediate postoperative urinary retention is common after incontinence surgery. Two previous series of TVT procedures found that 45%–49% of patients required some catheterization at discharge, he said.

Patients in the current study had a mean age of 53 and a median parity of two. A majority of the women were menopausal. Preoperatively, 55% of patients had stress urinary incontinence only, 45% had mixed incontinence, 11% had detrusor instability, and 87% had urethral hypermobility. Six percent had undergone previous surgery for pelvic organ prolapse, and 12% had undergone surgery for incontinence. The procedures lasted a median of 42 minutes each.

The lead investigator in the study was Kim I. Barron, a medical student at the university.

SAN DIEGO — All atypical antipsychotics carry the same risks for the development of diabetes, according to the Food and Drug Administration, but some experts have a more nuanced view.

Everyone agrees that some atypical antipsychotics are more likely to cause weight gain than are other drugs of the same class. That's enough to make some experts outside the FDA believe that there's also a tiered risk for diabetes in patients who take these medications, Stephen M. Stahl, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Clozapine (Clozaril) and olanzapine (Zyprexa) cause the most weight gain among atypical antipsychotics. Risperidone (Risperdal) and quetiapine (Seroquel) inhabit a middle ground, and little or no weight gain is seen in patients on ziprasidone (Geodon) or aripiprazole (Abilify).

“As goes weight, so goes risk for diabetes,” said Dr. Stahl of the University of California, San Diego. He has been a consultant for—or received financial support from—the companies that make olanzapine (Eli Lilly & Co.), quetiapine (AstraZeneca), and ziprasidone (Pfizer Inc.).

The divide between the FDA warnings and other expert opinions might be understood as a division between concern about acute hyperglycemic events and the development of diabetes over time, Ramachandiran Cooppan, M.D., said at the same session in a copresentation with Dr. Stahl.

Because there are not enough long-term data to rule out an increased risk for diabetes with all the atypical antipsychotics, and because they seem to have equal risks for causing acute hyperglycemic events, the FDA decided to err on the side of caution and place a blanket warning for diabetes risk on the whole class, said Dr. Cooppan of the Joslin Diabetes Center, Boston.

He has been a speaker or consultant for, or received grants from, the companies that make olanzapine and ziprasidone.

The useful point of the FDA warning is that “there is a myth out there that type 2 diabetes patients can't go into diabetic ketoacidosis. We need to change that,” because up to 40% of people with type 2 diabetes can slip into diabetic ketoacidosis, he noted.

On the other hand, at the time that most case reports of acute hyperglycemic events emerged in patients on atypical antipsychotics, most psychiatrists were not screening patients for impaired glucose tolerance or other diabetes risk factors. “It doesn't take much weight gain to tip you over [into diabetes] if you're genetically predisposed,” Dr. Cooppan said.

The American Diabetes Association guidelines on diabetes risk consider other factors that the FDA did not address, such as changes in lipids, blood pressure, or coagulation, he and Dr. Stahl said.

Comparisons of separate pharmaceutical company-sponsored studies suggest that aripiprazole can significantly reduce triglyceride levels in patients previously treated with an atypical antipsychotic, and that clozapine and olanzapine are associated with the largest elevations in triglyceride levels, Dr. Stahl said. The triglyceride effects of other atypical antipsychotics fall between these two zones.

“We think that there may be a differential risk” for diabetes among atypical antipsychotics, but only time will tell, Dr. Cooppan said.

Dr. Stahl still uses clozapine and olanzapine when needed, despite their potentially higher risk for diabetes.

The important thing is to start balancing the benefits of the drugs with risk differentials when choosing therapy, he explained.

Physicians who prescribe these drugs must be prepared to monitor all severely mentally ill patients for diabetes risk factors regardless of the drug used, he emphasized.

On the front of each chart, put the patient's blood pressure, lipid levels, recent triglyceride level, weight or body mass index, and “maybe even a waist circumference” measurement. “People like us have leverage on our patients to get them to change their lifestyles,” Dr. Stahl said. “None of [this] is very simple, but we should at least try.”

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

SAN DIEGO — All atypical antipsychotics carry the same risks for the development of diabetes, according to the Food and Drug Administration, but some experts have a more nuanced view.

Everyone agrees that some atypical antipsychotics are more likely to cause weight gain than are other drugs of the same class. That's enough to make some experts outside the FDA believe that there's also a tiered risk for diabetes in patients who take these medications, Stephen M. Stahl, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Clozapine (Clozaril) and olanzapine (Zyprexa) cause the most weight gain among atypical antipsychotics. Risperidone (Risperdal) and quetiapine (Seroquel) inhabit a middle ground, and little or no weight gain is seen in patients on ziprasidone (Geodon) or aripiprazole (Abilify).

“As goes weight, so goes risk for diabetes,” said Dr. Stahl of the University of California, San Diego. He has been a consultant for—or received financial support from—the companies that make olanzapine (Eli Lilly & Co.), quetiapine (AstraZeneca), and ziprasidone (Pfizer Inc.).

The divide between the FDA warnings and other expert opinions might be understood as a division between concern about acute hyperglycemic events and the development of diabetes over time, Ramachandiran Cooppan, M.D., said at the same session in a copresentation with Dr. Stahl.

Because there are not enough long-term data to rule out an increased risk for diabetes with all the atypical antipsychotics, and because they seem to have equal risks for causing acute hyperglycemic events, the FDA decided to err on the side of caution and place a blanket warning for diabetes risk on the whole class, said Dr. Cooppan of the Joslin Diabetes Center, Boston.

