Betsy Bates

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, researchers from the University of Southern California, Los Angeles, suggested at the annual Digestive Disease Week.

Dr. Joaquin Estrada and associates in the department of surgery at the university reported that patients with a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed charts of 41 patients found to have a gangrenous/perforated appendix at surgery and 116 patients admitted for suspected acute appendicitis who were not found to have a perforated or gangrenous appendix. A pathologically normal appendix was found in 13 patients in the latter group.

Among patients with perforation, 23, or 56%, had an elevated bilirubin upon admission compared with 36, or 31%, of those not found to have a perforated or gangrenous appendix.

Factors that did not distinguish the two groups included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and age.

Although larger studies are needed, Dr. Estrada said the findings may assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, he said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, researchers from the University of Southern California, Los Angeles, suggested at the annual Digestive Disease Week.

Dr. Joaquin Estrada and associates in the department of surgery at the university reported that patients with a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed charts of 41 patients found to have a gangrenous/perforated appendix at surgery and 116 patients admitted for suspected acute appendicitis who were not found to have a perforated or gangrenous appendix. A pathologically normal appendix was found in 13 patients in the latter group.

Among patients with perforation, 23, or 56%, had an elevated bilirubin upon admission compared with 36, or 31%, of those not found to have a perforated or gangrenous appendix.

Factors that did not distinguish the two groups included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and age.

Although larger studies are needed, Dr. Estrada said the findings may assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, he said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

LOS ANGELES — Elevated serum bilirubin on admission may be a tip-off to a perforated appendix, researchers from the University of Southern California, Los Angeles, suggested at the annual Digestive Disease Week.

Dr. Joaquin Estrada and associates in the department of surgery at the university reported that patients with a gangrenous and/or perforated appendix were 2.9 times more likely than were other patients with suspected appendicitis to have a total bilirubin greater than 1 mg/dL upon admission.

The team retrospectively reviewed charts of 41 patients found to have a gangrenous/perforated appendix at surgery and 116 patients admitted for suspected acute appendicitis who were not found to have a perforated or gangrenous appendix. A pathologically normal appendix was found in 13 patients in the latter group.

Among patients with perforation, 23, or 56%, had an elevated bilirubin upon admission compared with 36, or 31%, of those not found to have a perforated or gangrenous appendix.

Factors that did not distinguish the two groups included the duration of symptoms, the total white blood count, elevated temperature, systemic inflammatory response score, and age.

Although larger studies are needed, Dr. Estrada said the findings may assist clinicians “in determining which patients you'd like to get a CT scan on.”

A potential mechanism for raising bilirubin, based on animal studies, is a biochemical response to bacteremia, he said.

Patients were not included in the 12-month review of cases if they had liver disease, alcoholism, hemolytic disorders, or biliary disease.

LOS ANGELES — Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, Dr. Miller said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to begin to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. Approximately one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Diabetes care can be severely impacted by depression, on many levels, she continued. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels].”

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using two pivotal questions (see box) and the PHQ-9 at least once a year. When a patient screens positive for depression, she sees them more often than usual—at least three times in 90 days if they are receiving an antidepressant—and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain.

By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Depressed patients often will self-medicate their depression by eating more. DR. MILLER

Questions Can Reveal Depression

Screening for depression in patients with diabetes can begin with two simple questions, according to Dr. Doriane C. Miller of Rush University Medical College and Stroger Hospital of Cook County in Chicago.

She asks every patient at every visit:

▸ How's your mood?

▸ What do you do for fun?

Sometimes patients' responses, along with clues from their facial expressions, vague aches and pains, and noncompliance with a diabetes care plan, can be enough to warrant a more targeted depression screening with an instrument such as the Patient Health Questionnaire (PHQ-9), she said.

LOS ANGELES — Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, Dr. Miller said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to begin to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. Approximately one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Diabetes care can be severely impacted by depression, on many levels, she continued. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels].”

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using two pivotal questions (see box) and the PHQ-9 at least once a year. When a patient screens positive for depression, she sees them more often than usual—at least three times in 90 days if they are receiving an antidepressant—and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain.

By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Depressed patients often will self-medicate their depression by eating more. DR. MILLER

Questions Can Reveal Depression

Screening for depression in patients with diabetes can begin with two simple questions, according to Dr. Doriane C. Miller of Rush University Medical College and Stroger Hospital of Cook County in Chicago.

She asks every patient at every visit:

▸ How's your mood?

▸ What do you do for fun?

Sometimes patients' responses, along with clues from their facial expressions, vague aches and pains, and noncompliance with a diabetes care plan, can be enough to warrant a more targeted depression screening with an instrument such as the Patient Health Questionnaire (PHQ-9), she said.

LOS ANGELES — Adherence to a self-care action plan helped primary care patients exceed national goals for reducing their depression, reported Dr. Doriane C. Miller, associate division chief of general internal medicine at Stroger Hospital of Cook County in Chicago.

The study of 403 depressed adults in rural South Carolina has implications for improving outcomes for patients with diabetes, whose depression undermines their ability to manage a complex disease, Dr. Miller said at the annual meeting of the American Association of Diabetes Educators.

Patients at CareSouth, a series of federally qualified health centers serving mostly minority, low-income residents, were screened using the Patient Health Questionnaire-9 (PHQ-9), an instrument made available by Pfizer (www.pfizer.com/pfizer/phq-9/index.jsp

Those whose scores indicated they had clinically significant depression were enrolled in a collaborative self-management program that included the Depression Self-Care Action Plan (www.collaborativeselfmanagement.org/uploads/ManagingDepression.pdf

Focusing on “simple goals and small steps,” the plan helps patients establish concrete ways to stay physically active, engage in pleasurable activities, spend time with supportive people, incorporate relaxation into their daily lives, and identify life stresses and ways to begin to deal with them.

It's a “living process document,” reviewed at appointments and adapted to the reality of patients' often troubled lives, Dr. Miller said.

After 1 year, 56% of patients had reduced their depression scores by more than 50%, compared with a national goal of 40%. Fully 85% of patients had documented their self-management of depression, compared with a national goal of 70%. Approximately one-fourth of patients participating in the depression collaborative, sponsored by the Health Resources and Services Administration's Bureau of Primary Health Care, had diabetes as a comorbidity.

Perhaps most dramatically, 53% of patients no longer met the PHQ-9 threshold for depression, compared with a national goal of 40%.

“We find this kind of self-care action plan can be a very useful tool for people who have depression and, particularly, people with diabetes [who have depression],” said Dr. Miller, who also serves as national program director of Quality Allies, an effort aimed at improving ambulatory care that is sponsored by the Robert Wood Johnson Foundation and the California HealthCare Foundation.

As many as one in four patients with diabetes have depression, but it can be missed in quick office visits or disguised as hostility, apathetic noncompliance, or a seeming inability to concentrate and follow directions.

People with diabetes are especially burdened by a sense of hopelessness and helplessness about downstream consequences of their disease, such as amputation, blindness, myocardial infarction, or stroke, Dr. Miller said.

“It can have a strong influence on their thinking,” she said. “[They start thinking] 'if it happened to my brother, my grandfather, my mother, it's going to happen to me. It's just a hopeless situation and something I need to bear.'”

Diabetes care can be severely impacted by depression, on many levels, she continued. “Patients oftentimes will self-medicate their depression by eating more. They won't check their blood sugar [levels].”

When concentration is hampered by depression, patients will return to the office failing to recall even a simple care plan they agreed to on a previous visit.

“If you're not able to address some of the underlying causes for medication nonadherence, you're not going to get anywhere in terms of clinical treatment,” she said.

Dr. Miller currently screens all of her patients with diabetes using two pivotal questions (see box) and the PHQ-9 at least once a year. When a patient screens positive for depression, she sees them more often than usual—at least three times in 90 days if they are receiving an antidepressant—and rescreens them with the PHQ-9 every 4–6 weeks.

She has seen clear benefits of this approach in her own practice, she said.

She described a patient in her late 50s whose diabetes control was falling apart even as she coped with the loss of a job and ensuing financial difficulties and weight gain.

By identifying her depression and helping her to implement a self-care plan, Dr. Miller was able to watch as her patient became more physically active and lost weight, began an earnest job search, and returned to HbA_1c levels in the range of 7%–8%, down from a level of 10%.

Dr. Miller has no financial ties to Pfizer, sponsor of the PHQ-9.

Depressed patients often will self-medicate their depression by eating more. DR. MILLER

Questions Can Reveal Depression

Screening for depression in patients with diabetes can begin with two simple questions, according to Dr. Doriane C. Miller of Rush University Medical College and Stroger Hospital of Cook County in Chicago.

She asks every patient at every visit:

▸ How's your mood?

▸ What do you do for fun?

Sometimes patients' responses, along with clues from their facial expressions, vague aches and pains, and noncompliance with a diabetes care plan, can be enough to warrant a more targeted depression screening with an instrument such as the Patient Health Questionnaire (PHQ-9), she said.

LOS ANGELES — Physicians, patients with diabetes, and diabetes educators expressed reservations about the current state of diabetes education in a series of focus groups sponsored by the American Association of Diabetes Educators and presented at the organization's annual meeting.

Preliminary findings suggest that there are significant gaps in awareness of diabetes education resources and an underlying uneasiness about the role of educators in overall diabetes care, reported Mark Peyrot, Ph.D., professor of sociology at Loyola College in Baltimore.

The six focus groups each consisted of about 15 members of a particular constituency—physicians who care for patients with diabetes, diabetes educators, or patients.

During teleconference calls, participants discussed a wide range of issues involving the general topic of diabetes education. Results will be used to devise an Internet survey to better capture positive and negative impressions of diabetes education and direct future resources in improving the field, explained Dr. Peyrot.

Early focus group findings suggest there is work to be done in improving access to, awareness of, usefulness of, and funding for diabetes education programs offered through hospitals, health care groups, and communities.

“A few bad experiences will turn you off,” said one physician during a focus group session.

Physicians suggested they would like to see diabetes education programs that personalize messages for their patients rather than rely on textbooklike, pedantic lessons. They want an easier referral process, better feedback from diabetes educators, and an assurance that treatment decisions will be left to them.

One physician also expressed the concern that diabetes educators may try to “steal patients.” Others also feared that patients' allegiances might be torn if they were taking advice from two different health care providers.

On a positive note, physicians said they appreciated diabetes education programs based on scientifically reliable, authoritative sources that offered practical strategies for dealing with everyday issues of diabetes control.

Several diabetes educators noted that they had customized their education programs based on physician requests: for example, by taking patients to the grocery store to help them learn how to make good nutritional choices.

Diabetes educators universally said they felt economic pressure to justify their positions. They bemoaned the lack of reasonable reimbursement for their services and a general dearth of awareness regarding the benefits they can provide to patients with diabetes.

They perceived that “need [for their services] was much higher than actual demand,” said Dr. Peyrot. Use of services seemed to vary greatly; some educators reported 3- to 6-month waiting lists for their services, whereas others had “wide open” appointment books.

Many diabetes educators believed that physicians did not sufficiently emphasize the importance of diabetes education to their patients: for example, by failing to ask whether patients had actually attended sessions they had prescribed.

Physicians “didn't give the impression it was critical,” said Dr. Peyrot, in summarizing the statements of diabetes educators.

Patients in separate focus groups displayed little understanding of diabetes education, in many cases failing to even recall whether they had attended educational sessions on diet, blood glucose monitoring, or medication management.

Exposure to diabetes education was broad, ranging from none to 40 hours. Patients had mixed impressions of its effectiveness, saying that in some cases, education sessions were too long, presented too much information at once, focused too much on negative messages, and could be overwhelming. On the other hand, they said they liked assistance with dealing with any type of technologic device, such as insulin pumps, and appreciated dietary advice and take-home materials they could study later.

Patients who had not sought out education sometimes volunteered that they did not need it, saying they learned whatever they needed to know from sources such as the Internet or family members with diabetes.

LOS ANGELES — Physicians, patients with diabetes, and diabetes educators expressed reservations about the current state of diabetes education in a series of focus groups sponsored by the American Association of Diabetes Educators and presented at the organization's annual meeting.

Preliminary findings suggest that there are significant gaps in awareness of diabetes education resources and an underlying uneasiness about the role of educators in overall diabetes care, reported Mark Peyrot, Ph.D., professor of sociology at Loyola College in Baltimore.

The six focus groups each consisted of about 15 members of a particular constituency—physicians who care for patients with diabetes, diabetes educators, or patients.

During teleconference calls, participants discussed a wide range of issues involving the general topic of diabetes education. Results will be used to devise an Internet survey to better capture positive and negative impressions of diabetes education and direct future resources in improving the field, explained Dr. Peyrot.

Early focus group findings suggest there is work to be done in improving access to, awareness of, usefulness of, and funding for diabetes education programs offered through hospitals, health care groups, and communities.

“A few bad experiences will turn you off,” said one physician during a focus group session.

Physicians suggested they would like to see diabetes education programs that personalize messages for their patients rather than rely on textbooklike, pedantic lessons. They want an easier referral process, better feedback from diabetes educators, and an assurance that treatment decisions will be left to them.

One physician also expressed the concern that diabetes educators may try to “steal patients.” Others also feared that patients' allegiances might be torn if they were taking advice from two different health care providers.

On a positive note, physicians said they appreciated diabetes education programs based on scientifically reliable, authoritative sources that offered practical strategies for dealing with everyday issues of diabetes control.

Several diabetes educators noted that they had customized their education programs based on physician requests: for example, by taking patients to the grocery store to help them learn how to make good nutritional choices.

Diabetes educators universally said they felt economic pressure to justify their positions. They bemoaned the lack of reasonable reimbursement for their services and a general dearth of awareness regarding the benefits they can provide to patients with diabetes.

They perceived that “need [for their services] was much higher than actual demand,” said Dr. Peyrot. Use of services seemed to vary greatly; some educators reported 3- to 6-month waiting lists for their services, whereas others had “wide open” appointment books.

Many diabetes educators believed that physicians did not sufficiently emphasize the importance of diabetes education to their patients: for example, by failing to ask whether patients had actually attended sessions they had prescribed.

Physicians “didn't give the impression it was critical,” said Dr. Peyrot, in summarizing the statements of diabetes educators.

Patients in separate focus groups displayed little understanding of diabetes education, in many cases failing to even recall whether they had attended educational sessions on diet, blood glucose monitoring, or medication management.

Exposure to diabetes education was broad, ranging from none to 40 hours. Patients had mixed impressions of its effectiveness, saying that in some cases, education sessions were too long, presented too much information at once, focused too much on negative messages, and could be overwhelming. On the other hand, they said they liked assistance with dealing with any type of technologic device, such as insulin pumps, and appreciated dietary advice and take-home materials they could study later.

Patients who had not sought out education sometimes volunteered that they did not need it, saying they learned whatever they needed to know from sources such as the Internet or family members with diabetes.

LOS ANGELES — Physicians, patients with diabetes, and diabetes educators expressed reservations about the current state of diabetes education in a series of focus groups sponsored by the American Association of Diabetes Educators and presented at the organization's annual meeting.

Preliminary findings suggest that there are significant gaps in awareness of diabetes education resources and an underlying uneasiness about the role of educators in overall diabetes care, reported Mark Peyrot, Ph.D., professor of sociology at Loyola College in Baltimore.

The six focus groups each consisted of about 15 members of a particular constituency—physicians who care for patients with diabetes, diabetes educators, or patients.

During teleconference calls, participants discussed a wide range of issues involving the general topic of diabetes education. Results will be used to devise an Internet survey to better capture positive and negative impressions of diabetes education and direct future resources in improving the field, explained Dr. Peyrot.

Early focus group findings suggest there is work to be done in improving access to, awareness of, usefulness of, and funding for diabetes education programs offered through hospitals, health care groups, and communities.

“A few bad experiences will turn you off,” said one physician during a focus group session.

Physicians suggested they would like to see diabetes education programs that personalize messages for their patients rather than rely on textbooklike, pedantic lessons. They want an easier referral process, better feedback from diabetes educators, and an assurance that treatment decisions will be left to them.

One physician also expressed the concern that diabetes educators may try to “steal patients.” Others also feared that patients' allegiances might be torn if they were taking advice from two different health care providers.

On a positive note, physicians said they appreciated diabetes education programs based on scientifically reliable, authoritative sources that offered practical strategies for dealing with everyday issues of diabetes control.

Several diabetes educators noted that they had customized their education programs based on physician requests: for example, by taking patients to the grocery store to help them learn how to make good nutritional choices.

Diabetes educators universally said they felt economic pressure to justify their positions. They bemoaned the lack of reasonable reimbursement for their services and a general dearth of awareness regarding the benefits they can provide to patients with diabetes.

They perceived that “need [for their services] was much higher than actual demand,” said Dr. Peyrot. Use of services seemed to vary greatly; some educators reported 3- to 6-month waiting lists for their services, whereas others had “wide open” appointment books.

Many diabetes educators believed that physicians did not sufficiently emphasize the importance of diabetes education to their patients: for example, by failing to ask whether patients had actually attended sessions they had prescribed.

Physicians “didn't give the impression it was critical,” said Dr. Peyrot, in summarizing the statements of diabetes educators.

Patients in separate focus groups displayed little understanding of diabetes education, in many cases failing to even recall whether they had attended educational sessions on diet, blood glucose monitoring, or medication management.

Exposure to diabetes education was broad, ranging from none to 40 hours. Patients had mixed impressions of its effectiveness, saying that in some cases, education sessions were too long, presented too much information at once, focused too much on negative messages, and could be overwhelming. On the other hand, they said they liked assistance with dealing with any type of technologic device, such as insulin pumps, and appreciated dietary advice and take-home materials they could study later.

Patients who had not sought out education sometimes volunteered that they did not need it, saying they learned whatever they needed to know from sources such as the Internet or family members with diabetes.

TUCSON, ARIZ. — There is a substantial recurrence rate following surgery for pelvic organ prolapse, particularly in the context of cystocele repair, University of Washington researchers reported at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Michael Fialkow and associates examined records for 142 women who underwent surgery primarily for pelvic organ prolapse in 1993 and were then followed for up to 10 years.

A total of 36 recurrent cases were identified during the 1,050 woman-years studied, for an overall recurrence rate of 3.43 per 100 woman-years.

“A cystocele was the most common site of both primary (87%) and recurrent (75%) prolapse … which is consistent with previous literature documenting the difficulty of repairing this condition durably,” the investigators noted in a poster presented at the meeting.

More than half of the recurrences—21 of 36—developed at the same site as the original prolapse, but 11 patients developed prolapse at a new site and 4 had evidence of recurrent prolapse at the original site and a new occurence elsewhere.

Of note, just 6 patients opted for a surgical repair following recurrence, whereas 16 opted for conservative management, and 14 had no documented management of the recurrent prolapse.

Dr. Fialkow of the university's department of obstetrics and gynecology and another investigator disclosed that they have participated in the speaker's bureau for Pfizer Inc., which makes products used in the treatment of pelvic organ prolapse.

The study's coinvestigators represented the Center for Health Studies of the Group Health Cooperative and the department of epidemiology at the University of Washington, Seattle.

TUCSON, ARIZ. — There is a substantial recurrence rate following surgery for pelvic organ prolapse, particularly in the context of cystocele repair, University of Washington researchers reported at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Michael Fialkow and associates examined records for 142 women who underwent surgery primarily for pelvic organ prolapse in 1993 and were then followed for up to 10 years.

A total of 36 recurrent cases were identified during the 1,050 woman-years studied, for an overall recurrence rate of 3.43 per 100 woman-years.

“A cystocele was the most common site of both primary (87%) and recurrent (75%) prolapse … which is consistent with previous literature documenting the difficulty of repairing this condition durably,” the investigators noted in a poster presented at the meeting.

More than half of the recurrences—21 of 36—developed at the same site as the original prolapse, but 11 patients developed prolapse at a new site and 4 had evidence of recurrent prolapse at the original site and a new occurence elsewhere.

Of note, just 6 patients opted for a surgical repair following recurrence, whereas 16 opted for conservative management, and 14 had no documented management of the recurrent prolapse.

Dr. Fialkow of the university's department of obstetrics and gynecology and another investigator disclosed that they have participated in the speaker's bureau for Pfizer Inc., which makes products used in the treatment of pelvic organ prolapse.

The study's coinvestigators represented the Center for Health Studies of the Group Health Cooperative and the department of epidemiology at the University of Washington, Seattle.

TUCSON, ARIZ. — There is a substantial recurrence rate following surgery for pelvic organ prolapse, particularly in the context of cystocele repair, University of Washington researchers reported at the annual meeting of the Society of Gynecologic Surgeons.

Dr. Michael Fialkow and associates examined records for 142 women who underwent surgery primarily for pelvic organ prolapse in 1993 and were then followed for up to 10 years.

A total of 36 recurrent cases were identified during the 1,050 woman-years studied, for an overall recurrence rate of 3.43 per 100 woman-years.

“A cystocele was the most common site of both primary (87%) and recurrent (75%) prolapse … which is consistent with previous literature documenting the difficulty of repairing this condition durably,” the investigators noted in a poster presented at the meeting.

More than half of the recurrences—21 of 36—developed at the same site as the original prolapse, but 11 patients developed prolapse at a new site and 4 had evidence of recurrent prolapse at the original site and a new occurence elsewhere.

Of note, just 6 patients opted for a surgical repair following recurrence, whereas 16 opted for conservative management, and 14 had no documented management of the recurrent prolapse.

Dr. Fialkow of the university's department of obstetrics and gynecology and another investigator disclosed that they have participated in the speaker's bureau for Pfizer Inc., which makes products used in the treatment of pelvic organ prolapse.

The study's coinvestigators represented the Center for Health Studies of the Group Health Cooperative and the department of epidemiology at the University of Washington, Seattle.

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.

PORTLAND, ORE. — Gingival lichen planus, particularly forms that are erosive, ulcerative, or bullous, should raise the red flag of suspicion about the presence of genital lesions, Dr. Roy S. Rogers III said at the Pacific Northwest Dermatological annual scientific meeting.

“The gynecologists usually don't ask about the mouth or look there. The dentists certainly don't ask about the vulva, nor do they look there. Neither do the ENT [ear, nose, throat] physicians,” said Dr. Rogers, professor of dermatology at the Mayo Clinic in Rochester, Minn.

“It's really up to us to be the internist and externist [in order to diagnose extraoral lichen planus],” he said.

Studies suggest that genital lesions are present in 1 of 5 women and 1 in 20 men with oral lichen planus.

When oral lesions are reticular, linear, and feature papular and plaquelike lesions, “these are low-hanging fruit and are rather easy to deal with,” he said.

In fact, many such lesions are asymptomatic and discovered by a dentist during a routine examination.

It is lesions that are atrophic, erosive, ulcerative, and/or bullous that can be extremely painful, often with extraoral manifestations. “They require our very expert care,” Dr. Rogers said.

Vulvovaginal lesions may be eroded, leading in some cases to desquamatous vaginitis. Known as vulvovaginal-gingival syndrome, this form of the disease is chronic and may involve other areas of the body, including the skin, scalp, nails, ear canal, and esophagus.

Much rarer, but clinically similar, is peno-gingival syndrome in men, which is characterized by desquamative gingivitis and penile involvement.

Histopathology and immunopathology usually have findings typical of classic lichen planus lesions.

Therapy can be challenging, but may include the topical immunomodulator tacrolimus, systemic and topical corticosteroids, hydroxychloroquine, cyclosporine, dapsone, griseofulvin, interferon α-2b, retinoids, and mycophenolate mofetil.

Topical tacrolimus is particularly effective in reducing symptoms of both oral and vulvar lichen planus, which is a T cell-mediated disorder, he said.

Studies performed by Dr. Rogers' group at the Mayo Clinic found that the application of topical tacrolimus produced meaningful symptomatic improvement in 33 of 37 patients with oral lichen planus and 15 of 16 patients with vulvar lichen planus within about 1 month (Arch. Dermatol. 2004;140:1,508–12; Arch. Dermatol. 2004;140:715–20).

Burning and stinging were reported in roughly one-third of patients but became less pronounced over time.

In both studies, discontinuation of treatment resulted in a return of lesions; however, they were less severe and could be controlled with reinitiation of tacrolimus treatment.

Meticulous oral hygiene is critically important to control perioral disease, because patients tend to develop secondary candidiasis that may become koebnerized from poor oral hygiene, Dr. Rogers said.

Patients with oral lichen planus face a 1% lifetime risk of malignant transformation of their lesions. “Tell them you want them to be seen every 6 months by their dentist and/or by you,” he said.

Dr. Rogers reported no financial disclosures.

PORTLAND, ORE. — Actinic prurigo, a disorder once considered a variant of polymorphous light eruption in Native Americans, may be neither a form of PMLE nor a condition limited to Native Americans, Dr. Lisa H. Williams said at the annual meeting of the Pacific Northwest Dermatological Society.

“Classically described in Native Americans, actinic prurigo is now increasingly recognized in [white] populations,” said Dr. Williams, a dermatology resident at the University of Washington in Seattle.

Actinic prurigo falls within the category of idiopathic photosensitive dermatoses, but it has several distinguishing characteristics. Its onset is usually within the first decade of life and it may improve by puberty. In addition, it can be tricky to trace outbreaks to sunlight, because lesions are persistent and may occur on sun-exposed or non-sun-exposed skin at any time of the year.

Dr. Williams described two patients, the first, a 6-year-old white boy with a 2-year history of excoriated papules that appeared year-round in contrast to the seasonal appearance of most PMLE eruptions. The lesions appeared on his forehead, cheeks, ears, lower back, calves, and shins. He was otherwise a healthy child with no personal or family history of atopic dermatitis. Phototesting yielded normal findings.

Pivotal in the diagnosis of the boy was a positive association with an HLA DR4 test subtype: DRB1

Similarly, Mexican mestizos with actinic prurigo are likely to test positive to HLA A29-B39, and Canadian Cree First Nations people tend to test positive to the HLA A24 subtype.

“There are different HLA types for each different ethnic group that can have the disorder. [It] can really help you when you're trying to diagnose it,” Dr. Williams said.

Native Americans are, in fact, more likely than are other patients with actinic prurigo to experience conjunctivis and/or cheilitis, which can be excellent diagnostic clues. Conjunctivitis occurs in about 10%–30% of all patients.

A second case featured by Dr. Williams was a 7-year-old Mexican American boy with both conjunctivitis and cheilitis. These were key to the diagnosis of actinic prurigo, along with the fact that his photosensitive rash consisted of itchy papules that developed 30 minutes after sun exposure.

The lack of vesicles, burning pain, crusting, scarring, or an elevated red blood cell protoporphyrin test ruled out other differential diagnoses, including hydroa vacciniforme and erythropoietic protoporphyria.

Dr. Williams said recent publications call into question the traditional notion that actinic prurigo is a form of PMLE. Clinically, there are sharp differences, including the fact that PMLE is noteworthy for “hardening,” a sparing of the face and the dorsal hands after repeated exposure to the sun. Clothing-covered areas are rarely involved in PMLE, in contrast to actinic prurigo.

Phototesting is more sensitive in actinic prurigo, producing positive results in about 60% of patients, compared with only about 20% of patients with PMLE.

In the case of the 6-year-old, the positive HLA subtype pointed solidly to actinic prurigo. His parents kept him inside during a 2-week winter school vacation and he cleared.

Both children are being treated with antimalarial drugs.

Other treatment options include psoralen ultraviolet light treatment, corticosteroids, antihistamines, vitamin E, pentoxifylline, β-carotene, and especially thalidomide. The latter is so effective for the treatment of actinic prurigo that some investigators believe that a trial of the drug, if successful, could nail down the diagnosis.

PORTLAND, ORE. — Actinic prurigo, a disorder once considered a variant of polymorphous light eruption in Native Americans, may be neither a form of PMLE nor a condition limited to Native Americans, Dr. Lisa H. Williams said at the annual meeting of the Pacific Northwest Dermatological Society.

“Classically described in Native Americans, actinic prurigo is now increasingly recognized in [white] populations,” said Dr. Williams, a dermatology resident at the University of Washington in Seattle.

Actinic prurigo falls within the category of idiopathic photosensitive dermatoses, but it has several distinguishing characteristics. Its onset is usually within the first decade of life and it may improve by puberty. In addition, it can be tricky to trace outbreaks to sunlight, because lesions are persistent and may occur on sun-exposed or non-sun-exposed skin at any time of the year.

Dr. Williams described two patients, the first, a 6-year-old white boy with a 2-year history of excoriated papules that appeared year-round in contrast to the seasonal appearance of most PMLE eruptions. The lesions appeared on his forehead, cheeks, ears, lower back, calves, and shins. He was otherwise a healthy child with no personal or family history of atopic dermatitis. Phototesting yielded normal findings.

Pivotal in the diagnosis of the boy was a positive association with an HLA DR4 test subtype: DRB1

Similarly, Mexican mestizos with actinic prurigo are likely to test positive to HLA A29-B39, and Canadian Cree First Nations people tend to test positive to the HLA A24 subtype.

“There are different HLA types for each different ethnic group that can have the disorder. [It] can really help you when you're trying to diagnose it,” Dr. Williams said.

Native Americans are, in fact, more likely than are other patients with actinic prurigo to experience conjunctivis and/or cheilitis, which can be excellent diagnostic clues. Conjunctivitis occurs in about 10%–30% of all patients.

A second case featured by Dr. Williams was a 7-year-old Mexican American boy with both conjunctivitis and cheilitis. These were key to the diagnosis of actinic prurigo, along with the fact that his photosensitive rash consisted of itchy papules that developed 30 minutes after sun exposure.

The lack of vesicles, burning pain, crusting, scarring, or an elevated red blood cell protoporphyrin test ruled out other differential diagnoses, including hydroa vacciniforme and erythropoietic protoporphyria.

Dr. Williams said recent publications call into question the traditional notion that actinic prurigo is a form of PMLE. Clinically, there are sharp differences, including the fact that PMLE is noteworthy for “hardening,” a sparing of the face and the dorsal hands after repeated exposure to the sun. Clothing-covered areas are rarely involved in PMLE, in contrast to actinic prurigo.

Phototesting is more sensitive in actinic prurigo, producing positive results in about 60% of patients, compared with only about 20% of patients with PMLE.

In the case of the 6-year-old, the positive HLA subtype pointed solidly to actinic prurigo. His parents kept him inside during a 2-week winter school vacation and he cleared.

Both children are being treated with antimalarial drugs.

Other treatment options include psoralen ultraviolet light treatment, corticosteroids, antihistamines, vitamin E, pentoxifylline, β-carotene, and especially thalidomide. The latter is so effective for the treatment of actinic prurigo that some investigators believe that a trial of the drug, if successful, could nail down the diagnosis.

PORTLAND, ORE. — Actinic prurigo, a disorder once considered a variant of polymorphous light eruption in Native Americans, may be neither a form of PMLE nor a condition limited to Native Americans, Dr. Lisa H. Williams said at the annual meeting of the Pacific Northwest Dermatological Society.

“Classically described in Native Americans, actinic prurigo is now increasingly recognized in [white] populations,” said Dr. Williams, a dermatology resident at the University of Washington in Seattle.

Actinic prurigo falls within the category of idiopathic photosensitive dermatoses, but it has several distinguishing characteristics. Its onset is usually within the first decade of life and it may improve by puberty. In addition, it can be tricky to trace outbreaks to sunlight, because lesions are persistent and may occur on sun-exposed or non-sun-exposed skin at any time of the year.

Dr. Williams described two patients, the first, a 6-year-old white boy with a 2-year history of excoriated papules that appeared year-round in contrast to the seasonal appearance of most PMLE eruptions. The lesions appeared on his forehead, cheeks, ears, lower back, calves, and shins. He was otherwise a healthy child with no personal or family history of atopic dermatitis. Phototesting yielded normal findings.

Pivotal in the diagnosis of the boy was a positive association with an HLA DR4 test subtype: DRB1

Similarly, Mexican mestizos with actinic prurigo are likely to test positive to HLA A29-B39, and Canadian Cree First Nations people tend to test positive to the HLA A24 subtype.

“There are different HLA types for each different ethnic group that can have the disorder. [It] can really help you when you're trying to diagnose it,” Dr. Williams said.

Native Americans are, in fact, more likely than are other patients with actinic prurigo to experience conjunctivis and/or cheilitis, which can be excellent diagnostic clues. Conjunctivitis occurs in about 10%–30% of all patients.

A second case featured by Dr. Williams was a 7-year-old Mexican American boy with both conjunctivitis and cheilitis. These were key to the diagnosis of actinic prurigo, along with the fact that his photosensitive rash consisted of itchy papules that developed 30 minutes after sun exposure.

The lack of vesicles, burning pain, crusting, scarring, or an elevated red blood cell protoporphyrin test ruled out other differential diagnoses, including hydroa vacciniforme and erythropoietic protoporphyria.

Dr. Williams said recent publications call into question the traditional notion that actinic prurigo is a form of PMLE. Clinically, there are sharp differences, including the fact that PMLE is noteworthy for “hardening,” a sparing of the face and the dorsal hands after repeated exposure to the sun. Clothing-covered areas are rarely involved in PMLE, in contrast to actinic prurigo.

Phototesting is more sensitive in actinic prurigo, producing positive results in about 60% of patients, compared with only about 20% of patients with PMLE.

In the case of the 6-year-old, the positive HLA subtype pointed solidly to actinic prurigo. His parents kept him inside during a 2-week winter school vacation and he cleared.

Both children are being treated with antimalarial drugs.

Other treatment options include psoralen ultraviolet light treatment, corticosteroids, antihistamines, vitamin E, pentoxifylline, β-carotene, and especially thalidomide. The latter is so effective for the treatment of actinic prurigo that some investigators believe that a trial of the drug, if successful, could nail down the diagnosis.

PASADENA, CALIF. – Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with representatives from the state medical board.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators.

But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards.

Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries. Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Mr. Osinoff said he is frequently asked whether physicians should report medical board investigations to their insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice: “Call a lawyer first,” he said.

He reminded audience members that most investigations are closed before an accusation is even brought, and said he “can't even think of a case” where malpractice coverage was affected in such a case.

If a formal accusation is made, it becomes public information that will be discovered by the insurance company anyway, “so there's no sense trying to hide it,” Mr. Osinoff said.

Going it alone 'is like walking into the police station as the prime suspectin a case.' MR. OSINOFF

PASADENA, CALIF. – Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with representatives from the state medical board.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators.

But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards.

Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries. Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Mr. Osinoff said he is frequently asked whether physicians should report medical board investigations to their insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice: “Call a lawyer first,” he said.

He reminded audience members that most investigations are closed before an accusation is even brought, and said he “can't even think of a case” where malpractice coverage was affected in such a case.

If a formal accusation is made, it becomes public information that will be discovered by the insurance company anyway, “so there's no sense trying to hide it,” Mr. Osinoff said.

Going it alone 'is like walking into the police station as the prime suspectin a case.' MR. OSINOFF

PASADENA, CALIF. – Your state medical board requests medical and billing records from your office.

You are advised to appear for an interview with representatives from the state medical board.

Investigators from the state medical board show up in your waiting room and demand to inspect your office.

What should you do? In all three instances, the answer is the same.

“Call a lawyer,” advised Peter R. Osinoff, a Los Angeles lawyer who specializes in defending physicians in malpractice cases and before the Medical Board of California.

Physicians who believe they've done nothing wrong often think they will have no problem dealing with questions from medical board investigators.

But legal representation is critical, even for preliminary investigations that may be prompted by a call from a mentally imbalanced patient or a former staff member with an axe to grind, Mr. Osinoff asserted at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The physician who is thinking, “There really is nothing to this case!” may very well be right, Mr. Osinoff said.

“I want to assure you that the vast majority of cases [in California] are resolved without an accusation,” once the facts are known. However, going it alone “is like walking into the police station as the prime suspect in a case. You would never think of doing that without a lawyer by your side, well-prepared,” he said.

Physician oversight boards operate differently in every state, following independent statutes and proceeding with investigations based on state-based criteria.

However, there are common themes.

Medical oversight boards generally fall within consumer protection divisions of state government. Accordingly, they often look for patterns of conduct that might present a danger to patients, rather than focusing on an isolated error in a lengthy and well-conducted career. Yet a surprising number of medical board cases are based on the treatment of a single patient.

Dishonesty, illegal conduct, and psychological or physical problems often generate interest among state boards.

Finally, in quality of care cases, boards look for such things as gross negligence or an “extreme departure” from standard of care or repeated negligent acts.

As in medical malpractice cases, inadequate record-keeping can be a serious problem for a physician under investigation, Mr. Osinoff said.

Sexual offenses may involve overt conduct, such as having sex with patients, but can also be interpreted as including inappropriate conversations or violating professional boundaries. Mr. Osinoff strongly recommended that physicians “avoid the danger zone,” which could mean something as simple as doing a special favor for a patient or meeting her outside the office.

Lies often prompt action from medical boards. Coding errors or revisions on charts may be “interpreted in the most sinister way.” A history of aboveboard record keeping and honesty in dealing with patients, staff, and insurers will help to protect the physician.

Mr. Osinoff said he is frequently asked whether physicians should report medical board investigations to their insurance carrier. In general, the answer is yes; in fact, some insurance carriers can invalidate coverage if they are not notified in a timely manner, and most policies include coverage of costs associated with an investigation.

However, he repeated his basic advice: “Call a lawyer first,” he said.

He reminded audience members that most investigations are closed before an accusation is even brought, and said he “can't even think of a case” where malpractice coverage was affected in such a case.

If a formal accusation is made, it becomes public information that will be discovered by the insurance company anyway, “so there's no sense trying to hide it,” Mr. Osinoff said.

Going it alone 'is like walking into the police station as the prime suspectin a case.' MR. OSINOFF

LOS ANGELES – A handheld transcranial magnetic stimulation device delivered mixed results in a small study of patients with migraine headaches, Dr. Yousef Mohammad reported at the annual meeting of the American Headache Society.

Numerically, the device extinguished more migraines within 2 hours than did a sham device that made an audible buzz but delivered no magnetic pulses to the head, said Dr. Mohammad.

Among 23 patients who received two brief magnetic pulses, 30 seconds apart, 17 (74%) were headache-free or reported only minimal pain at 2 hours, compared with 9 of 20 patients (45%) randomized to sham device treatment. But perhaps because of the small sample size, the difference was not statistically significant, said Dr. Mohammad, a member of the neurology faculty at Ohio State University, Columbus.

The transcranial magnetic stimulation (TMS) treatment significantly reduced photophobia and phonophobia at 2 hours, compared with placebo, and more patients receiving TMS treatments rated the effectiveness as “excellent” or “very good.”

Statistical trends were seen in the ability of TMS to reduce nausea and restore patients to normal functioning at 2 hours post treatment, although these end points also failed to reach statistical significance, he reported. The only adverse event found was left-sided numbness reported by one patient, but this symptom developed before administration of TMS.

Dr. Mohammad pointed out that the study design called for patients to receive their TMS or sham treatments at a hospital, leading to delays that potentially outlasted the device's potential to abort a migraine.

Patients with a history of migraine with aura were instructed to report to preselected hospitals immediately upon experiencing an aura. The TMS device or the sham device was placed either over the occipital region, if only aura was present, or over the area of maximum pain, if the headache had begun.

Efforts are underway to develop a user-friendly portable device that patients could use at home at the first sign of an impending migraine. This version of the device will be put to the test in a large, multicenter trial that will also use sham devices as placebo, said Dr. Mohammad, who disclosed that he is an investigator for Neuralieve Inc., the commercial sponsor of the study.

LOS ANGELES – A handheld transcranial magnetic stimulation device delivered mixed results in a small study of patients with migraine headaches, Dr. Yousef Mohammad reported at the annual meeting of the American Headache Society.

Numerically, the device extinguished more migraines within 2 hours than did a sham device that made an audible buzz but delivered no magnetic pulses to the head, said Dr. Mohammad.

Among 23 patients who received two brief magnetic pulses, 30 seconds apart, 17 (74%) were headache-free or reported only minimal pain at 2 hours, compared with 9 of 20 patients (45%) randomized to sham device treatment. But perhaps because of the small sample size, the difference was not statistically significant, said Dr. Mohammad, a member of the neurology faculty at Ohio State University, Columbus.

The transcranial magnetic stimulation (TMS) treatment significantly reduced photophobia and phonophobia at 2 hours, compared with placebo, and more patients receiving TMS treatments rated the effectiveness as “excellent” or “very good.”

Statistical trends were seen in the ability of TMS to reduce nausea and restore patients to normal functioning at 2 hours post treatment, although these end points also failed to reach statistical significance, he reported. The only adverse event found was left-sided numbness reported by one patient, but this symptom developed before administration of TMS.

Dr. Mohammad pointed out that the study design called for patients to receive their TMS or sham treatments at a hospital, leading to delays that potentially outlasted the device's potential to abort a migraine.

Patients with a history of migraine with aura were instructed to report to preselected hospitals immediately upon experiencing an aura. The TMS device or the sham device was placed either over the occipital region, if only aura was present, or over the area of maximum pain, if the headache had begun.

Efforts are underway to develop a user-friendly portable device that patients could use at home at the first sign of an impending migraine. This version of the device will be put to the test in a large, multicenter trial that will also use sham devices as placebo, said Dr. Mohammad, who disclosed that he is an investigator for Neuralieve Inc., the commercial sponsor of the study.

LOS ANGELES – A handheld transcranial magnetic stimulation device delivered mixed results in a small study of patients with migraine headaches, Dr. Yousef Mohammad reported at the annual meeting of the American Headache Society.

Numerically, the device extinguished more migraines within 2 hours than did a sham device that made an audible buzz but delivered no magnetic pulses to the head, said Dr. Mohammad.

Among 23 patients who received two brief magnetic pulses, 30 seconds apart, 17 (74%) were headache-free or reported only minimal pain at 2 hours, compared with 9 of 20 patients (45%) randomized to sham device treatment. But perhaps because of the small sample size, the difference was not statistically significant, said Dr. Mohammad, a member of the neurology faculty at Ohio State University, Columbus.

The transcranial magnetic stimulation (TMS) treatment significantly reduced photophobia and phonophobia at 2 hours, compared with placebo, and more patients receiving TMS treatments rated the effectiveness as “excellent” or “very good.”

Statistical trends were seen in the ability of TMS to reduce nausea and restore patients to normal functioning at 2 hours post treatment, although these end points also failed to reach statistical significance, he reported. The only adverse event found was left-sided numbness reported by one patient, but this symptom developed before administration of TMS.

Dr. Mohammad pointed out that the study design called for patients to receive their TMS or sham treatments at a hospital, leading to delays that potentially outlasted the device's potential to abort a migraine.

Patients with a history of migraine with aura were instructed to report to preselected hospitals immediately upon experiencing an aura. The TMS device or the sham device was placed either over the occipital region, if only aura was present, or over the area of maximum pain, if the headache had begun.

Efforts are underway to develop a user-friendly portable device that patients could use at home at the first sign of an impending migraine. This version of the device will be put to the test in a large, multicenter trial that will also use sham devices as placebo, said Dr. Mohammad, who disclosed that he is an investigator for Neuralieve Inc., the commercial sponsor of the study.

LOS ANGELES – Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91–nearly a doubling of risk–in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours, compared with 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference.

Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days.

Dizziness, the most common side effect, occurred in about 7% of patients.

The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year–on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients.

In that pivotal study, the investigators found that 67% patients assigned to placebo experienced migraines.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES – Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91–nearly a doubling of risk–in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours, compared with 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference.

Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days.

Dizziness, the most common side effect, occurred in about 7% of patients.

The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year–on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients.

In that pivotal study, the investigators found that 67% patients assigned to placebo experienced migraines.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

ELSEVIER GLOBAL MEDICAL NEWS

LOS ANGELES – Migraine headaches were twice as likely during the menstrual cycle, and they lasted longer, were somewhat more painful, and proved significantly more resistant to treatment than migraines suffered during other times of the month, according to a study released at the annual meeting of the American Headache Society.

