Sherry Boschert

SAN FRANCISCO – Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO – Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

SAN FRANCISCO – Nonphysician staff in 10 primary care clinics initially were leery of giving patients the ability to e-mail their clinics, but they became more enthusiastic 6 months after using an electronic communication system, a study of 76 staff members found.

Physicians might be more willing to offer electronic communications to patients if e-mails could be triaged by their staff, Anne F. Kittler and her associates said in a poster presentation at the triennial congress of the International Medical Informatics Association. The study suggests that staff can overcome their initial reservations to embrace the benefits of electronic communications, said Ms. Kittler of Partners HealthCare System, Wellesley, Mass.

Paper-based surveys of 76 staff before adoption of Patient Gateway, a secure Web portal for electronic communication with patients, found that 44 feared that patient e-mails would increase their workload. Only 13 (17%) were enthusiastic about adopting the system, 28 (37%) were hesitant, and the rest were indifferent or unsure about it. A majority already used e-mail in their daily work routine, usually to communicate with physicians or other staff in the practice.

After full implementation of Patient Gateway in three of clinics, half of 21 staff members who had used the system for at least 6 months were enthusiastic about the system, repeat surveys found. The proportion of staff members hesitant to use the system dropped to 20% (four people). A majority said that Patient Gateway either reduced or did not change their overall workload.

They particularly found the system helpful for dealing with requests for medication refills, the investigators reported.

All the clinics used electronic health records before adding Patient Gateway.

KOHALA COAST, HAWAII — A secondary infection may be at the root of atopic dermatitis flares, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

In many patients, the flares are due simply to severe disease. But Dr. Berger looks for secondary infection as well as four other factors to find opportunities to intervene. He listed the five factors in descending order: noncompliance (for example, the patient is tired of taking medications, leading to a flare); secondary infection; photosensitivity; allergic or contact dermatitis; or conversion to cutaneous T-cell lymphoma.

Of the five factors, infection is where most of the action is when sleuthing the cause of atopic dermatitis flares, said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco. Infection is “an axis of atopic dermatitis that we tend to undertreat,” he said.

He described a typical case: a 47-year-old man with moderate to severe chronic atopic dermatitis who had a 3-week-long severe flare of disease at presentation. He had extensive excoriations, redness, focal erosions, and crusts. He had been on and off systemic steroids to treat atopic dermatitis flares several times in the past.

When you see crusts or erosions, get cultures. This patient's culture grew methicillin-resistant Staphylococcus aureus (MRSA) even though he had no association with traditional avenues for exposure to MRSA such as intravenous drug use or stays in a hospital, nursing home, or prison, he said.

Doxycycline is recommended by infectious disease specialists as the first choice for treating MRSA because 95% of MRSA strains will be sensitive to the drug. Minocycline is an alternative, but is a bit more expensive, he said.

Second choice for treatment would be trimethoprim-sulfamethoxazole (TMP/SMZ), except in patients with AIDS, who are almost guaranteed to have a strain of MRSA resistant to TMP/SMZ, Dr. Berger said.

He adds rifampin to one of these drug choices for a better shot at success with combination therapy. He usually prescribes doxycycline 100 mg b.i.d. for 10 days plus rifampin 600 mg/day for 5 days to treat atopic dermatitis flares related to MRSA.

Clindamycin also can be a good therapeutic option, but if the culture produced bacteria resistant to erythromycin, the MRSA will have a gene for inducing resistance to clindamycin. These patients will start to improve on clindamycin only to relapse.

Linezolid also is an option “if your patient is Bill Gates,” because it's extremely expensive, Dr. Berger said. Don't use macrolides or cephalosporins, because of high rates of resistance in MRSA. Avoid quinolones, because the infection tends to recur, leading to overuse of these drugs, he added.

Dr. Berger's MRSA patient improved dramatically on doxycycline-rifampin combination therapy but returned 1 month later with another flare and cultures again showing MRSA. Dr. Berger sent him home with a repeat prescription and a swab to get samples from his girlfriend's nose and groin. Cultures showed that the girlfriend carried MRSA and infected the patient.

“When the axis is along infection and patients reflare, I look into family members and close contacts,” and treat them, he said. “That stabilizes their disease.”

In similar situations, be sure to ask if the female partner uses oral contraceptives, because rifampin will interfere with the pills' effectiveness, he cautioned. Dr. Berger treated the patient's girlfriend with doxycycline and mupirocin (instead of rifampin). The patient's atopic dermatitis now is stable, and he has stopped intermittent systemic steroids because his flares have ended.

KOHALA COAST, HAWAII — A secondary infection may be at the root of atopic dermatitis flares, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

In many patients, the flares are due simply to severe disease. But Dr. Berger looks for secondary infection as well as four other factors to find opportunities to intervene. He listed the five factors in descending order: noncompliance (for example, the patient is tired of taking medications, leading to a flare); secondary infection; photosensitivity; allergic or contact dermatitis; or conversion to cutaneous T-cell lymphoma.

Of the five factors, infection is where most of the action is when sleuthing the cause of atopic dermatitis flares, said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco. Infection is “an axis of atopic dermatitis that we tend to undertreat,” he said.

He described a typical case: a 47-year-old man with moderate to severe chronic atopic dermatitis who had a 3-week-long severe flare of disease at presentation. He had extensive excoriations, redness, focal erosions, and crusts. He had been on and off systemic steroids to treat atopic dermatitis flares several times in the past.

When you see crusts or erosions, get cultures. This patient's culture grew methicillin-resistant Staphylococcus aureus (MRSA) even though he had no association with traditional avenues for exposure to MRSA such as intravenous drug use or stays in a hospital, nursing home, or prison, he said.

Doxycycline is recommended by infectious disease specialists as the first choice for treating MRSA because 95% of MRSA strains will be sensitive to the drug. Minocycline is an alternative, but is a bit more expensive, he said.

Second choice for treatment would be trimethoprim-sulfamethoxazole (TMP/SMZ), except in patients with AIDS, who are almost guaranteed to have a strain of MRSA resistant to TMP/SMZ, Dr. Berger said.

He adds rifampin to one of these drug choices for a better shot at success with combination therapy. He usually prescribes doxycycline 100 mg b.i.d. for 10 days plus rifampin 600 mg/day for 5 days to treat atopic dermatitis flares related to MRSA.

Clindamycin also can be a good therapeutic option, but if the culture produced bacteria resistant to erythromycin, the MRSA will have a gene for inducing resistance to clindamycin. These patients will start to improve on clindamycin only to relapse.

Linezolid also is an option “if your patient is Bill Gates,” because it's extremely expensive, Dr. Berger said. Don't use macrolides or cephalosporins, because of high rates of resistance in MRSA. Avoid quinolones, because the infection tends to recur, leading to overuse of these drugs, he added.

Dr. Berger's MRSA patient improved dramatically on doxycycline-rifampin combination therapy but returned 1 month later with another flare and cultures again showing MRSA. Dr. Berger sent him home with a repeat prescription and a swab to get samples from his girlfriend's nose and groin. Cultures showed that the girlfriend carried MRSA and infected the patient.

“When the axis is along infection and patients reflare, I look into family members and close contacts,” and treat them, he said. “That stabilizes their disease.”

In similar situations, be sure to ask if the female partner uses oral contraceptives, because rifampin will interfere with the pills' effectiveness, he cautioned. Dr. Berger treated the patient's girlfriend with doxycycline and mupirocin (instead of rifampin). The patient's atopic dermatitis now is stable, and he has stopped intermittent systemic steroids because his flares have ended.

KOHALA COAST, HAWAII — A secondary infection may be at the root of atopic dermatitis flares, Timothy G. Berger, M.D., said at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communications Inc.

In many patients, the flares are due simply to severe disease. But Dr. Berger looks for secondary infection as well as four other factors to find opportunities to intervene. He listed the five factors in descending order: noncompliance (for example, the patient is tired of taking medications, leading to a flare); secondary infection; photosensitivity; allergic or contact dermatitis; or conversion to cutaneous T-cell lymphoma.

Of the five factors, infection is where most of the action is when sleuthing the cause of atopic dermatitis flares, said Dr. Berger, professor of clinical dermatology at the University of California, San Francisco. Infection is “an axis of atopic dermatitis that we tend to undertreat,” he said.

He described a typical case: a 47-year-old man with moderate to severe chronic atopic dermatitis who had a 3-week-long severe flare of disease at presentation. He had extensive excoriations, redness, focal erosions, and crusts. He had been on and off systemic steroids to treat atopic dermatitis flares several times in the past.

When you see crusts or erosions, get cultures. This patient's culture grew methicillin-resistant Staphylococcus aureus (MRSA) even though he had no association with traditional avenues for exposure to MRSA such as intravenous drug use or stays in a hospital, nursing home, or prison, he said.

Doxycycline is recommended by infectious disease specialists as the first choice for treating MRSA because 95% of MRSA strains will be sensitive to the drug. Minocycline is an alternative, but is a bit more expensive, he said.

Second choice for treatment would be trimethoprim-sulfamethoxazole (TMP/SMZ), except in patients with AIDS, who are almost guaranteed to have a strain of MRSA resistant to TMP/SMZ, Dr. Berger said.

He adds rifampin to one of these drug choices for a better shot at success with combination therapy. He usually prescribes doxycycline 100 mg b.i.d. for 10 days plus rifampin 600 mg/day for 5 days to treat atopic dermatitis flares related to MRSA.

Clindamycin also can be a good therapeutic option, but if the culture produced bacteria resistant to erythromycin, the MRSA will have a gene for inducing resistance to clindamycin. These patients will start to improve on clindamycin only to relapse.

Linezolid also is an option “if your patient is Bill Gates,” because it's extremely expensive, Dr. Berger said. Don't use macrolides or cephalosporins, because of high rates of resistance in MRSA. Avoid quinolones, because the infection tends to recur, leading to overuse of these drugs, he added.

Dr. Berger's MRSA patient improved dramatically on doxycycline-rifampin combination therapy but returned 1 month later with another flare and cultures again showing MRSA. Dr. Berger sent him home with a repeat prescription and a swab to get samples from his girlfriend's nose and groin. Cultures showed that the girlfriend carried MRSA and infected the patient.

“When the axis is along infection and patients reflare, I look into family members and close contacts,” and treat them, he said. “That stabilizes their disease.”

In similar situations, be sure to ask if the female partner uses oral contraceptives, because rifampin will interfere with the pills' effectiveness, he cautioned. Dr. Berger treated the patient's girlfriend with doxycycline and mupirocin (instead of rifampin). The patient's atopic dermatitis now is stable, and he has stopped intermittent systemic steroids because his flares have ended.

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

▸ Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the urge to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, he said.

▸ Don't add risk management comments like “There weren't enough beds available.' Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. Put your comments there, and they're unlikely to be accessible to lawyers.

▸ Don't include peer-review comments. Saying things like “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

▸ Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the urge to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, he said.

▸ Don't add risk management comments like “There weren't enough beds available.' Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. Put your comments there, and they're unlikely to be accessible to lawyers.

▸ Don't include peer-review comments. Saying things like “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

CABO SAN LUCAS, MEXICO — What you put in a patient's medical record could drive a potential lawsuit to court or away from litigation, Dennis J. Sinclitico, J.D., said.

“You can't control the labor and delivery. The one thing you can do is control what appears in the medical record,” he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

The biggest problem he said he sees in documentation is incompleteness—charts that lack important information about the physician's role, decision-making process, and justifications for management.

Many physicians complain that they don't have time to write sufficient records, said Mr. Sinclitico, a defense attorney, in Long Beach, Calif. “Would you rather spend the time in court for 12 weeks, 5 days a week, from 9 a.m. to 5 p.m.?” he asked.

Adequate documentation may be less than physicians imagine. Writing “Matter was discussed with patient” is better than saying what you discussed, because you risk leaving something out of the record. Writing “Exam was done” or “Doctor was notified” is better than giving details because these statements free you to add details orally later if questioned, he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Rules concerning medical documentation may differ somewhat from state to state, he said, but the following do's and don'ts will help create records that should help offset potential lawsuits:

▸ Don't destroy evidence. No matter how bad the fetal monitoring strip looks, resist the urge to make it disappear. In some states, destroying a record is an added offense, exposing you to additional liability.

▸ Don't ever change the record. “It's simple advice, but I see it happen over and over again,” Mr. Sinclitico said. Sophisticated technology can detect alteration of records. In some states, changing a record is an added offense.

▸ Do label any addition to the chart as a “late entry.” Late entries are common when there's a good reason why the physician can't adequately document things as they happen, such as being busy with the patient's care. Ideally, wait and do all the documentation as a late entry once you're able, rather than writing some contemporaneously and adding some later.

“To the extent that it's a self-serving addition, the lawyers will hammer you with it. To the extent that it attempts to be objective about what occurred and the timing of what occurred, then it's appropriate,” he said.

▸ Do time and date your entries in the record. Chronicity is very important in reconstructing how things happened. Don't rely on memory; recall is faulty.

▸ Do include significant positives and negatives from the patient's history and physical exam. “To the extent these form a basis for clinical judgment, they better be on the chart,” he said. Often records lack any mention of the history, or references to the history are illegible.

▸ Do indicate that you reviewed the laboratory data and the fetal monitoring strip. Physicians frequently neglect to note these things in the record.

▸ Do describe your management plan well. Provide enough detail to support the orders you give.

▸ Don't editorialize about the patient or anyone else. Personal comments are a prescription for legal disaster, he said.

▸ Don't add risk management comments like “There weren't enough beds available.' Most institutions use a report of unusual occurrence or a similar form to gather risk-management information. Put your comments there, and they're unlikely to be accessible to lawyers.

▸ Don't include peer-review comments. Saying things like “Dr. Jones failed to arrive in a timely fashion” is probably going to get Dr. Jones and you in legal trouble. “If it's a matter that you feel strongly about, and it requires peer-reviewed evaluation, use the appropriate hospital committees to take that matter up,” Mr. Sinclitico advised.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%-90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levofloxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%-90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levofloxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

SAN FRANCISCO — The culprit behind most noncomplicated urinary tract infections in outpatients—Escherichia coli—plays less of a role as patients age, a study of 2,751 urine cultures showed.

Other pathogens, particularly enterococcus, played a greater role in urinary tract infections (UTIs) in older patients, and the rates of antibiotic-resistant enterococcus increased in older patients, David J. Blehar, M.D., said at the annual meeting of the American College of Emergency Physicians.

The prospective study of serial cases from 80 outpatient offices and four emergency departments divided adult patients into five age groups and looked at the pathogens responsible for UTIs and their susceptibility to antibiotic treatment.

In the youngest group, 18- to 40-year-olds, E. coli caused more than 75% of UTIs, a finding similar to previous estimates that E. coli causes 75%-90% of UTIs overall. The role of E. coli fell with increasing age, however, with a proportional increase in other pathogens. In patients older than 80 years, E. coli accounted for fewer than half of UTIs, but enterococcus caused up to 20% of UTIs, said Dr. Blehar of the University of Massachusetts, Worcester.

The study looked at rates of resistance to four antibiotic therapies. Although trimethoprim/sulfamethoxazole (TMP/SMX) is the formal first-line drug therapy for noncomplicated UTI, guidelines suggest substituting a fluoroquinolone in areas where rates of E. coli resistance to TMP/SMX exceed 10%-20%. Dr. Blehar's institution and others have adopted levofloxacin as first-line therapy for noncomplicated UTIs. The study also looked at ceftriaxone and ampicillin resistance.

E. coli generally maintained susceptibility to the various antibiotics across age groups, except for a statistically nonsignificant trend toward greater resistance to TMP/SMX with increasing age. Pathogen resistance to ceftriaxone or ampicillin also held steady across age groups.

While E. coli resistance rates to levofloxacin remained low across age groups, enterococcus resistance rates climbed with age. In patients aged 70 years or older, 22% of enterococci were resistant to levofloxacin, and 38% of enterococci showed resistance to levofloxacin in patients aged 80 years and older.

KOHALA COAST, HAWAII — New data suggest that etanercept can be given intermittently like other psoriasis treatments, according to a poster that Alice B. Gottlieb, M.D., presented at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Data from the first study of intermittent or rotational use of etanercept came from a large phase III study in U.S. psoriasis patients. After the initial 24 weeks of the randomized, double-blind, controlled trial, 409 patients who responded with at least a 50% improvement in their Psoriasis Area Severity Index (PASI) scores stopped etanercept therapy.

Patients were followed monthly, and if their psoriasis relapsed (defined as losing at least half of the improvement seen in PASI while on treatment), they restarted etanercept at the dose originally assigned to them during the initial blinded phase of the study: weekly at 25 mg or twice-weekly at 25 or 50 mg.

At 60 weeks after all patients had started the original study, 46 remained in remission, 347 had relapsed and restarted etanercept therapy for psoriasis, and 16 patients withdrew from the study before reaching 60 weeks, she wrote.

The median time to relapse among the 498 patients was 85 days after the week-24 visit, when patients first discontinued etanercept. “After discontinuing etanercept, psoriasis gradually relapsed over approximately 3 months,” wrote Dr. Gottlieb of Robert Wood Johnson Medical School, New Brunswick, N.J.

Of the 347 patients who relapsed and restarted etanercept, 297 finished 12 weeks of retreatment. Improvements in PASI scores after retreatment were similar to improvements seen after initial treatment, she reported.

The study was funded in part by the makers of etanercept, Immunex Corp., a wholly owned subsidiary of Amgen Inc. Dr. Gottlieb is a consultant and speaker for the company. An Amgen employee served as a coinvestigator in the study.

The percentages of patients who achieved at least a 75% improvement in PASI scores ranged from 14% to 49% after the first 12 weeks of treatment (depending on dosage group) and 19%-45% after 12 weeks of retreatment.

In the 297 patients who stopped and restarted etanercept, mean PASI scores were 19 at baseline, 6 after the initial 12 weeks of treatment and before disease relapse, and 6 after 12 weeks of retreatment.

About 33% of the 297 patients developed an adverse event during retreatment and 32% developed infection, rates that were similar to those seen in the initial treatment phase of the study.

Stopping etanercept was not associated with severe flares of disease or conversion of psoriasis morphology, and was generally well tolerated by patients, according to Dr. Gottlieb. Retreatment was not associated with an increase in antigenicity to etanercept or with formation of neutralizing antibodies to etanercept.

A subset analysis of 252 patients who achieved at least a 75% improvement in PASI scores after the first 24 weeks of treatment found that a median of 91 days passed between stopping therapy and disease relapse.

Only one patient had a relapse that met the National Psoriasis Foundation's definition of rebound—a PASI score that's 125% or greater of baseline within 3 months of stopping therapy.

Etanercept is a fully human soluble tumor necrosis factor receptor that has been approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis.

Many psoriasis drugs are used intermittently or in a rotating manner because they lose their effectiveness over time or cause cumulative, dose-dependent toxicity. Etanercept does not appear to produce cumulative toxicity with chronic, continuous treatment of rheumatoid arthritis, according to Dr. Gottlieb.

KOHALA COAST, HAWAII — New data suggest that etanercept can be given intermittently like other psoriasis treatments, according to a poster that Alice B. Gottlieb, M.D., presented at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Data from the first study of intermittent or rotational use of etanercept came from a large phase III study in U.S. psoriasis patients. After the initial 24 weeks of the randomized, double-blind, controlled trial, 409 patients who responded with at least a 50% improvement in their Psoriasis Area Severity Index (PASI) scores stopped etanercept therapy.

Patients were followed monthly, and if their psoriasis relapsed (defined as losing at least half of the improvement seen in PASI while on treatment), they restarted etanercept at the dose originally assigned to them during the initial blinded phase of the study: weekly at 25 mg or twice-weekly at 25 or 50 mg.

At 60 weeks after all patients had started the original study, 46 remained in remission, 347 had relapsed and restarted etanercept therapy for psoriasis, and 16 patients withdrew from the study before reaching 60 weeks, she wrote.

The median time to relapse among the 498 patients was 85 days after the week-24 visit, when patients first discontinued etanercept. “After discontinuing etanercept, psoriasis gradually relapsed over approximately 3 months,” wrote Dr. Gottlieb of Robert Wood Johnson Medical School, New Brunswick, N.J.

Of the 347 patients who relapsed and restarted etanercept, 297 finished 12 weeks of retreatment. Improvements in PASI scores after retreatment were similar to improvements seen after initial treatment, she reported.

The study was funded in part by the makers of etanercept, Immunex Corp., a wholly owned subsidiary of Amgen Inc. Dr. Gottlieb is a consultant and speaker for the company. An Amgen employee served as a coinvestigator in the study.

The percentages of patients who achieved at least a 75% improvement in PASI scores ranged from 14% to 49% after the first 12 weeks of treatment (depending on dosage group) and 19%-45% after 12 weeks of retreatment.

In the 297 patients who stopped and restarted etanercept, mean PASI scores were 19 at baseline, 6 after the initial 12 weeks of treatment and before disease relapse, and 6 after 12 weeks of retreatment.

About 33% of the 297 patients developed an adverse event during retreatment and 32% developed infection, rates that were similar to those seen in the initial treatment phase of the study.

Stopping etanercept was not associated with severe flares of disease or conversion of psoriasis morphology, and was generally well tolerated by patients, according to Dr. Gottlieb. Retreatment was not associated with an increase in antigenicity to etanercept or with formation of neutralizing antibodies to etanercept.

A subset analysis of 252 patients who achieved at least a 75% improvement in PASI scores after the first 24 weeks of treatment found that a median of 91 days passed between stopping therapy and disease relapse.

Only one patient had a relapse that met the National Psoriasis Foundation's definition of rebound—a PASI score that's 125% or greater of baseline within 3 months of stopping therapy.

Etanercept is a fully human soluble tumor necrosis factor receptor that has been approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis.

Many psoriasis drugs are used intermittently or in a rotating manner because they lose their effectiveness over time or cause cumulative, dose-dependent toxicity. Etanercept does not appear to produce cumulative toxicity with chronic, continuous treatment of rheumatoid arthritis, according to Dr. Gottlieb.

KOHALA COAST, HAWAII — New data suggest that etanercept can be given intermittently like other psoriasis treatments, according to a poster that Alice B. Gottlieb, M.D., presented at a conference on clinical dermatology sponsored by the Center for Bio-Medical Communication Inc.

Data from the first study of intermittent or rotational use of etanercept came from a large phase III study in U.S. psoriasis patients. After the initial 24 weeks of the randomized, double-blind, controlled trial, 409 patients who responded with at least a 50% improvement in their Psoriasis Area Severity Index (PASI) scores stopped etanercept therapy.

Patients were followed monthly, and if their psoriasis relapsed (defined as losing at least half of the improvement seen in PASI while on treatment), they restarted etanercept at the dose originally assigned to them during the initial blinded phase of the study: weekly at 25 mg or twice-weekly at 25 or 50 mg.

At 60 weeks after all patients had started the original study, 46 remained in remission, 347 had relapsed and restarted etanercept therapy for psoriasis, and 16 patients withdrew from the study before reaching 60 weeks, she wrote.

The median time to relapse among the 498 patients was 85 days after the week-24 visit, when patients first discontinued etanercept. “After discontinuing etanercept, psoriasis gradually relapsed over approximately 3 months,” wrote Dr. Gottlieb of Robert Wood Johnson Medical School, New Brunswick, N.J.

Of the 347 patients who relapsed and restarted etanercept, 297 finished 12 weeks of retreatment. Improvements in PASI scores after retreatment were similar to improvements seen after initial treatment, she reported.

The study was funded in part by the makers of etanercept, Immunex Corp., a wholly owned subsidiary of Amgen Inc. Dr. Gottlieb is a consultant and speaker for the company. An Amgen employee served as a coinvestigator in the study.

The percentages of patients who achieved at least a 75% improvement in PASI scores ranged from 14% to 49% after the first 12 weeks of treatment (depending on dosage group) and 19%-45% after 12 weeks of retreatment.

In the 297 patients who stopped and restarted etanercept, mean PASI scores were 19 at baseline, 6 after the initial 12 weeks of treatment and before disease relapse, and 6 after 12 weeks of retreatment.

About 33% of the 297 patients developed an adverse event during retreatment and 32% developed infection, rates that were similar to those seen in the initial treatment phase of the study.

Stopping etanercept was not associated with severe flares of disease or conversion of psoriasis morphology, and was generally well tolerated by patients, according to Dr. Gottlieb. Retreatment was not associated with an increase in antigenicity to etanercept or with formation of neutralizing antibodies to etanercept.

A subset analysis of 252 patients who achieved at least a 75% improvement in PASI scores after the first 24 weeks of treatment found that a median of 91 days passed between stopping therapy and disease relapse.

Only one patient had a relapse that met the National Psoriasis Foundation's definition of rebound—a PASI score that's 125% or greater of baseline within 3 months of stopping therapy.

Etanercept is a fully human soluble tumor necrosis factor receptor that has been approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and psoriasis.

Many psoriasis drugs are used intermittently or in a rotating manner because they lose their effectiveness over time or cause cumulative, dose-dependent toxicity. Etanercept does not appear to produce cumulative toxicity with chronic, continuous treatment of rheumatoid arthritis, according to Dr. Gottlieb.

SAN FRANCISCO — Educational videos on handheld computers were a hit with patients learning how to start or switch HIV medications, a preliminary study of 50 patients found.

Handheld computers, also called personal digital assistants (PDAs), could be useful tools in educating patients with low literacy levels, Scott R. Smith, Ph.D., said in a poster presentation at the triennial congress of the International Medical Informatics Association.

Previous data have shown that one in four patients living with HIV or AIDS has a hard time understanding simple medical instructions or medical terms and concepts. A previous assessment of literacy levels in patients at the University of North Carolina Hospitals Infectious Diseases Clinic found reading abilities at the eighth-grade level or lower in 30 of 75 patients, noted Dr. Smith of the university.

In the current study, pharmacists created interactive educational audio and video clips geared toward patients of different ethnicities that explained how to take antiretroviral medications, manage side effects, and adhere to treatment. Patients answered questionnaires before and after using the PDAs.

At the start of the study, 19 patients reported some or a lot of trouble adhering to medication regimens, 14 reported a little trouble, 2 said they had no trouble, and 15 were just starting a new regimen.

After watching the PDA movies, 48 of 49 patients who answered follow-up surveys said they felt very or extremely sure that they would be able to adhere to therapy. Forty-five patients said they believed that the medicine would have a positive effect on their health, and 47 patients agreed that not taking their medications would make the HIV become resistant to the drugs.

Twelve patients in the study were white, and 38 were African American. Nineteen had never used a computer before. The average age of the subjects was 42 years, with a range of 25-70 years. On average, they were supposed to take three antiretroviral drugs, twice per day.

Most patients said the PDA movie was helpful, valuable, easy to follow, and exciting, rather than boring. Nearly all rated the movie as excellent, and said it made the information easier to remember, that they found it easier to learn from movies than from books, and that they liked using a handheld computer to watch the movie.

In general, printed health education materials are written for people with at least a 10th-grade reading ability, Dr. Smith said. Literacy increasingly is being recognized as a contributor to disparities in health outcomes.

“As devices become smaller, more portable, easier to use, and less costly, they hold potential for innovative uses in patient education,” he added.

Dr. Smith reported no relationship with the company that makes the PDAs.

SAN FRANCISCO — Educational videos on handheld computers were a hit with patients learning how to start or switch HIV medications, a preliminary study of 50 patients found.

Handheld computers, also called personal digital assistants (PDAs), could be useful tools in educating patients with low literacy levels, Scott R. Smith, Ph.D., said in a poster presentation at the triennial congress of the International Medical Informatics Association.

Previous data have shown that one in four patients living with HIV or AIDS has a hard time understanding simple medical instructions or medical terms and concepts. A previous assessment of literacy levels in patients at the University of North Carolina Hospitals Infectious Diseases Clinic found reading abilities at the eighth-grade level or lower in 30 of 75 patients, noted Dr. Smith of the university.

In the current study, pharmacists created interactive educational audio and video clips geared toward patients of different ethnicities that explained how to take antiretroviral medications, manage side effects, and adhere to treatment. Patients answered questionnaires before and after using the PDAs.

At the start of the study, 19 patients reported some or a lot of trouble adhering to medication regimens, 14 reported a little trouble, 2 said they had no trouble, and 15 were just starting a new regimen.

After watching the PDA movies, 48 of 49 patients who answered follow-up surveys said they felt very or extremely sure that they would be able to adhere to therapy. Forty-five patients said they believed that the medicine would have a positive effect on their health, and 47 patients agreed that not taking their medications would make the HIV become resistant to the drugs.

Twelve patients in the study were white, and 38 were African American. Nineteen had never used a computer before. The average age of the subjects was 42 years, with a range of 25-70 years. On average, they were supposed to take three antiretroviral drugs, twice per day.

Most patients said the PDA movie was helpful, valuable, easy to follow, and exciting, rather than boring. Nearly all rated the movie as excellent, and said it made the information easier to remember, that they found it easier to learn from movies than from books, and that they liked using a handheld computer to watch the movie.

In general, printed health education materials are written for people with at least a 10th-grade reading ability, Dr. Smith said. Literacy increasingly is being recognized as a contributor to disparities in health outcomes.

“As devices become smaller, more portable, easier to use, and less costly, they hold potential for innovative uses in patient education,” he added.

Dr. Smith reported no relationship with the company that makes the PDAs.

SAN FRANCISCO — Educational videos on handheld computers were a hit with patients learning how to start or switch HIV medications, a preliminary study of 50 patients found.

Handheld computers, also called personal digital assistants (PDAs), could be useful tools in educating patients with low literacy levels, Scott R. Smith, Ph.D., said in a poster presentation at the triennial congress of the International Medical Informatics Association.

Previous data have shown that one in four patients living with HIV or AIDS has a hard time understanding simple medical instructions or medical terms and concepts. A previous assessment of literacy levels in patients at the University of North Carolina Hospitals Infectious Diseases Clinic found reading abilities at the eighth-grade level or lower in 30 of 75 patients, noted Dr. Smith of the university.

In the current study, pharmacists created interactive educational audio and video clips geared toward patients of different ethnicities that explained how to take antiretroviral medications, manage side effects, and adhere to treatment. Patients answered questionnaires before and after using the PDAs.

At the start of the study, 19 patients reported some or a lot of trouble adhering to medication regimens, 14 reported a little trouble, 2 said they had no trouble, and 15 were just starting a new regimen.

After watching the PDA movies, 48 of 49 patients who answered follow-up surveys said they felt very or extremely sure that they would be able to adhere to therapy. Forty-five patients said they believed that the medicine would have a positive effect on their health, and 47 patients agreed that not taking their medications would make the HIV become resistant to the drugs.

Twelve patients in the study were white, and 38 were African American. Nineteen had never used a computer before. The average age of the subjects was 42 years, with a range of 25-70 years. On average, they were supposed to take three antiretroviral drugs, twice per day.

Most patients said the PDA movie was helpful, valuable, easy to follow, and exciting, rather than boring. Nearly all rated the movie as excellent, and said it made the information easier to remember, that they found it easier to learn from movies than from books, and that they liked using a handheld computer to watch the movie.

In general, printed health education materials are written for people with at least a 10th-grade reading ability, Dr. Smith said. Literacy increasingly is being recognized as a contributor to disparities in health outcomes.

“As devices become smaller, more portable, easier to use, and less costly, they hold potential for innovative uses in patient education,” he added.

Dr. Smith reported no relationship with the company that makes the PDAs.

SAN FRANCISCO — Patients seen in the emergency department for acute decompensated heart failure fared much worse if they had elevated serum troponin, W. Frank Peacock IV, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

The results should have a profound impact on controversy about the clinical implications of elevating troponin in patients with heart failure, several speakers said at the meeting.

The analysis of data on 67,924 patients in the Acute Decompensated Heart Failure National Registry (ADHERE) showed that 6% had elevated troponin levels, and the rest were considered troponin negative. Patients with elevated serum troponin were more likely than troponin-negative patients to develop systolic heart failure (61% vs. 51%) or undergo coronary artery bypass grafting (4% vs. 1%), intra-aortic balloon counterpulsation (3% vs. less than 1%), mechanical ventilation (11% vs. 4%), or cardioversion (3% vs. 2%), said Dr. Peacock of the Cleveland Clinic and his associates.

Patients with acute decompensated heart failure and elevated serum troponin also had longer hospitalizations (median 5.1 vs. 4.1 days) and longer ICU stays (a median of 2.9 vs. 2.3 days) and were more likely to die in the hospital (8% vs. 3%) compared with troponin-negative patients.

The study defined elevated serum troponin as a level of at least 1 ng/ml for troponin I or at least 0.1 ng/ml for troponin T. Patients with levels below those cutoffs were considered troponin-negative.

“This [study] is important, because cardiologists everywhere—particularly our heart failure cardiologists—tend to pooh-pooh troponin leaks,” said Judd E. Hollander, M.D., professor of emergency medicine at the University of Pennsylvania, Philadelphia.

Elevated troponin in heart failure does not necessarily indicate underlying coronary disease, he said. “What this doesn't tell us is whether there's something we can fix in the hospital to decrease that mortality” associated with elevated troponin, he added.

Particularly in older patients, elevated troponin has been a marker for sick patients in studies of sepsis, shock, chest pain, or congestive heart failure. “It's a worrisome marker and should be treated as such,” said Charles V. Pollack, Jr., M.D., chair of emergency medicine at the University of Pennsylvania.

Troponin is a structural protein, and elevated levels are produced by cell death, noted Brian J. O'Neil, M.D., of Wayne State University, Detroit. “These are not 'leaks,' “ he said.

In a separate interview, cardiologist Christopher P. Cannon, M.D., agreed that some of his colleagues have been misled by the common use of elevated troponin levels as a marker for acute coronary syndrome. When catheterizations found no arterial blockage in some patients with elevated troponin, the marker gained a reputation for false positives.

“We've learned that there are other things that cause elevations in troponin. We're all learning how to use this in these other patient groups. People are realizing it's a good marker of high-risk patients independent of whether the arteries have blockages or not,” said Dr. Cannon of Brigham and Women's Hospital, Boston.

Previous studies have shown that troponin is a biomarker for myocardial injury. In earlier studies of patients hospitalized for heart failure, troponin elevations have been associated with lower ejection fractions, worse functional status, repeat hospitalizations for heart failure, and death. Studies on the clinical implications of troponin in heart failure are few, however, and have been plagued by methodological problems.

Although speakers at the meeting lauded the current study for the number and breadth of patients in the database, Jerome R. Hoffman, M.D., pointed out one major limitation: possible incorporation bias. Higher rates of procedures and longer hospitalizations may be due to physicians' reactions.

“When somebody tells you a patient has a high troponin level, you might keep them in the hospital or ICU a little longer. It may be a self-fulfilling prophecy” and not necessarily an appropriate step, said Dr. Hoffman of the University of California, Los Angeles.

Sorin J. Brener, M.D., called the study “important and well executed” but agreed with Dr. Hoffman's criticism. A multivariate logistic regression analysis controlling for the differences between patients in the two troponin groups would be necessary to isolate the independent effect of elevated troponin on outcomes, he said in a separate interview.

“Elevated troponin levels are indeed a marker of adverse prognosis and cannot be ignored. Unfortunately, more often than not there is no specific intervention tailored to this finding in patients with decompensated heart failure that one would not apply in patients without elevated troponin,” said Dr. Brener, director of the angiography core laboratory at the Cleveland Clinic.

SAN FRANCISCO — Patients seen in the emergency department for acute decompensated heart failure fared much worse if they had elevated serum troponin, W. Frank Peacock IV, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

The results should have a profound impact on controversy about the clinical implications of elevating troponin in patients with heart failure, several speakers said at the meeting.

The analysis of data on 67,924 patients in the Acute Decompensated Heart Failure National Registry (ADHERE) showed that 6% had elevated troponin levels, and the rest were considered troponin negative. Patients with elevated serum troponin were more likely than troponin-negative patients to develop systolic heart failure (61% vs. 51%) or undergo coronary artery bypass grafting (4% vs. 1%), intra-aortic balloon counterpulsation (3% vs. less than 1%), mechanical ventilation (11% vs. 4%), or cardioversion (3% vs. 2%), said Dr. Peacock of the Cleveland Clinic and his associates.

Patients with acute decompensated heart failure and elevated serum troponin also had longer hospitalizations (median 5.1 vs. 4.1 days) and longer ICU stays (a median of 2.9 vs. 2.3 days) and were more likely to die in the hospital (8% vs. 3%) compared with troponin-negative patients.

The study defined elevated serum troponin as a level of at least 1 ng/ml for troponin I or at least 0.1 ng/ml for troponin T. Patients with levels below those cutoffs were considered troponin-negative.

“This [study] is important, because cardiologists everywhere—particularly our heart failure cardiologists—tend to pooh-pooh troponin leaks,” said Judd E. Hollander, M.D., professor of emergency medicine at the University of Pennsylvania, Philadelphia.

Elevated troponin in heart failure does not necessarily indicate underlying coronary disease, he said. “What this doesn't tell us is whether there's something we can fix in the hospital to decrease that mortality” associated with elevated troponin, he added.

Particularly in older patients, elevated troponin has been a marker for sick patients in studies of sepsis, shock, chest pain, or congestive heart failure. “It's a worrisome marker and should be treated as such,” said Charles V. Pollack, Jr., M.D., chair of emergency medicine at the University of Pennsylvania.

Troponin is a structural protein, and elevated levels are produced by cell death, noted Brian J. O'Neil, M.D., of Wayne State University, Detroit. “These are not 'leaks,' “ he said.

In a separate interview, cardiologist Christopher P. Cannon, M.D., agreed that some of his colleagues have been misled by the common use of elevated troponin levels as a marker for acute coronary syndrome. When catheterizations found no arterial blockage in some patients with elevated troponin, the marker gained a reputation for false positives.

“We've learned that there are other things that cause elevations in troponin. We're all learning how to use this in these other patient groups. People are realizing it's a good marker of high-risk patients independent of whether the arteries have blockages or not,” said Dr. Cannon of Brigham and Women's Hospital, Boston.

Previous studies have shown that troponin is a biomarker for myocardial injury. In earlier studies of patients hospitalized for heart failure, troponin elevations have been associated with lower ejection fractions, worse functional status, repeat hospitalizations for heart failure, and death. Studies on the clinical implications of troponin in heart failure are few, however, and have been plagued by methodological problems.

Although speakers at the meeting lauded the current study for the number and breadth of patients in the database, Jerome R. Hoffman, M.D., pointed out one major limitation: possible incorporation bias. Higher rates of procedures and longer hospitalizations may be due to physicians' reactions.

“When somebody tells you a patient has a high troponin level, you might keep them in the hospital or ICU a little longer. It may be a self-fulfilling prophecy” and not necessarily an appropriate step, said Dr. Hoffman of the University of California, Los Angeles.

Sorin J. Brener, M.D., called the study “important and well executed” but agreed with Dr. Hoffman's criticism. A multivariate logistic regression analysis controlling for the differences between patients in the two troponin groups would be necessary to isolate the independent effect of elevated troponin on outcomes, he said in a separate interview.

“Elevated troponin levels are indeed a marker of adverse prognosis and cannot be ignored. Unfortunately, more often than not there is no specific intervention tailored to this finding in patients with decompensated heart failure that one would not apply in patients without elevated troponin,” said Dr. Brener, director of the angiography core laboratory at the Cleveland Clinic.

SAN FRANCISCO — Patients seen in the emergency department for acute decompensated heart failure fared much worse if they had elevated serum troponin, W. Frank Peacock IV, M.D., said in a poster at the annual meeting of the American College of Emergency Physicians.

The results should have a profound impact on controversy about the clinical implications of elevating troponin in patients with heart failure, several speakers said at the meeting.

The analysis of data on 67,924 patients in the Acute Decompensated Heart Failure National Registry (ADHERE) showed that 6% had elevated troponin levels, and the rest were considered troponin negative. Patients with elevated serum troponin were more likely than troponin-negative patients to develop systolic heart failure (61% vs. 51%) or undergo coronary artery bypass grafting (4% vs. 1%), intra-aortic balloon counterpulsation (3% vs. less than 1%), mechanical ventilation (11% vs. 4%), or cardioversion (3% vs. 2%), said Dr. Peacock of the Cleveland Clinic and his associates.

Patients with acute decompensated heart failure and elevated serum troponin also had longer hospitalizations (median 5.1 vs. 4.1 days) and longer ICU stays (a median of 2.9 vs. 2.3 days) and were more likely to die in the hospital (8% vs. 3%) compared with troponin-negative patients.

The study defined elevated serum troponin as a level of at least 1 ng/ml for troponin I or at least 0.1 ng/ml for troponin T. Patients with levels below those cutoffs were considered troponin-negative.

“This [study] is important, because cardiologists everywhere—particularly our heart failure cardiologists—tend to pooh-pooh troponin leaks,” said Judd E. Hollander, M.D., professor of emergency medicine at the University of Pennsylvania, Philadelphia.

Elevated troponin in heart failure does not necessarily indicate underlying coronary disease, he said. “What this doesn't tell us is whether there's something we can fix in the hospital to decrease that mortality” associated with elevated troponin, he added.

Particularly in older patients, elevated troponin has been a marker for sick patients in studies of sepsis, shock, chest pain, or congestive heart failure. “It's a worrisome marker and should be treated as such,” said Charles V. Pollack, Jr., M.D., chair of emergency medicine at the University of Pennsylvania.

Troponin is a structural protein, and elevated levels are produced by cell death, noted Brian J. O'Neil, M.D., of Wayne State University, Detroit. “These are not 'leaks,' “ he said.

In a separate interview, cardiologist Christopher P. Cannon, M.D., agreed that some of his colleagues have been misled by the common use of elevated troponin levels as a marker for acute coronary syndrome. When catheterizations found no arterial blockage in some patients with elevated troponin, the marker gained a reputation for false positives.

“We've learned that there are other things that cause elevations in troponin. We're all learning how to use this in these other patient groups. People are realizing it's a good marker of high-risk patients independent of whether the arteries have blockages or not,” said Dr. Cannon of Brigham and Women's Hospital, Boston.

Previous studies have shown that troponin is a biomarker for myocardial injury. In earlier studies of patients hospitalized for heart failure, troponin elevations have been associated with lower ejection fractions, worse functional status, repeat hospitalizations for heart failure, and death. Studies on the clinical implications of troponin in heart failure are few, however, and have been plagued by methodological problems.

Although speakers at the meeting lauded the current study for the number and breadth of patients in the database, Jerome R. Hoffman, M.D., pointed out one major limitation: possible incorporation bias. Higher rates of procedures and longer hospitalizations may be due to physicians' reactions.

“When somebody tells you a patient has a high troponin level, you might keep them in the hospital or ICU a little longer. It may be a self-fulfilling prophecy” and not necessarily an appropriate step, said Dr. Hoffman of the University of California, Los Angeles.

Sorin J. Brener, M.D., called the study “important and well executed” but agreed with Dr. Hoffman's criticism. A multivariate logistic regression analysis controlling for the differences between patients in the two troponin groups would be necessary to isolate the independent effect of elevated troponin on outcomes, he said in a separate interview.

“Elevated troponin levels are indeed a marker of adverse prognosis and cannot be ignored. Unfortunately, more often than not there is no specific intervention tailored to this finding in patients with decompensated heart failure that one would not apply in patients without elevated troponin,” said Dr. Brener, director of the angiography core laboratory at the Cleveland Clinic.

SAN DIEGO – Expanding the staff and scope of its Multicultural Affairs Office over the last 4 years helped increase the numbers of African American, Native American, and Hispanic medical residents who opted to train at Boston's Massachusetts General Hospital, said Elena B. Olson, the office's administrative director.

Founded in 1992 to increase diversity specifically in the department of medicine, the office expanded to eight employees (many of them part time) in 2000 to collaborate with all 20 residency programs at the hospital in recruiting, retaining, and advancing underrepresented minorities at the hospital.

“It appears that we are one of the few hospitals that actually do this,” Ms. Olson said. Massachusetts General competes with other hospitals in the Harvard University system for residency applicants.

Ms. Olson and Dr. Ronald Dixon, the office's manager of trainee affairs, hope that the hospital's model can be used by other institutions to increase the number of physicians from underrepresented minority groups.

They presented the first public description of the program at the annual meeting of the National Medical Association.

Data on residency matches collected by the office since 2001 show that the annual percentage of underrepresented minorities who match with residency programs at the hospital has improved to 10%, which parallels the proportion of underrepresented minorities in medical schools. In 2002, the office helped match residents to programs at the hospital that traditionally had failed to attract underrepresented minorities–such as all the surgical services, she said.

The “ranking match rates”–the number of medical students ranked high on the hospital's match list that chose to come to Massachusetts General–improved in the last few years as well.

In 2001, the hospital ranked 62 underrepresented minority applicants for acceptance, and the rankings of 21 of these students matched them with residency programs there.

In 2002, 33 of 62 underrepresented minorities matched with the hospital. In 2003, 21 of 51 matched. And in 2004, 26 of 62 underrepresented minorities matched with the hospital's training programs. “Our recruitment efforts were paying off,” she said.

The rank-to-match ratio was higher for underrepresented minorities, compared with residency applicants overall. In 2003, 41% of underrepresented minorities and 34% of applicants overall matched with the hospital. In 2004, 42% of underrepresented minorities and 36% of applicants overall matched with the hospital.

The office offers the hospital's 20 residency program directors two levels of assistance. First, an introductory letter invites applicants to consider training there and gives them contact information for staff and current minority residents. Beyond that, the office can arrange informal meetings, provide funds for applicants to visit the hospital, and make some follow-up contacts.

The office also coordinates an 8-week summer research trainee program for minority college students to encourage them to pursue careers in medicine. Strengthening the pipeline of students “is crucial to building a robust resident pool,” she said.

SAN DIEGO – Expanding the staff and scope of its Multicultural Affairs Office over the last 4 years helped increase the numbers of African American, Native American, and Hispanic medical residents who opted to train at Boston's Massachusetts General Hospital, said Elena B. Olson, the office's administrative director.

Founded in 1992 to increase diversity specifically in the department of medicine, the office expanded to eight employees (many of them part time) in 2000 to collaborate with all 20 residency programs at the hospital in recruiting, retaining, and advancing underrepresented minorities at the hospital.

“It appears that we are one of the few hospitals that actually do this,” Ms. Olson said. Massachusetts General competes with other hospitals in the Harvard University system for residency applicants.

Ms. Olson and Dr. Ronald Dixon, the office's manager of trainee affairs, hope that the hospital's model can be used by other institutions to increase the number of physicians from underrepresented minority groups.

They presented the first public description of the program at the annual meeting of the National Medical Association.

Data on residency matches collected by the office since 2001 show that the annual percentage of underrepresented minorities who match with residency programs at the hospital has improved to 10%, which parallels the proportion of underrepresented minorities in medical schools. In 2002, the office helped match residents to programs at the hospital that traditionally had failed to attract underrepresented minorities–such as all the surgical services, she said.

The “ranking match rates”–the number of medical students ranked high on the hospital's match list that chose to come to Massachusetts General–improved in the last few years as well.

In 2001, the hospital ranked 62 underrepresented minority applicants for acceptance, and the rankings of 21 of these students matched them with residency programs there.

In 2002, 33 of 62 underrepresented minorities matched with the hospital. In 2003, 21 of 51 matched. And in 2004, 26 of 62 underrepresented minorities matched with the hospital's training programs. “Our recruitment efforts were paying off,” she said.

The rank-to-match ratio was higher for underrepresented minorities, compared with residency applicants overall. In 2003, 41% of underrepresented minorities and 34% of applicants overall matched with the hospital. In 2004, 42% of underrepresented minorities and 36% of applicants overall matched with the hospital.

The office offers the hospital's 20 residency program directors two levels of assistance. First, an introductory letter invites applicants to consider training there and gives them contact information for staff and current minority residents. Beyond that, the office can arrange informal meetings, provide funds for applicants to visit the hospital, and make some follow-up contacts.

The office also coordinates an 8-week summer research trainee program for minority college students to encourage them to pursue careers in medicine. Strengthening the pipeline of students “is crucial to building a robust resident pool,” she said.

SAN DIEGO – Expanding the staff and scope of its Multicultural Affairs Office over the last 4 years helped increase the numbers of African American, Native American, and Hispanic medical residents who opted to train at Boston's Massachusetts General Hospital, said Elena B. Olson, the office's administrative director.

Founded in 1992 to increase diversity specifically in the department of medicine, the office expanded to eight employees (many of them part time) in 2000 to collaborate with all 20 residency programs at the hospital in recruiting, retaining, and advancing underrepresented minorities at the hospital.

“It appears that we are one of the few hospitals that actually do this,” Ms. Olson said. Massachusetts General competes with other hospitals in the Harvard University system for residency applicants.

Ms. Olson and Dr. Ronald Dixon, the office's manager of trainee affairs, hope that the hospital's model can be used by other institutions to increase the number of physicians from underrepresented minority groups.

They presented the first public description of the program at the annual meeting of the National Medical Association.

Data on residency matches collected by the office since 2001 show that the annual percentage of underrepresented minorities who match with residency programs at the hospital has improved to 10%, which parallels the proportion of underrepresented minorities in medical schools. In 2002, the office helped match residents to programs at the hospital that traditionally had failed to attract underrepresented minorities–such as all the surgical services, she said.

The “ranking match rates”–the number of medical students ranked high on the hospital's match list that chose to come to Massachusetts General–improved in the last few years as well.

In 2001, the hospital ranked 62 underrepresented minority applicants for acceptance, and the rankings of 21 of these students matched them with residency programs there.

In 2002, 33 of 62 underrepresented minorities matched with the hospital. In 2003, 21 of 51 matched. And in 2004, 26 of 62 underrepresented minorities matched with the hospital's training programs. “Our recruitment efforts were paying off,” she said.

The rank-to-match ratio was higher for underrepresented minorities, compared with residency applicants overall. In 2003, 41% of underrepresented minorities and 34% of applicants overall matched with the hospital. In 2004, 42% of underrepresented minorities and 36% of applicants overall matched with the hospital.

The office offers the hospital's 20 residency program directors two levels of assistance. First, an introductory letter invites applicants to consider training there and gives them contact information for staff and current minority residents. Beyond that, the office can arrange informal meetings, provide funds for applicants to visit the hospital, and make some follow-up contacts.

The office also coordinates an 8-week summer research trainee program for minority college students to encourage them to pursue careers in medicine. Strengthening the pipeline of students “is crucial to building a robust resident pool,” she said.

SAN FRANCISCO – The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C. He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses.

Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.

SAN FRANCISCO – The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C. He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses.

Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.

SAN FRANCISCO – The digital divide in your waiting room can be crossed, and technology can compensate for low literacy levels in some patients, said David F. Lobach, M.D.

A randomized, controlled, crossover study of 567 patients found that patients of differing literacy levels and differing levels of computer skills successfully answered a 75-item computerized clinical questionnaire that adapted to their skill levels through a tool named MADELINE (Multimedia Adaptive Data Entry and Learning Interface within a Networked Environment), he said at the triennial congress of the International Medical Informatics Association.

Patients in two clinics (an academic family practice and a health center for indigent patients) were randomized to first complete either a paper version of the questionnaire or the computer version, then the other version, with satisfaction surveys immediately following each version and a separate questionnaire at the end asking them to compare the two modalities. Questions at the beginning of each survey assessed patient literacy and computer skill and ranked them as low or high.

Patients with low literacy levels were less likely to complete the paper questionnaire, compared with highly literate patients; 80% vs. 90%, respectively, answered all questions. Thanks to MADELINE, completion rates increased significantly in both groups, to 96% and 97%, respectively.

“We lessened the digital divide and brought the low-literacy users up to par with the high-literacy users,” said Dr. Lobach of Duke University Medical Center, Durham, N.C. He and his associates developed MADELINE over a 3-year period. The U.S. Agency for Healthcare Quality and Research provided most of the funding for the study.

A review of charts on 20% of the patients found comparable accuracy between the paper and computer survey responses.

Low-literacy patients required an average of 28 minutes to complete the computer survey, compared with 16 minutes for the paper version. High-literacy patients completed the computer survey in 15 minutes and the paper survey in 11 minutes.

Approximately 50% of patients had high literacy and high computer skills, 25% had low literacy and computer skills, 15% were highly literate but had low computer skills, and 10% had low literacy but high computer skills.

Patients could take the survey in English or Spanish, and MADELINE can be configured to include other languages and questionnaires. It begins by asking about language preference, then introduces the user to the questionnaire via instructional videos and practice questions. The user then logs on using a number assigned to his or her name and record number and answers six questions to assess literacy and computer skill.

At this point MADELINE presents the questionnaire in different ways for patients with low or high skills.

Those with low computer skills, for example, hear an audio component that reads a question on the screen, and they pick an answer by touching the screen. Patients with high computer skills see multiple questions per screen and use a mouse to click on responses.

For low-literacy patients, the program adapts to a fifth-grade reading level and predominantly uses multiple-choice questions. For high-literacy patients, the program adapts to a 10th- to 12th-grade reading level and has more questions requiring text-entry responses instead of a multiple-choice selection.

Below a fifth-grade reading level “we lost the ability to collect any meaningful information” by paper or computer, Dr. Lobach said.

A report on the patient's answers could be read online or could be printed out after completing the questionnaire.