He has been a speaker or consultant for, or received grants from, the companies that make olanzapine and ziprasidone.

The useful point of the FDA warning is that “there is a myth out there that type 2 diabetes patients can't go into diabetic ketoacidosis. We need to change that,” because up to 40% of people with type 2 diabetes can slip into diabetic ketoacidosis, he noted.

On the other hand, at the time that most case reports of acute hyperglycemic events emerged in patients on atypical antipsychotics, most psychiatrists were not screening patients for impaired glucose tolerance or other diabetes risk factors. “It doesn't take much weight gain to tip you over [into diabetes] if you're genetically predisposed,” Dr. Cooppan said.

The American Diabetes Association guidelines on diabetes risk consider other factors that the FDA did not address, such as changes in lipids, blood pressure, or coagulation, he and Dr. Stahl said.

Comparisons of separate pharmaceutical company-sponsored studies suggest that aripiprazole can significantly reduce triglyceride levels in patients previously treated with an atypical antipsychotic, and that clozapine and olanzapine are associated with the largest elevations in triglyceride levels, Dr. Stahl said. The triglyceride effects of other atypical antipsychotics fall between these two zones.

“We think that there may be a differential risk” for diabetes among atypical antipsychotics, but only time will tell, Dr. Cooppan said.

Dr. Stahl still uses clozapine and olanzapine when needed, despite their potentially higher risk for diabetes.

The important thing is to start balancing the benefits of the drugs with risk differentials when choosing therapy, he explained.

Physicians who prescribe these drugs must be prepared to monitor all severely mentally ill patients for diabetes risk factors regardless of the drug used, he emphasized.

On the front of each chart, put the patient's blood pressure, lipid levels, recent triglyceride level, weight or body mass index, and “maybe even a waist circumference” measurement. “People like us have leverage on our patients to get them to change their lifestyles,” Dr. Stahl said. “None of [this] is very simple, but we should at least try.”

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

SAN DIEGO — All atypical antipsychotics carry the same risks for the development of diabetes, according to the Food and Drug Administration, but some experts have a more nuanced view.

Everyone agrees that some atypical antipsychotics are more likely to cause weight gain than are other drugs of the same class. That's enough to make some experts outside the FDA believe that there's also a tiered risk for diabetes in patients who take these medications, Stephen M. Stahl, M.D., said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.

Clozapine (Clozaril) and olanzapine (Zyprexa) cause the most weight gain among atypical antipsychotics. Risperidone (Risperdal) and quetiapine (Seroquel) inhabit a middle ground, and little or no weight gain is seen in patients on ziprasidone (Geodon) or aripiprazole (Abilify).

“As goes weight, so goes risk for diabetes,” said Dr. Stahl of the University of California, San Diego. He has been a consultant for—or received financial support from—the companies that make olanzapine (Eli Lilly & Co.), quetiapine (AstraZeneca), and ziprasidone (Pfizer Inc.).

The divide between the FDA warnings and other expert opinions might be understood as a division between concern about acute hyperglycemic events and the development of diabetes over time, Ramachandiran Cooppan, M.D., said at the same session in a copresentation with Dr. Stahl.

Because there are not enough long-term data to rule out an increased risk for diabetes with all the atypical antipsychotics, and because they seem to have equal risks for causing acute hyperglycemic events, the FDA decided to err on the side of caution and place a blanket warning for diabetes risk on the whole class, said Dr. Cooppan of the Joslin Diabetes Center, Boston.

He has been a speaker or consultant for, or received grants from, the companies that make olanzapine and ziprasidone.

The useful point of the FDA warning is that “there is a myth out there that type 2 diabetes patients can't go into diabetic ketoacidosis. We need to change that,” because up to 40% of people with type 2 diabetes can slip into diabetic ketoacidosis, he noted.

On the other hand, at the time that most case reports of acute hyperglycemic events emerged in patients on atypical antipsychotics, most psychiatrists were not screening patients for impaired glucose tolerance or other diabetes risk factors. “It doesn't take much weight gain to tip you over [into diabetes] if you're genetically predisposed,” Dr. Cooppan said.

The American Diabetes Association guidelines on diabetes risk consider other factors that the FDA did not address, such as changes in lipids, blood pressure, or coagulation, he and Dr. Stahl said.

Comparisons of separate pharmaceutical company-sponsored studies suggest that aripiprazole can significantly reduce triglyceride levels in patients previously treated with an atypical antipsychotic, and that clozapine and olanzapine are associated with the largest elevations in triglyceride levels, Dr. Stahl said. The triglyceride effects of other atypical antipsychotics fall between these two zones.

“We think that there may be a differential risk” for diabetes among atypical antipsychotics, but only time will tell, Dr. Cooppan said.

Dr. Stahl still uses clozapine and olanzapine when needed, despite their potentially higher risk for diabetes.

The important thing is to start balancing the benefits of the drugs with risk differentials when choosing therapy, he explained.

Physicians who prescribe these drugs must be prepared to monitor all severely mentally ill patients for diabetes risk factors regardless of the drug used, he emphasized.

On the front of each chart, put the patient's blood pressure, lipid levels, recent triglyceride level, weight or body mass index, and “maybe even a waist circumference” measurement. “People like us have leverage on our patients to get them to change their lifestyles,” Dr. Stahl said. “None of [this] is very simple, but we should at least try.”

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN