Jane Salodof MacNeil

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

SCOTTSDALE, ARIZ. – Cognitive-behavioral treatments can help people overcome chronic insomnia, even when a medical or psychiatric disorder appears to be the primary cause of sleeplessness, Edward J. Stepanski, Ph.D., said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Traditionally, behavioral treatments have been reserved for primary insomnia and not recommended for people whose lack of sleep is secondary to other conditions, said Dr. Stepanski, vice president for scientific affairs of the Accelerated Community Oncology Research Network (ACORN) in Memphis, Tenn.

The underlying assumptions–both of which he challenged–are that insomnia will remit if the primary condition is resolved and that cognitive-behavioral treatment (CBT) approaches will not be effective against an etiology such as pain or depression. People continue to sleep poorly after successful treatment of posttraumatic stress disorder, he said, and randomized controlled trials have shown that people with a primary condition such as arthritis or chronic obstructive pulmonary disease can sleep better after CBT.

“Use [CBT] in any chronic insomnia,” Dr. Stepanski said, suggesting comorbid insomnia would be a better name than secondary insomnia when diagnosed in patients with other conditions. “CBT has its place,” he said. “There are always behavioral and cognitive features to a chronic patient with insomnia.”

For most patients, he recommended that behavioral treatments come before cognitive therapy. Many worry that they will have a mental breakdown or lose their jobs if they don't get more sleep. Once they are sleeping better, he suggested they may be more open to cognitive restructuring–in particular, to considering how their lives would be different without insomnia. Not everyone will embrace the possibility.

“If every failure in their entire life is due to insomnia, they are not going to give that up,” warned Dr. Stepanski. “Some personality disorder patients don't really want help.”

For insomniacs who do want better sleep, he recommended trying a variety of behavioral treatments, as there is no way to predict which would be the most beneficial to a particular patient. These include:

▸ Sleep hygiene education. For example, telling patients that they can't drink coffee before bedtime or nap 3 hours in the afternoon and then expect to sleep through the night.

▸ Stimulus control therapy. The patient should only go to bed when sleepy and not use the bedroom for activities, such as television viewing or aerobic exercises, that are incompatible with sleep. If the patient can't sleep, he should get up and leave the bedroom. “If you force yourself to lie in bed wide awake, you are doing damage to yourself. [There's] nothing else to do but ruminate and catastrophize,” he said.

▸ Sleep restriction therapy. The goal is to use partial sleep deprivation to increase homeostatic sleep drive. Use a sleep log to reduce time in bed to the amount of time the patient actually sleeps. Five hours of good sleep is better than 8 hours of intermittent sleep, said Dr. Stepanski: “Excess time in bed is death to normal sleep.”

▸ Relaxation training. Examples include progressive muscle relaxation, guided imagery, biofeedback, and self-hypnosis.

As none of these techniques work quickly, Dr. Stepanski said practitioners should devote time early on to educating, reassuring, and encouraging patients–and preparing them for relapse. Patients “must understand the rationale for the treatment approach,” he said. “Sleep is a biological rhythm. It doesn't change right away.”

Medication works faster than CBT, but is not as effective, said Dr. Stepanski. Combining the two approaches can relieve panic about sleep deprivation while giving CBT more time to work. Studies have shown, however, that CBT alone is more effective than CBT combined with medication.

'There are always behavioral and cognitive features to a chronic patient with insomnia.' DR. STEPANSKI

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

CHICAGO — Whether a man consults with a urologist, a radiation oncologist, or a primary care physician after being diagnosed with clinically localized prostate cancer can lead to different treatment choices.

A study of 85,088 men, aged 65 years and older and diagnosed from 1994 to 2002, found that half saw only a urologist. These patients were more likely to have a radical prostatectomy, primary androgen deprivation therapy, or expectant management. Only 5% went on to radiation therapy.

Fewer than half (44%) of men diagnosed during this time period consulted a radiation oncologist after diagnosis by a urologist. Most men who saw both specialists had radiation therapy. Only 8% underwent radical prostatectomy. Even fewer chose the conservative options of hormone treatment or watchful waiting.

For the most part, men did not visit their primary care physicians after diagnosis. The 17% who did tended to be older and usually opted for a conservative strategy.

Just 6% of all men in the study also consulted a medical oncologist.

“[Whom you see] does sort of influence what you get,” Dr. Thomas L. Jang said after reporting the results of the study at the annual meeting of the American Society of Clinical Oncology.

Dr. Jang, a urologist at Memorial Sloan-Kettering Cancer Center, New York, emphasized that no treatment has been proved better than others for early prostate cancer. The results show that treatment choices are strongly associated with which specialists a patient consults, he said, but other factors—such as patient preferences and distance to radiation or surgical facilities—might also play a role.

Urologists generally make the diagnosis of prostate cancer and coordinate care. Dr. Jang said he did not recommend that urologists send all prostate cancer patients to consult with both radiation oncologists and medical oncologists. The health care costs would be too great, and it would lessen the efficiency of physician practices.

Rather, he advocated that urologists and radiation oncologists collaborate on standard informational materials that urologists could give to patients. “It is essential that all men with prostate cancer have balanced information prior to making a treatment decision,” he said, noting that urologists, radiation oncologists, and medical oncologists collaborated on the study he presented.

Dr. Jang and his coinvestigators matched information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database with Medicare claims and the American Medical Association's Physician Masterfile. They found that for the 8-year period studied, 42% of localized prostate cancer patients aged 65 and older underwent radiation therapy, 21% had a radical prostatectomy, 17% had primary androgen deprivation therapy, and 20% had expectant management.

In general, patients younger than 75 were more likely to have surgery and/or radiation, whereas most of those aged 80 and older opted for more conservative strategies. During the in-between age of 75–79 years, half had radiation therapy, 24% expectant management, 20% primary androgen deprivation therapy, and just 6% radical prostatectomy.

Radical prostatectomies were performed in 34% of all 42,309 men who saw only a urologist, but the proportion fell from 70% of those aged 65–69, to 45% of those 70–74, to 10% of those 75–79, and to just 1% of those 80 and older.

In contrast, 83% of 37,540 patients who also consulted a radiation oncologist had radiation therapy. The lowest rate, 78%, was in the group aged 65–69. The rate climbed to 85% of those aged 70–74, and 87% of those aged 75–79, before leveling at 79% of those 80 and older.

Just 14,599 men also visited a primary care physician. Expectant management was the leading treatment in these patients, followed by androgen deprivation. Even among those who also consulted a urologist and a radiation oncologist, 51% chose watchful waiting, whereas just over a third (34%) opted for radiation therapy. Regardless of which specialists they consulted, fewer than 10% of men who saw a primary care provider decided on surgery.

Dr. Archie Bleyer, moderator of a press briefing on patterns of care, called the study a tour de force. “The results are of concern and affect more men than not,” said Dr. Bleyer of St. Charles Medical Center, Bend, Ore.

The 17% who saw a primary care physician tended to be older and opted for a conservative strategy. DR. JANG

CHICAGO — Whether a man consults with a urologist, a radiation oncologist, or a primary care physician after being diagnosed with clinically localized prostate cancer can lead to different treatment choices.

A study of 85,088 men, aged 65 years and older and diagnosed from 1994 to 2002, found that half saw only a urologist. These patients were more likely to have a radical prostatectomy, primary androgen deprivation therapy, or expectant management. Only 5% went on to radiation therapy.

Fewer than half (44%) of men diagnosed during this time period consulted a radiation oncologist after diagnosis by a urologist. Most men who saw both specialists had radiation therapy. Only 8% underwent radical prostatectomy. Even fewer chose the conservative options of hormone treatment or watchful waiting.

For the most part, men did not visit their primary care physicians after diagnosis. The 17% who did tended to be older and usually opted for a conservative strategy.

Just 6% of all men in the study also consulted a medical oncologist.

“[Whom you see] does sort of influence what you get,” Dr. Thomas L. Jang said after reporting the results of the study at the annual meeting of the American Society of Clinical Oncology.

Dr. Jang, a urologist at Memorial Sloan-Kettering Cancer Center, New York, emphasized that no treatment has been proved better than others for early prostate cancer. The results show that treatment choices are strongly associated with which specialists a patient consults, he said, but other factors—such as patient preferences and distance to radiation or surgical facilities—might also play a role.

Urologists generally make the diagnosis of prostate cancer and coordinate care. Dr. Jang said he did not recommend that urologists send all prostate cancer patients to consult with both radiation oncologists and medical oncologists. The health care costs would be too great, and it would lessen the efficiency of physician practices.

Rather, he advocated that urologists and radiation oncologists collaborate on standard informational materials that urologists could give to patients. “It is essential that all men with prostate cancer have balanced information prior to making a treatment decision,” he said, noting that urologists, radiation oncologists, and medical oncologists collaborated on the study he presented.

Dr. Jang and his coinvestigators matched information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database with Medicare claims and the American Medical Association's Physician Masterfile. They found that for the 8-year period studied, 42% of localized prostate cancer patients aged 65 and older underwent radiation therapy, 21% had a radical prostatectomy, 17% had primary androgen deprivation therapy, and 20% had expectant management.

In general, patients younger than 75 were more likely to have surgery and/or radiation, whereas most of those aged 80 and older opted for more conservative strategies. During the in-between age of 75–79 years, half had radiation therapy, 24% expectant management, 20% primary androgen deprivation therapy, and just 6% radical prostatectomy.

Radical prostatectomies were performed in 34% of all 42,309 men who saw only a urologist, but the proportion fell from 70% of those aged 65–69, to 45% of those 70–74, to 10% of those 75–79, and to just 1% of those 80 and older.

In contrast, 83% of 37,540 patients who also consulted a radiation oncologist had radiation therapy. The lowest rate, 78%, was in the group aged 65–69. The rate climbed to 85% of those aged 70–74, and 87% of those aged 75–79, before leveling at 79% of those 80 and older.

Just 14,599 men also visited a primary care physician. Expectant management was the leading treatment in these patients, followed by androgen deprivation. Even among those who also consulted a urologist and a radiation oncologist, 51% chose watchful waiting, whereas just over a third (34%) opted for radiation therapy. Regardless of which specialists they consulted, fewer than 10% of men who saw a primary care provider decided on surgery.

Dr. Archie Bleyer, moderator of a press briefing on patterns of care, called the study a tour de force. “The results are of concern and affect more men than not,” said Dr. Bleyer of St. Charles Medical Center, Bend, Ore.

The 17% who saw a primary care physician tended to be older and opted for a conservative strategy. DR. JANG

CHICAGO — Whether a man consults with a urologist, a radiation oncologist, or a primary care physician after being diagnosed with clinically localized prostate cancer can lead to different treatment choices.

A study of 85,088 men, aged 65 years and older and diagnosed from 1994 to 2002, found that half saw only a urologist. These patients were more likely to have a radical prostatectomy, primary androgen deprivation therapy, or expectant management. Only 5% went on to radiation therapy.

Fewer than half (44%) of men diagnosed during this time period consulted a radiation oncologist after diagnosis by a urologist. Most men who saw both specialists had radiation therapy. Only 8% underwent radical prostatectomy. Even fewer chose the conservative options of hormone treatment or watchful waiting.

For the most part, men did not visit their primary care physicians after diagnosis. The 17% who did tended to be older and usually opted for a conservative strategy.

Just 6% of all men in the study also consulted a medical oncologist.

“[Whom you see] does sort of influence what you get,” Dr. Thomas L. Jang said after reporting the results of the study at the annual meeting of the American Society of Clinical Oncology.

Dr. Jang, a urologist at Memorial Sloan-Kettering Cancer Center, New York, emphasized that no treatment has been proved better than others for early prostate cancer. The results show that treatment choices are strongly associated with which specialists a patient consults, he said, but other factors—such as patient preferences and distance to radiation or surgical facilities—might also play a role.

Urologists generally make the diagnosis of prostate cancer and coordinate care. Dr. Jang said he did not recommend that urologists send all prostate cancer patients to consult with both radiation oncologists and medical oncologists. The health care costs would be too great, and it would lessen the efficiency of physician practices.

Rather, he advocated that urologists and radiation oncologists collaborate on standard informational materials that urologists could give to patients. “It is essential that all men with prostate cancer have balanced information prior to making a treatment decision,” he said, noting that urologists, radiation oncologists, and medical oncologists collaborated on the study he presented.

Dr. Jang and his coinvestigators matched information from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database with Medicare claims and the American Medical Association's Physician Masterfile. They found that for the 8-year period studied, 42% of localized prostate cancer patients aged 65 and older underwent radiation therapy, 21% had a radical prostatectomy, 17% had primary androgen deprivation therapy, and 20% had expectant management.

In general, patients younger than 75 were more likely to have surgery and/or radiation, whereas most of those aged 80 and older opted for more conservative strategies. During the in-between age of 75–79 years, half had radiation therapy, 24% expectant management, 20% primary androgen deprivation therapy, and just 6% radical prostatectomy.

Radical prostatectomies were performed in 34% of all 42,309 men who saw only a urologist, but the proportion fell from 70% of those aged 65–69, to 45% of those 70–74, to 10% of those 75–79, and to just 1% of those 80 and older.

In contrast, 83% of 37,540 patients who also consulted a radiation oncologist had radiation therapy. The lowest rate, 78%, was in the group aged 65–69. The rate climbed to 85% of those aged 70–74, and 87% of those aged 75–79, before leveling at 79% of those 80 and older.

Just 14,599 men also visited a primary care physician. Expectant management was the leading treatment in these patients, followed by androgen deprivation. Even among those who also consulted a urologist and a radiation oncologist, 51% chose watchful waiting, whereas just over a third (34%) opted for radiation therapy. Regardless of which specialists they consulted, fewer than 10% of men who saw a primary care provider decided on surgery.

Dr. Archie Bleyer, moderator of a press briefing on patterns of care, called the study a tour de force. “The results are of concern and affect more men than not,” said Dr. Bleyer of St. Charles Medical Center, Bend, Ore.

The 17% who saw a primary care physician tended to be older and opted for a conservative strategy. DR. JANG

SANTA FE, N.M. – The suggestions for diagnosing postconcussional disorder that appear in the text revision of the DSM-IV are inadequate for the assessment of mild traumatic brain injury, Dr. Stephen D. Anderson said at the annual meeting of the American College of Forensic Psychiatry.

Numerous studies have shown that people do not have to be unconscious after a head trauma or experience more than 1 hour of posttraumatic amnesia to suffer from postconcussional disorder, said Dr. Anderson of the University of British Columbia, Vancouver.

Yet the DSM-IV-TR would require that they fulfill two of the following three criteria to meet a threshold for closed head injuries: more than 5 minutes of unconsciousness, more than 12 hours of posttraumatic amnesia, or seizures. As seizures rarely follow a mild traumatic brain injury (TBI), most people would have to meet the first two overly rigorous criteria to satisfy the definition proposed in an appendix to the manual, he said.

Dr. Anderson also listed a multitude of symptoms as missing from the DSM-IV-TR discussion of postconcussional disorder.

He cited the omission of nausea; decreased balance and coordination; tinnitus; and sensitivity to light and noise as physical symptoms, and noted that cognitive defects in initiation and planning; judgment and perception; information-processing speed; and communication ability are not discussed. Likewise, increased sensitivity to lack of sleep, fatigue, stress, drugs, or alcohol is not mentioned, and loss of libido and decreased appetite are not included under psychological symptoms.

“It is easier to make a diagnosis of dementia [resulting from head trauma] than postconcussional disorder,” Dr. Anderson said.

The definition of postconcussional disorder “does not cut it,” he summarized in an interview after his talk. “It is in an appendix, so it is not fully accepted, but the fact that it is included in DSM IV lends it some legitimacy.”

Mild TBI is a real but underdiagnosed condition, according to Dr. Anderson, who offered as examples impairments in football, soccer, and hockey players. The same problems have been observed in patients with severe traumatic brain injuries, but the effects are more subtle with mild TBI.

Despite concerns about people using mild TBI to excuse malingering, researchers have shown that unemployment and underemployment can occur, and that some people struggle on neurocognitive tests. Patients with mild TBI have performed comparably with control groups in several studies, but imaging showed that their brains worked harder to achieve the same results. This may help explain why fatigue is a common complaint, Dr. Anderson said.

He also cited a study of brains taken from five people who died of causes not related to their mild TBI. The researchers found multifocal axonal injury and axonal damage to fornices in all five patients.

Unless structural damage is clearly seen, neither MRI nor CT is a good measure of mild TBI. Without images taken before the trauma, imaging cannot compare brain function before and after the injury, Dr. Anderson said.

An hour or more of posttraumatic amnesia is one of the best predictors of mild TBI, Dr. Anderson said. He recommended the Glasgow Coma Scale-Extended (GCS-E) amnesia scale but volunteered that results are rarely available. “It is great, but no one uses it,” he said. “You never see it in an ambulance report.”

Another option is to use the American Congress of Rehabilitation Medicine criteria instead of the DSM-IV-TR recommendations. “You don't have to have loss of consciousness,” he said. “You just have to be dazed at the scene.” He has also posted a list of symptoms in a paper on postconcussional disorder that can be accessed under the heading “Medical Articles” on the Web site www.braininjurylaw.ca

People do not have to be unconscious or experience more than 1 hour of posttraumatic amnesia. DR. ANDERSON

SANTA FE, N.M. – The suggestions for diagnosing postconcussional disorder that appear in the text revision of the DSM-IV are inadequate for the assessment of mild traumatic brain injury, Dr. Stephen D. Anderson said at the annual meeting of the American College of Forensic Psychiatry.

Numerous studies have shown that people do not have to be unconscious after a head trauma or experience more than 1 hour of posttraumatic amnesia to suffer from postconcussional disorder, said Dr. Anderson of the University of British Columbia, Vancouver.

Yet the DSM-IV-TR would require that they fulfill two of the following three criteria to meet a threshold for closed head injuries: more than 5 minutes of unconsciousness, more than 12 hours of posttraumatic amnesia, or seizures. As seizures rarely follow a mild traumatic brain injury (TBI), most people would have to meet the first two overly rigorous criteria to satisfy the definition proposed in an appendix to the manual, he said.

Dr. Anderson also listed a multitude of symptoms as missing from the DSM-IV-TR discussion of postconcussional disorder.

He cited the omission of nausea; decreased balance and coordination; tinnitus; and sensitivity to light and noise as physical symptoms, and noted that cognitive defects in initiation and planning; judgment and perception; information-processing speed; and communication ability are not discussed. Likewise, increased sensitivity to lack of sleep, fatigue, stress, drugs, or alcohol is not mentioned, and loss of libido and decreased appetite are not included under psychological symptoms.

“It is easier to make a diagnosis of dementia [resulting from head trauma] than postconcussional disorder,” Dr. Anderson said.

The definition of postconcussional disorder “does not cut it,” he summarized in an interview after his talk. “It is in an appendix, so it is not fully accepted, but the fact that it is included in DSM IV lends it some legitimacy.”

Mild TBI is a real but underdiagnosed condition, according to Dr. Anderson, who offered as examples impairments in football, soccer, and hockey players. The same problems have been observed in patients with severe traumatic brain injuries, but the effects are more subtle with mild TBI.

Despite concerns about people using mild TBI to excuse malingering, researchers have shown that unemployment and underemployment can occur, and that some people struggle on neurocognitive tests. Patients with mild TBI have performed comparably with control groups in several studies, but imaging showed that their brains worked harder to achieve the same results. This may help explain why fatigue is a common complaint, Dr. Anderson said.

He also cited a study of brains taken from five people who died of causes not related to their mild TBI. The researchers found multifocal axonal injury and axonal damage to fornices in all five patients.

Unless structural damage is clearly seen, neither MRI nor CT is a good measure of mild TBI. Without images taken before the trauma, imaging cannot compare brain function before and after the injury, Dr. Anderson said.

An hour or more of posttraumatic amnesia is one of the best predictors of mild TBI, Dr. Anderson said. He recommended the Glasgow Coma Scale-Extended (GCS-E) amnesia scale but volunteered that results are rarely available. “It is great, but no one uses it,” he said. “You never see it in an ambulance report.”

Another option is to use the American Congress of Rehabilitation Medicine criteria instead of the DSM-IV-TR recommendations. “You don't have to have loss of consciousness,” he said. “You just have to be dazed at the scene.” He has also posted a list of symptoms in a paper on postconcussional disorder that can be accessed under the heading “Medical Articles” on the Web site www.braininjurylaw.ca

People do not have to be unconscious or experience more than 1 hour of posttraumatic amnesia. DR. ANDERSON

SANTA FE, N.M. – The suggestions for diagnosing postconcussional disorder that appear in the text revision of the DSM-IV are inadequate for the assessment of mild traumatic brain injury, Dr. Stephen D. Anderson said at the annual meeting of the American College of Forensic Psychiatry.

Numerous studies have shown that people do not have to be unconscious after a head trauma or experience more than 1 hour of posttraumatic amnesia to suffer from postconcussional disorder, said Dr. Anderson of the University of British Columbia, Vancouver.

Yet the DSM-IV-TR would require that they fulfill two of the following three criteria to meet a threshold for closed head injuries: more than 5 minutes of unconsciousness, more than 12 hours of posttraumatic amnesia, or seizures. As seizures rarely follow a mild traumatic brain injury (TBI), most people would have to meet the first two overly rigorous criteria to satisfy the definition proposed in an appendix to the manual, he said.

Dr. Anderson also listed a multitude of symptoms as missing from the DSM-IV-TR discussion of postconcussional disorder.

He cited the omission of nausea; decreased balance and coordination; tinnitus; and sensitivity to light and noise as physical symptoms, and noted that cognitive defects in initiation and planning; judgment and perception; information-processing speed; and communication ability are not discussed. Likewise, increased sensitivity to lack of sleep, fatigue, stress, drugs, or alcohol is not mentioned, and loss of libido and decreased appetite are not included under psychological symptoms.

“It is easier to make a diagnosis of dementia [resulting from head trauma] than postconcussional disorder,” Dr. Anderson said.

The definition of postconcussional disorder “does not cut it,” he summarized in an interview after his talk. “It is in an appendix, so it is not fully accepted, but the fact that it is included in DSM IV lends it some legitimacy.”

Mild TBI is a real but underdiagnosed condition, according to Dr. Anderson, who offered as examples impairments in football, soccer, and hockey players. The same problems have been observed in patients with severe traumatic brain injuries, but the effects are more subtle with mild TBI.

Despite concerns about people using mild TBI to excuse malingering, researchers have shown that unemployment and underemployment can occur, and that some people struggle on neurocognitive tests. Patients with mild TBI have performed comparably with control groups in several studies, but imaging showed that their brains worked harder to achieve the same results. This may help explain why fatigue is a common complaint, Dr. Anderson said.

He also cited a study of brains taken from five people who died of causes not related to their mild TBI. The researchers found multifocal axonal injury and axonal damage to fornices in all five patients.

Unless structural damage is clearly seen, neither MRI nor CT is a good measure of mild TBI. Without images taken before the trauma, imaging cannot compare brain function before and after the injury, Dr. Anderson said.

An hour or more of posttraumatic amnesia is one of the best predictors of mild TBI, Dr. Anderson said. He recommended the Glasgow Coma Scale-Extended (GCS-E) amnesia scale but volunteered that results are rarely available. “It is great, but no one uses it,” he said. “You never see it in an ambulance report.”

Another option is to use the American Congress of Rehabilitation Medicine criteria instead of the DSM-IV-TR recommendations. “You don't have to have loss of consciousness,” he said. “You just have to be dazed at the scene.” He has also posted a list of symptoms in a paper on postconcussional disorder that can be accessed under the heading “Medical Articles” on the Web site www.braininjurylaw.ca

People do not have to be unconscious or experience more than 1 hour of posttraumatic amnesia. DR. ANDERSON

PHOENIX — Physician assistants and nurse practitioners should be trained to treat, biopsy, and bill patients as if they were the physicians for whom they work, Dr. Allan Wirtzer said at a clinical dermatology conference sponsored by Medicis.

"Your extender should be your clone," said Dr. Wirtzer, who has a practice in Sherman Oaks, Calif., and endorses the hiring of physician extenders as an alternative to recruiting first-year dermatologists.

Extenders can enable a practice to see more patients and to significantly increase revenues, he said. Patient acceptance is critical, however, and can be undermined if the extender is not consistent with the physician.

As an example, Dr. Wirtzer offered the hypothetical situation in which an extender recommends a course of treatment for a skin condition. For the dermatologist to disagree and suggest changing the plan on a follow-up visit could be worse than embarrassing, he warned: "It is not going to bode well for the patient's confidence in the practice."

Here are more of Dr. Wirtzer's tips on how to incorporate a physician extender into a dermatology practice:

Whom to Hire

A third of dermatologists are seeking associates, he said. Not only is patient demand for services high, but also dermatologists are in short supply. As a result, he contended, some new dermatologists are pricing themselves out of the market with unrealistic expectations of their first-year earnings.

Physician assistants and nurse practitioners are easier to find, according to Dr. Wirtzer. They also can be easier to work with and may contribute more to a practice. He cited a 2002 survey that found the average extender was paid $100,000 annually while revenues increased by $500,000 each year.

He said that he has chosen to hire physician assistants because they "are trained to be physician assistants—exactly what it says" as opposed to nurse practitioners who can work independently and want to expand the number of states in which they can practice without physician supervision. A physician assistant cannot establish a competing practice.

Another consideration, he added, is whether your patients and staff will accept an extender. Be sensitive to the feelings of long-term employees who might see their turf as threatened, he advised. Provide patients with literature describing what a physician assistant does and the professional biography of the person hired.

How to Train

In 2004, 38% of physician assistants had less than 2 years' experience and 23% had more than 6 years, according to unpublished data cited by Dr. Wirtzer. Education levels ranged from an associate's degree (16%) to a bachelor's degree (41%) to a master's degree (43%). He said he prefers to hire an extender who has just completed schooling rather than risk hiring an experienced extender introducing incompatible treatment approaches from another practice.

Most training is by direct observation and proctoring, he said. He recommended that the new extender follow the physician for 3–6 months. The person also might attend courses or use continuing medical education materials. If the extender is experienced, the training period could be shorter, Dr. Wirtzer said, but oversight should be greater to ensure compatible approaches to treatment.

Training should include coding and office management, he added, again to ensure consistency when dealing with patients. He advocated developing clear treatment plans for common conditions, policies on when biopsies are appropriate, and fee schedules.

Rules to Know

Dr. Wirtzer noted that state regulations vary on how many extenders can be supervised by one physician and whether the physician must be in the office or available by phone when the extender sees a patient. Medicaid covers physician assistants and nurse practitioners, he added, but policies vary and there are no set rules for private insurers.

Medicare has strict requirements on "incident to billing," he continued. It requires that the physician examine the patient on the first visit for a particular condition. The physician assistant can provide subsequent care as long as a physician is in the office.

If these criteria are met, services provided by a physician assistant or nurse practitioner can be billed at 100% under the physician's name, according to Dr. Wirtzer.

If the physician is not on site or the physician assistant treats a new Medicare patient or a Medicare patient with a new problem, then only 85% can be billed and it must be done under the physician assistant's name. Defining a new condition can be "a gray area," he warned, suggesting a check with the local Medicare carrier.

Smart Practices

Design a contract that covers the initial mentoring period, starting salary, and bonus arrangement, Dr. Wirtzer advised. He suggested putting a dollar value on training and including a noncompete clause in case the person leaves the practice. "Don't be cheap," he said, warning that inadequate compensation can lead to loss of valuable staff members.

Consider paying for employee practices insurance, he added. It covers the practice against lawsuits by employees.

These are not covered by malpractice or office overhead insurance, and can be expensive to fight even when the practice is in the right.

PHOENIX — Physician assistants and nurse practitioners should be trained to treat, biopsy, and bill patients as if they were the physicians for whom they work, Dr. Allan Wirtzer said at a clinical dermatology conference sponsored by Medicis.

"Your extender should be your clone," said Dr. Wirtzer, who has a practice in Sherman Oaks, Calif., and endorses the hiring of physician extenders as an alternative to recruiting first-year dermatologists.

Extenders can enable a practice to see more patients and to significantly increase revenues, he said. Patient acceptance is critical, however, and can be undermined if the extender is not consistent with the physician.

As an example, Dr. Wirtzer offered the hypothetical situation in which an extender recommends a course of treatment for a skin condition. For the dermatologist to disagree and suggest changing the plan on a follow-up visit could be worse than embarrassing, he warned: "It is not going to bode well for the patient's confidence in the practice."

Here are more of Dr. Wirtzer's tips on how to incorporate a physician extender into a dermatology practice:

Whom to Hire

A third of dermatologists are seeking associates, he said. Not only is patient demand for services high, but also dermatologists are in short supply. As a result, he contended, some new dermatologists are pricing themselves out of the market with unrealistic expectations of their first-year earnings.

Physician assistants and nurse practitioners are easier to find, according to Dr. Wirtzer. They also can be easier to work with and may contribute more to a practice. He cited a 2002 survey that found the average extender was paid $100,000 annually while revenues increased by $500,000 each year.

He said that he has chosen to hire physician assistants because they "are trained to be physician assistants—exactly what it says" as opposed to nurse practitioners who can work independently and want to expand the number of states in which they can practice without physician supervision. A physician assistant cannot establish a competing practice.

Another consideration, he added, is whether your patients and staff will accept an extender. Be sensitive to the feelings of long-term employees who might see their turf as threatened, he advised. Provide patients with literature describing what a physician assistant does and the professional biography of the person hired.

How to Train

In 2004, 38% of physician assistants had less than 2 years' experience and 23% had more than 6 years, according to unpublished data cited by Dr. Wirtzer. Education levels ranged from an associate's degree (16%) to a bachelor's degree (41%) to a master's degree (43%). He said he prefers to hire an extender who has just completed schooling rather than risk hiring an experienced extender introducing incompatible treatment approaches from another practice.

Most training is by direct observation and proctoring, he said. He recommended that the new extender follow the physician for 3–6 months. The person also might attend courses or use continuing medical education materials. If the extender is experienced, the training period could be shorter, Dr. Wirtzer said, but oversight should be greater to ensure compatible approaches to treatment.

Training should include coding and office management, he added, again to ensure consistency when dealing with patients. He advocated developing clear treatment plans for common conditions, policies on when biopsies are appropriate, and fee schedules.

Rules to Know

Dr. Wirtzer noted that state regulations vary on how many extenders can be supervised by one physician and whether the physician must be in the office or available by phone when the extender sees a patient. Medicaid covers physician assistants and nurse practitioners, he added, but policies vary and there are no set rules for private insurers.

Medicare has strict requirements on "incident to billing," he continued. It requires that the physician examine the patient on the first visit for a particular condition. The physician assistant can provide subsequent care as long as a physician is in the office.

If these criteria are met, services provided by a physician assistant or nurse practitioner can be billed at 100% under the physician's name, according to Dr. Wirtzer.

If the physician is not on site or the physician assistant treats a new Medicare patient or a Medicare patient with a new problem, then only 85% can be billed and it must be done under the physician assistant's name. Defining a new condition can be "a gray area," he warned, suggesting a check with the local Medicare carrier.

Smart Practices

Design a contract that covers the initial mentoring period, starting salary, and bonus arrangement, Dr. Wirtzer advised. He suggested putting a dollar value on training and including a noncompete clause in case the person leaves the practice. "Don't be cheap," he said, warning that inadequate compensation can lead to loss of valuable staff members.

Consider paying for employee practices insurance, he added. It covers the practice against lawsuits by employees.

These are not covered by malpractice or office overhead insurance, and can be expensive to fight even when the practice is in the right.