Dr. Brenda F. Pinkerman of the James A. Haley Veterans' Hospital in Tampa, Fla., reported a sharp spike in migraines on day 1 of the menstrual cycle in a prospective study of 107 women with a history of menstrual-related migraine.

The women were subjects in a larger study cosponsored by Ohio University in Athens and the National Institutes of Health. To be eligible, patients had to have a history of disabling migraines 3–20 days a month.

Those enrolled in the menstrual migraine portion of the study had a mean age of 35 and suffered from migraines a mean 9 days per month. The odds ratio of a migraine was 1.91–nearly a doubling of risk–in a 4-day window beginning 2 days prior to and ending 2 days after day 1 of the menstrual cycle, compared with any other time of the month.

Perimenstrual migraines were significantly different from those occurring at other times of the month in a number of ways, including the following:

▸ Duration: 23 hours, compared with 16 hours

▸ Disability: occurring in conjunction with 86% of menstrual headaches vs. 76% of other headaches

▸ Doses of triptans: 2 vs. 1.6; and rescue medications: 2.3 vs. 1.7

▸ Pain-free response to medication at 2 hours: 7% vs. 13%

▸ Recurrence after 4 pain-free hours: 36%, compared with 20%

Other poster presentations at the meeting detailed the efficacy of rizatriptan administered early in the course of menstrual migraines and the safety and tolerability of frovatriptan taken prophylactically each month in women with regular menstrual cycles.

The TAME (Treat a Migraine Early) trials randomized 94 patients to take a single 10-mg dose of rizatriptan or placebo within 1 hour of the onset of any migraine occurring during the 2 days before to 3 days following day 1 of their menstrual cycles.

Freedom from pain at 2 hours was reported by 40 of 63 subjects (63.5%) taking rizatriptan, compared with 9 of 31 (29%) assigned to placebo, a highly significant difference.

Nausea was significantly less common in subjects taking rizatriptan, although photophobia and phonophobia responses did not reach significance in the Merck-sponsored, multicenter study presented by Dr. Vincent Martin of the University of Cincinnati.

A final poster featured results from a yearlong, open-label extension study of frovatriptan used to prevent migraines in 308 patients with regular menstrual cycles and a history of menstrual migraine.

Women were instructed to take two 5-mg doses of frovatriptan 2 days prior to the expected onset of menstruation, followed by 2.5 mg of frovatriptan twice daily for the next 5 days.

Dizziness, the most common side effect, occurred in about 7% of patients.

The drug was well tolerated, with just 25 patients discontinuing long-term treatment for reasons other than migraine, reported Dr. Anne MacGregor of the City of London Migraine Clinic.

Perimenstrual migraines occurred in 44% of women taking prophylactic frovatriptan for a year–on par with the 41% who experienced perimenstrual migraines during a 3-month randomized, double-blind, placebo-controlled trial of 433 patients.

In that pivotal study, the investigators found that 67% patients assigned to placebo experienced migraines.

The study was sponsored by Endo Pharmaceuticals of Chadds Ford, Pa., manufacturer of frovatriptan.

ELSEVIER GLOBAL MEDICAL NEWS

VANCOUVER, B.C. – It's hard to know just what to expect–or what to say–when you turn the examining room doorknob for an initial encounter with a patient who has a suspected eating disorder.

“You could have somebody who at best is extremely ambivalent about being there, at worst maybe very, very angry and upset about being there,” psychologist Ronald S. Manley said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Manley begins by offering a simplistic, research-based explanation of eating disorders, including the motivations behind them, their symptoms, and what models have been used to treat them, said Dr. Manley, clinical director of the eating disorders program at British Columbia Children's Hospital.

Using an emotional orientation, he draws on “relatively strong language” to forge a connection with the adolescent that hopefully will assist her in finding the part of herself that does want help. As an example, he might say, “Anorexia nervosa brings something to you that's very important. Why else would you hold onto it? … It's a powerful means of coping with your fears and gives you a sense of being strong and in control. But it is also a cause of suffering and weakness. And a sign of someone deeply troubled.”

In being blunt, “I'm hoping to convey that we do have an understanding of what this patient has been going through and offering her a sense of hope,” he said.

VANCOUVER, B.C. – It's hard to know just what to expect–or what to say–when you turn the examining room doorknob for an initial encounter with a patient who has a suspected eating disorder.

“You could have somebody who at best is extremely ambivalent about being there, at worst maybe very, very angry and upset about being there,” psychologist Ronald S. Manley said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Manley begins by offering a simplistic, research-based explanation of eating disorders, including the motivations behind them, their symptoms, and what models have been used to treat them, said Dr. Manley, clinical director of the eating disorders program at British Columbia Children's Hospital.

Using an emotional orientation, he draws on “relatively strong language” to forge a connection with the adolescent that hopefully will assist her in finding the part of herself that does want help. As an example, he might say, “Anorexia nervosa brings something to you that's very important. Why else would you hold onto it? … It's a powerful means of coping with your fears and gives you a sense of being strong and in control. But it is also a cause of suffering and weakness. And a sign of someone deeply troubled.”

In being blunt, “I'm hoping to convey that we do have an understanding of what this patient has been going through and offering her a sense of hope,” he said.

VANCOUVER, B.C. – It's hard to know just what to expect–or what to say–when you turn the examining room doorknob for an initial encounter with a patient who has a suspected eating disorder.

“You could have somebody who at best is extremely ambivalent about being there, at worst maybe very, very angry and upset about being there,” psychologist Ronald S. Manley said at a conference sponsored by the North Pacific Pediatric Society.

Dr. Manley begins by offering a simplistic, research-based explanation of eating disorders, including the motivations behind them, their symptoms, and what models have been used to treat them, said Dr. Manley, clinical director of the eating disorders program at British Columbia Children's Hospital.

Using an emotional orientation, he draws on “relatively strong language” to forge a connection with the adolescent that hopefully will assist her in finding the part of herself that does want help. As an example, he might say, “Anorexia nervosa brings something to you that's very important. Why else would you hold onto it? … It's a powerful means of coping with your fears and gives you a sense of being strong and in control. But it is also a cause of suffering and weakness. And a sign of someone deeply troubled.”

In being blunt, “I'm hoping to convey that we do have an understanding of what this patient has been going through and offering her a sense of hope,” he said.