PHOENIX — Physician assistants and nurse practitioners should be trained to treat, biopsy, and bill patients as if they were the physicians for whom they work, Dr. Allan Wirtzer said at a clinical dermatology conference sponsored by Medicis.

"Your extender should be your clone," said Dr. Wirtzer, who has a practice in Sherman Oaks, Calif., and endorses the hiring of physician extenders as an alternative to recruiting first-year dermatologists.

Extenders can enable a practice to see more patients and to significantly increase revenues, he said. Patient acceptance is critical, however, and can be undermined if the extender is not consistent with the physician.

As an example, Dr. Wirtzer offered the hypothetical situation in which an extender recommends a course of treatment for a skin condition. For the dermatologist to disagree and suggest changing the plan on a follow-up visit could be worse than embarrassing, he warned: "It is not going to bode well for the patient's confidence in the practice."

Here are more of Dr. Wirtzer's tips on how to incorporate a physician extender into a dermatology practice:

Whom to Hire

A third of dermatologists are seeking associates, he said. Not only is patient demand for services high, but also dermatologists are in short supply. As a result, he contended, some new dermatologists are pricing themselves out of the market with unrealistic expectations of their first-year earnings.

Physician assistants and nurse practitioners are easier to find, according to Dr. Wirtzer. They also can be easier to work with and may contribute more to a practice. He cited a 2002 survey that found the average extender was paid $100,000 annually while revenues increased by $500,000 each year.

He said that he has chosen to hire physician assistants because they "are trained to be physician assistants—exactly what it says" as opposed to nurse practitioners who can work independently and want to expand the number of states in which they can practice without physician supervision. A physician assistant cannot establish a competing practice.

Another consideration, he added, is whether your patients and staff will accept an extender. Be sensitive to the feelings of long-term employees who might see their turf as threatened, he advised. Provide patients with literature describing what a physician assistant does and the professional biography of the person hired.

How to Train

In 2004, 38% of physician assistants had less than 2 years' experience and 23% had more than 6 years, according to unpublished data cited by Dr. Wirtzer. Education levels ranged from an associate's degree (16%) to a bachelor's degree (41%) to a master's degree (43%). He said he prefers to hire an extender who has just completed schooling rather than risk hiring an experienced extender introducing incompatible treatment approaches from another practice.

Most training is by direct observation and proctoring, he said. He recommended that the new extender follow the physician for 3–6 months. The person also might attend courses or use continuing medical education materials. If the extender is experienced, the training period could be shorter, Dr. Wirtzer said, but oversight should be greater to ensure compatible approaches to treatment.

Training should include coding and office management, he added, again to ensure consistency when dealing with patients. He advocated developing clear treatment plans for common conditions, policies on when biopsies are appropriate, and fee schedules.

Rules to Know

Dr. Wirtzer noted that state regulations vary on how many extenders can be supervised by one physician and whether the physician must be in the office or available by phone when the extender sees a patient. Medicaid covers physician assistants and nurse practitioners, he added, but policies vary and there are no set rules for private insurers.

Medicare has strict requirements on "incident to billing," he continued. It requires that the physician examine the patient on the first visit for a particular condition. The physician assistant can provide subsequent care as long as a physician is in the office.

If these criteria are met, services provided by a physician assistant or nurse practitioner can be billed at 100% under the physician's name, according to Dr. Wirtzer.

If the physician is not on site or the physician assistant treats a new Medicare patient or a Medicare patient with a new problem, then only 85% can be billed and it must be done under the physician assistant's name. Defining a new condition can be "a gray area," he warned, suggesting a check with the local Medicare carrier.

Smart Practices

Design a contract that covers the initial mentoring period, starting salary, and bonus arrangement, Dr. Wirtzer advised. He suggested putting a dollar value on training and including a noncompete clause in case the person leaves the practice. "Don't be cheap," he said, warning that inadequate compensation can lead to loss of valuable staff members.

Consider paying for employee practices insurance, he added. It covers the practice against lawsuits by employees.

These are not covered by malpractice or office overhead insurance, and can be expensive to fight even when the practice is in the right.

SAN DIEGO — A prospective study found 17.5% of geriatric patients developed delirium after surgery for gynecologic malignancies, Dr. Jessica N. McAlpine reported at the annual meeting of the Society of Gynecologic Oncologists.

The women diagnosed with postoperative delirium were older, took more medications, and received additional doses of narcotic, said Dr. McAlpine of the University of British Columbia, Vancouver.

Gynecologic surgery patients may also be at special risk from hypoalbuminemia, prolonged catheter use, and prolonged oxygen use, she said. All three were significantly associated with delirium in univariate but not multivariate analysis.

Dr. McAlpine described the study as the first to look at postoperative delirium in gynecologic oncology patients. She called the results comparable to those recorded in other fields with adult surgical patients.

Postoperative delirium is a particular concern for gynecologic oncologists, Dr. McAlpine said, because it is more common in the elderly, as are gynecologic cancers. Building on the study, she and her colleagues plan to develop interventions to prevent delirium in patients operated on for gynecologic cancers.

“I think for a long time we just attributed it [delirium] to sundowning without any formal diagnosis,” she added in an interview after her presentation. “It usually self-resolves, but long-term sequelae have not been properly addressed and need to be addressed as the population ages.”

The study enrolled 103 women, aged 60 years and older, who were scheduled for surgery for suspected cancers. After surgery, 88 women had confirmed malignancies, including 59 with advanced-stage disease. Using the Mini-Mental State Examination (MMSE) before and after surgery and the postoperative Confusion Assessment Method, the investigators diagnosed postoperative delirium in 18 women.

The women who developed delirium had a mean age of 77 years vs. 69 years for the patients who did not have delirium. They also had significantly higher scores on the Charlson's Comorbidity Index (4.2 vs. 1.3), worse performance status as measured by the Karnofsky score (67 vs. 86), and less education (12.2 years vs. 14.6 years).

Their mean albumin was significantly lower (2.66 vs. 3.33), and they took more preoperative medications on average (6.3 vs. 3.7). They also had a much greater change in their mental status tests (−7 vs. −0.12), and spent much more time on oxygen (4 days vs. 1.5 days).

Most of the women who became delirious had postoperative transfusions, received additional doses of narcotics, were restricted to bed rest, and had Foley catheters inserted for more than 2 days. This was significantly different among the nondelirious patients, a minority of whom required these measures. Additional narcotic use and bed rest were documented, respectively, in only two and three of the nondelirious patients.

Looking at the factors that remained significant with multivariate analysis, the investigators calculated the odds ratios for dementia as 1.2 with advanced age, 1.7 with multiple medications, and 107 with additional narcotics.

They called for improved care, suggesting preoperative screening to find patients vulnerable to delirium, minimization of factors known to be associated with postoperative delirium, and use of multidisciplinary teams for postoperative care that would include representatives of geriatric service, anesthesia, psychiatry, and pharmacy. While the age factor cannot be reduced, Dr. McAlpine said it could be given greater emphasis when counseling patients and their families before surgery.

In a discussion of the presentation, Dr. Susan C. Modesitt of the University of Virginia, Charlottesville, called the study innovative, relevant, and timely. Citing the ongoing aging of the population, she said, “This is something we are going to see, and we are going to have to learn how to deal with it adequately.”

Odds ratios for dementia were 1.2 with older age, 1.7 with multiple drugs, and 107 with additional narcotics. DR. MCALPINE

SAN DIEGO — A prospective study found 17.5% of geriatric patients developed delirium after surgery for gynecologic malignancies, Dr. Jessica N. McAlpine reported at the annual meeting of the Society of Gynecologic Oncologists.

The women diagnosed with postoperative delirium were older, took more medications, and received additional doses of narcotic, said Dr. McAlpine of the University of British Columbia, Vancouver.

Gynecologic surgery patients may also be at special risk from hypoalbuminemia, prolonged catheter use, and prolonged oxygen use, she said. All three were significantly associated with delirium in univariate but not multivariate analysis.

Dr. McAlpine described the study as the first to look at postoperative delirium in gynecologic oncology patients. She called the results comparable to those recorded in other fields with adult surgical patients.

Postoperative delirium is a particular concern for gynecologic oncologists, Dr. McAlpine said, because it is more common in the elderly, as are gynecologic cancers. Building on the study, she and her colleagues plan to develop interventions to prevent delirium in patients operated on for gynecologic cancers.

“I think for a long time we just attributed it [delirium] to sundowning without any formal diagnosis,” she added in an interview after her presentation. “It usually self-resolves, but long-term sequelae have not been properly addressed and need to be addressed as the population ages.”

The study enrolled 103 women, aged 60 years and older, who were scheduled for surgery for suspected cancers. After surgery, 88 women had confirmed malignancies, including 59 with advanced-stage disease. Using the Mini-Mental State Examination (MMSE) before and after surgery and the postoperative Confusion Assessment Method, the investigators diagnosed postoperative delirium in 18 women.

The women who developed delirium had a mean age of 77 years vs. 69 years for the patients who did not have delirium. They also had significantly higher scores on the Charlson's Comorbidity Index (4.2 vs. 1.3), worse performance status as measured by the Karnofsky score (67 vs. 86), and less education (12.2 years vs. 14.6 years).

Their mean albumin was significantly lower (2.66 vs. 3.33), and they took more preoperative medications on average (6.3 vs. 3.7). They also had a much greater change in their mental status tests (−7 vs. −0.12), and spent much more time on oxygen (4 days vs. 1.5 days).

Most of the women who became delirious had postoperative transfusions, received additional doses of narcotics, were restricted to bed rest, and had Foley catheters inserted for more than 2 days. This was significantly different among the nondelirious patients, a minority of whom required these measures. Additional narcotic use and bed rest were documented, respectively, in only two and three of the nondelirious patients.

Looking at the factors that remained significant with multivariate analysis, the investigators calculated the odds ratios for dementia as 1.2 with advanced age, 1.7 with multiple medications, and 107 with additional narcotics.

They called for improved care, suggesting preoperative screening to find patients vulnerable to delirium, minimization of factors known to be associated with postoperative delirium, and use of multidisciplinary teams for postoperative care that would include representatives of geriatric service, anesthesia, psychiatry, and pharmacy. While the age factor cannot be reduced, Dr. McAlpine said it could be given greater emphasis when counseling patients and their families before surgery.

In a discussion of the presentation, Dr. Susan C. Modesitt of the University of Virginia, Charlottesville, called the study innovative, relevant, and timely. Citing the ongoing aging of the population, she said, “This is something we are going to see, and we are going to have to learn how to deal with it adequately.”

Odds ratios for dementia were 1.2 with older age, 1.7 with multiple drugs, and 107 with additional narcotics. DR. MCALPINE

SAN DIEGO — A prospective study found 17.5% of geriatric patients developed delirium after surgery for gynecologic malignancies, Dr. Jessica N. McAlpine reported at the annual meeting of the Society of Gynecologic Oncologists.

The women diagnosed with postoperative delirium were older, took more medications, and received additional doses of narcotic, said Dr. McAlpine of the University of British Columbia, Vancouver.

Gynecologic surgery patients may also be at special risk from hypoalbuminemia, prolonged catheter use, and prolonged oxygen use, she said. All three were significantly associated with delirium in univariate but not multivariate analysis.

Dr. McAlpine described the study as the first to look at postoperative delirium in gynecologic oncology patients. She called the results comparable to those recorded in other fields with adult surgical patients.

Postoperative delirium is a particular concern for gynecologic oncologists, Dr. McAlpine said, because it is more common in the elderly, as are gynecologic cancers. Building on the study, she and her colleagues plan to develop interventions to prevent delirium in patients operated on for gynecologic cancers.

“I think for a long time we just attributed it [delirium] to sundowning without any formal diagnosis,” she added in an interview after her presentation. “It usually self-resolves, but long-term sequelae have not been properly addressed and need to be addressed as the population ages.”

The study enrolled 103 women, aged 60 years and older, who were scheduled for surgery for suspected cancers. After surgery, 88 women had confirmed malignancies, including 59 with advanced-stage disease. Using the Mini-Mental State Examination (MMSE) before and after surgery and the postoperative Confusion Assessment Method, the investigators diagnosed postoperative delirium in 18 women.

The women who developed delirium had a mean age of 77 years vs. 69 years for the patients who did not have delirium. They also had significantly higher scores on the Charlson's Comorbidity Index (4.2 vs. 1.3), worse performance status as measured by the Karnofsky score (67 vs. 86), and less education (12.2 years vs. 14.6 years).

Their mean albumin was significantly lower (2.66 vs. 3.33), and they took more preoperative medications on average (6.3 vs. 3.7). They also had a much greater change in their mental status tests (−7 vs. −0.12), and spent much more time on oxygen (4 days vs. 1.5 days).

Most of the women who became delirious had postoperative transfusions, received additional doses of narcotics, were restricted to bed rest, and had Foley catheters inserted for more than 2 days. This was significantly different among the nondelirious patients, a minority of whom required these measures. Additional narcotic use and bed rest were documented, respectively, in only two and three of the nondelirious patients.

Looking at the factors that remained significant with multivariate analysis, the investigators calculated the odds ratios for dementia as 1.2 with advanced age, 1.7 with multiple medications, and 107 with additional narcotics.

They called for improved care, suggesting preoperative screening to find patients vulnerable to delirium, minimization of factors known to be associated with postoperative delirium, and use of multidisciplinary teams for postoperative care that would include representatives of geriatric service, anesthesia, psychiatry, and pharmacy. While the age factor cannot be reduced, Dr. McAlpine said it could be given greater emphasis when counseling patients and their families before surgery.

In a discussion of the presentation, Dr. Susan C. Modesitt of the University of Virginia, Charlottesville, called the study innovative, relevant, and timely. Citing the ongoing aging of the population, she said, “This is something we are going to see, and we are going to have to learn how to deal with it adequately.”

Odds ratios for dementia were 1.2 with older age, 1.7 with multiple drugs, and 107 with additional narcotics. DR. MCALPINE

SAN FRANCISCO — Enoxaparin, a low-molecular-weight heparin, gave acute ischemic stroke patients significantly better protection against venous thromboembolism, compared with unfractionated heparin, in a large, open-label trial presented at the 32nd International Stroke Conference.

Venous thromboembolic (VTE) events occurred in 10.2% of 884 patients on enoxaparin prophylaxis, compared with 18.1% of 878 patients on unfractionated heparin, Dr. David G. Sherman reported. Enoxaparin reduced the relative risk of VTE by 43% in the trial, which randomized 1,762 patients who could not walk unassisted within 48 hours of acute ischemic stroke.

All subgroups benefited, including patients with more severe strokes and those who started prophylaxis more than 24 hours after their strokes, according to Dr. Sherman, a professor of medicine and chief of the division of neurology at the University of Texas Health Science Center in San Antonio. Compared with unfractionated heparin, enoxaparin reduced proximal deep vein thrombosis by 53%.

Sanofi-Aventis, which markets enoxaparin as the antithrombotic Lovenox, sponsored the Prevention of VTE After Acute Ischemic Stroke with Low-Molecular-Weight-Heparin Enoxaparin (PREVAIL) trial. Dr. Sherman is a consultant to and is on the speakers' bureau of the company.

Still to come is a thorough pharmacoeconomic analysis of enoxaparin prophylaxis. At a press briefing prior to the presentation, Dr. Sherman said the promised analysis would include indirect costs such as length of hospital stay as well as the price of the therapy.

Up to now, various stroke-care guidelines have called for VTE prophylaxis without specifying an agent or dose in the absence of large trials comparing agents, according to Dr. Sherman. PREVAIL gives physicians caring for paralyzed stroke patients “some guidance to direct them in making a decision on which anticoagulants to use,” he said.

The trial “suggests that enoxaparin 40 mg once daily for up to 14 days could become the preferred treatment for VTE prophylaxis in acute ischemic stroke patients,” he said in the conclusion of his presentation. He declined, however, to predict how standards-setting groups would react to PREVAIL.

The cost analysis could prove critical to how standards-setting groups view enoxaparin, according to Dr. Philip Gorelick, moderator of the press briefing. Despite its superiority in PREVAIL, he said in an interview that enoxaparin is an expensive drug that must compete with other stroke treatments as well as unfractionated heparin for health care dollars. “We have to see these data, because cost is very important,” said Dr. Gorelick, John S. Garvin professor and head of the department of neurology and rehabilitation at Rush Medical College, Chicago. “The absolute numbers of people that could be affected by the results of this trial are huge,” he added.

Patients in the study received either 40 mg of enoxaparin subcutaneously once a day or 5,000 IU of unfractionated heparin twice a day. Efficacy was based on whether patients had symptomatic or asymptomatic deep-vein thrombosis, symptomatic pulmonary embolism, or a fatal pulmonary embolism during 6–14 days of treatment. Both legs of asymptomatic patients were screened by venography.

Nearly two-thirds of patients in the trial started prophylaxis 24–48 hours after their strokes, but they had as much benefit as those who started sooner. “Even if we were not able to start in the first 24 hours, the treatment was effective,” Dr. Sherman said.

Adverse events were similar in both arms of PREVAIL. Dr. Sherman reported that clinically significant bleeds occurred in 1.3% of patients on enoxaparin and 0.7% of those given unfractionated heparin. Treating 13 patients with enoxaparin could prevent one VTE, he said; treating 435 patients could lead to one important clinical bleeding event.

At the end of 90 days' follow-up, investigators found no significant differences in neurologic end points, he said. Stroke progression and modified Rankin Scale scores of less than 2 were seen, respectively, in about 5% of both groups. Strokes recurred in fewer than 2% of patients regardless of prophylaxis.

SAN FRANCISCO — Enoxaparin, a low-molecular-weight heparin, gave acute ischemic stroke patients significantly better protection against venous thromboembolism, compared with unfractionated heparin, in a large, open-label trial presented at the 32nd International Stroke Conference.

Venous thromboembolic (VTE) events occurred in 10.2% of 884 patients on enoxaparin prophylaxis, compared with 18.1% of 878 patients on unfractionated heparin, Dr. David G. Sherman reported. Enoxaparin reduced the relative risk of VTE by 43% in the trial, which randomized 1,762 patients who could not walk unassisted within 48 hours of acute ischemic stroke.

All subgroups benefited, including patients with more severe strokes and those who started prophylaxis more than 24 hours after their strokes, according to Dr. Sherman, a professor of medicine and chief of the division of neurology at the University of Texas Health Science Center in San Antonio. Compared with unfractionated heparin, enoxaparin reduced proximal deep vein thrombosis by 53%.

Sanofi-Aventis, which markets enoxaparin as the antithrombotic Lovenox, sponsored the Prevention of VTE After Acute Ischemic Stroke with Low-Molecular-Weight-Heparin Enoxaparin (PREVAIL) trial. Dr. Sherman is a consultant to and is on the speakers' bureau of the company.

Still to come is a thorough pharmacoeconomic analysis of enoxaparin prophylaxis. At a press briefing prior to the presentation, Dr. Sherman said the promised analysis would include indirect costs such as length of hospital stay as well as the price of the therapy.

Up to now, various stroke-care guidelines have called for VTE prophylaxis without specifying an agent or dose in the absence of large trials comparing agents, according to Dr. Sherman. PREVAIL gives physicians caring for paralyzed stroke patients “some guidance to direct them in making a decision on which anticoagulants to use,” he said.

The trial “suggests that enoxaparin 40 mg once daily for up to 14 days could become the preferred treatment for VTE prophylaxis in acute ischemic stroke patients,” he said in the conclusion of his presentation. He declined, however, to predict how standards-setting groups would react to PREVAIL.

The cost analysis could prove critical to how standards-setting groups view enoxaparin, according to Dr. Philip Gorelick, moderator of the press briefing. Despite its superiority in PREVAIL, he said in an interview that enoxaparin is an expensive drug that must compete with other stroke treatments as well as unfractionated heparin for health care dollars. “We have to see these data, because cost is very important,” said Dr. Gorelick, John S. Garvin professor and head of the department of neurology and rehabilitation at Rush Medical College, Chicago. “The absolute numbers of people that could be affected by the results of this trial are huge,” he added.

Patients in the study received either 40 mg of enoxaparin subcutaneously once a day or 5,000 IU of unfractionated heparin twice a day. Efficacy was based on whether patients had symptomatic or asymptomatic deep-vein thrombosis, symptomatic pulmonary embolism, or a fatal pulmonary embolism during 6–14 days of treatment. Both legs of asymptomatic patients were screened by venography.

Nearly two-thirds of patients in the trial started prophylaxis 24–48 hours after their strokes, but they had as much benefit as those who started sooner. “Even if we were not able to start in the first 24 hours, the treatment was effective,” Dr. Sherman said.

Adverse events were similar in both arms of PREVAIL. Dr. Sherman reported that clinically significant bleeds occurred in 1.3% of patients on enoxaparin and 0.7% of those given unfractionated heparin. Treating 13 patients with enoxaparin could prevent one VTE, he said; treating 435 patients could lead to one important clinical bleeding event.

At the end of 90 days' follow-up, investigators found no significant differences in neurologic end points, he said. Stroke progression and modified Rankin Scale scores of less than 2 were seen, respectively, in about 5% of both groups. Strokes recurred in fewer than 2% of patients regardless of prophylaxis.

SAN FRANCISCO — Enoxaparin, a low-molecular-weight heparin, gave acute ischemic stroke patients significantly better protection against venous thromboembolism, compared with unfractionated heparin, in a large, open-label trial presented at the 32nd International Stroke Conference.

Venous thromboembolic (VTE) events occurred in 10.2% of 884 patients on enoxaparin prophylaxis, compared with 18.1% of 878 patients on unfractionated heparin, Dr. David G. Sherman reported. Enoxaparin reduced the relative risk of VTE by 43% in the trial, which randomized 1,762 patients who could not walk unassisted within 48 hours of acute ischemic stroke.

All subgroups benefited, including patients with more severe strokes and those who started prophylaxis more than 24 hours after their strokes, according to Dr. Sherman, a professor of medicine and chief of the division of neurology at the University of Texas Health Science Center in San Antonio. Compared with unfractionated heparin, enoxaparin reduced proximal deep vein thrombosis by 53%.

Sanofi-Aventis, which markets enoxaparin as the antithrombotic Lovenox, sponsored the Prevention of VTE After Acute Ischemic Stroke with Low-Molecular-Weight-Heparin Enoxaparin (PREVAIL) trial. Dr. Sherman is a consultant to and is on the speakers' bureau of the company.

Still to come is a thorough pharmacoeconomic analysis of enoxaparin prophylaxis. At a press briefing prior to the presentation, Dr. Sherman said the promised analysis would include indirect costs such as length of hospital stay as well as the price of the therapy.

Up to now, various stroke-care guidelines have called for VTE prophylaxis without specifying an agent or dose in the absence of large trials comparing agents, according to Dr. Sherman. PREVAIL gives physicians caring for paralyzed stroke patients “some guidance to direct them in making a decision on which anticoagulants to use,” he said.

The trial “suggests that enoxaparin 40 mg once daily for up to 14 days could become the preferred treatment for VTE prophylaxis in acute ischemic stroke patients,” he said in the conclusion of his presentation. He declined, however, to predict how standards-setting groups would react to PREVAIL.

The cost analysis could prove critical to how standards-setting groups view enoxaparin, according to Dr. Philip Gorelick, moderator of the press briefing. Despite its superiority in PREVAIL, he said in an interview that enoxaparin is an expensive drug that must compete with other stroke treatments as well as unfractionated heparin for health care dollars. “We have to see these data, because cost is very important,” said Dr. Gorelick, John S. Garvin professor and head of the department of neurology and rehabilitation at Rush Medical College, Chicago. “The absolute numbers of people that could be affected by the results of this trial are huge,” he added.

Patients in the study received either 40 mg of enoxaparin subcutaneously once a day or 5,000 IU of unfractionated heparin twice a day. Efficacy was based on whether patients had symptomatic or asymptomatic deep-vein thrombosis, symptomatic pulmonary embolism, or a fatal pulmonary embolism during 6–14 days of treatment. Both legs of asymptomatic patients were screened by venography.

Nearly two-thirds of patients in the trial started prophylaxis 24–48 hours after their strokes, but they had as much benefit as those who started sooner. “Even if we were not able to start in the first 24 hours, the treatment was effective,” Dr. Sherman said.

Adverse events were similar in both arms of PREVAIL. Dr. Sherman reported that clinically significant bleeds occurred in 1.3% of patients on enoxaparin and 0.7% of those given unfractionated heparin. Treating 13 patients with enoxaparin could prevent one VTE, he said; treating 435 patients could lead to one important clinical bleeding event.

At the end of 90 days' follow-up, investigators found no significant differences in neurologic end points, he said. Stroke progression and modified Rankin Scale scores of less than 2 were seen, respectively, in about 5% of both groups. Strokes recurred in fewer than 2% of patients regardless of prophylaxis.

SAN DIEGO — More attention needs to be paid to the risk of hereditary colorectal cancer in women diagnosed with endometrial and ovarian cancers—and vice versa, according to studies reported at the annual meeting of the Society of Gynecologic Oncologists.

Investigators from the University of Alabama, Birmingham, urged that all endometrial cancer patients younger than 50 years be screened for hereditary nonpolyposis colorectal cancer (HNPCC) mutations.

Another group, from the Roswell Park Cancer Institute in Buffalo, N.Y., recommended that HNPCC, also known as Lynch syndrome, be considered when evaluating patients who have a family history of ovarian cancer but do not screen positive for BRCA gene mutations.

For women diagnosed with HNPCC, researchers at the University of California, San Francisco, reported that prophylactic hysterectomy with bilateral salpingo-oophorectomy would be more cost effective than annual screenings or medical examinations for gynecologic cancers.

Lynch syndrome conveys lifetime risks of 60%–80% for colon cancer, 40%–60% for endometrial cancer, and 10%–20% for ovarian cancer in women, according to Dr. Lee-May Chen, who led the California project. Although endometrial cancer is more common, she said it is usually more treatable than ovarian cancer because endometrial bleeding leads to earlier detection.

Most women known to have HNPCC are screened by colonoscopy every year or two, Dr. Chen added, but tests for gynecologic cancers are not as effective or as routine.

The Alabama investigators, in looking for HNPCC in endometrial cancer patients, used immunohistochemical staining to screen pathologic specimens from 61 women younger than 50 years who were diagnosed between 1996 and 2006. They found mutations associated with HNPCC in 21 women (34%), of whom 5 had multiple mutations.

“The rate of HNPCC in this population is considerably higher than previous reports. These women, once diagnosed [with HNPCC], can benefit from further screening,” said Dr. Kellie Matthews, a resident who was lead author of the study.

Overall, the women's risk of HNPCC was three times higher than expected, added Dr. Rodney Rocconi, a fellow in gynecologic oncology.

For women who were not obese, it was six times as high. Consequently, the investigators urged that special attention be paid to those with a body mass index less than 30, even though they recommend that all endometrial cancer patients younger than age 50 be screened for HNPCC.

The Roswell Park group looked for HNPCC mutations in 77 patients in the Gilda Radner Familial Ovarian Cancer Registry. None had tested positive for BRCA gene mutations, and none met the Amsterdam criteria for diagnosing HNPCC.

The investigators reported that two patients tested positive for mutations in the MSH2 gene, and eight others had suspicious base-pair substitutions in the MLH1 or MSH2 genes.

Had the Amsterdam criteria included a family history of ovarian cancer, 13 patients would have been recognized as being at high risk for HNPCC.

“HNPCC should be considered in families with familial ovarian cancer if BRCA has been ruled out,” said Dr. Kerry Rodabaugh, senior author.

“We only identified 2 out of 77 patients with familial ovarian cancer to have HNPCC, but these 2 were previously unidentified and are probably unaware of their risk for colon cancer,” she added.

Dr. Rodabaugh said that she hoped the findings would lead to greater awareness of the relationship of gynecologic cancers to HNPCC.

Women who have HNPCC are known to be at risk of developing ovarian cancer, she said; it is recognized as a component of the syndrome, but not as a diagnostic criterion.

For women who have HNPCC, dealing with the risk of gynecologic cancer can be a lifelong endeavor with serious effects on quality of life, according to Dr. Chen. The primary options are:

▸ Risk-reducing surgery;

▸ An annual screening with ultrasound, CA-125 test, endometrial biopsy, and a medical examination; or

▸ An annual examination without special screening.

Dr. Chen and her associates applied a statistical model to data on cancer mortality and costs and found that risk-reducing surgery at age 30 was the most cost-effective option.

It is the most expensive option initially, but becomes less costly over time, according to Dr. Chen. By preventing cancer, the costs of annual screenings and examinations and of treating gynecologic cancers are eliminated.

Although the study's primary end point was cost-effectiveness, the calculations included survival.

Life expectancy was longest (80 years) among patients who had risk-reducing surgery, compared with 79 years in those who had annual screening, and 77 years in those who had only an annual examination.

Risk-reducing surgery at age 30 is the most cost-effective option long term, though initially, it's the most expensive. DR. CHEN

SAN DIEGO — More attention needs to be paid to the risk of hereditary colorectal cancer in women diagnosed with endometrial and ovarian cancers—and vice versa, according to studies reported at the annual meeting of the Society of Gynecologic Oncologists.

Investigators from the University of Alabama, Birmingham, urged that all endometrial cancer patients younger than 50 years be screened for hereditary nonpolyposis colorectal cancer (HNPCC) mutations.

Another group, from the Roswell Park Cancer Institute in Buffalo, N.Y., recommended that HNPCC, also known as Lynch syndrome, be considered when evaluating patients who have a family history of ovarian cancer but do not screen positive for BRCA gene mutations.

For women diagnosed with HNPCC, researchers at the University of California, San Francisco, reported that prophylactic hysterectomy with bilateral salpingo-oophorectomy would be more cost effective than annual screenings or medical examinations for gynecologic cancers.

Lynch syndrome conveys lifetime risks of 60%–80% for colon cancer, 40%–60% for endometrial cancer, and 10%–20% for ovarian cancer in women, according to Dr. Lee-May Chen, who led the California project. Although endometrial cancer is more common, she said it is usually more treatable than ovarian cancer because endometrial bleeding leads to earlier detection.

Most women known to have HNPCC are screened by colonoscopy every year or two, Dr. Chen added, but tests for gynecologic cancers are not as effective or as routine.

The Alabama investigators, in looking for HNPCC in endometrial cancer patients, used immunohistochemical staining to screen pathologic specimens from 61 women younger than 50 years who were diagnosed between 1996 and 2006. They found mutations associated with HNPCC in 21 women (34%), of whom 5 had multiple mutations.

“The rate of HNPCC in this population is considerably higher than previous reports. These women, once diagnosed [with HNPCC], can benefit from further screening,” said Dr. Kellie Matthews, a resident who was lead author of the study.

Overall, the women's risk of HNPCC was three times higher than expected, added Dr. Rodney Rocconi, a fellow in gynecologic oncology.

For women who were not obese, it was six times as high. Consequently, the investigators urged that special attention be paid to those with a body mass index less than 30, even though they recommend that all endometrial cancer patients younger than age 50 be screened for HNPCC.

The Roswell Park group looked for HNPCC mutations in 77 patients in the Gilda Radner Familial Ovarian Cancer Registry. None had tested positive for BRCA gene mutations, and none met the Amsterdam criteria for diagnosing HNPCC.

The investigators reported that two patients tested positive for mutations in the MSH2 gene, and eight others had suspicious base-pair substitutions in the MLH1 or MSH2 genes.

Had the Amsterdam criteria included a family history of ovarian cancer, 13 patients would have been recognized as being at high risk for HNPCC.

“HNPCC should be considered in families with familial ovarian cancer if BRCA has been ruled out,” said Dr. Kerry Rodabaugh, senior author.

“We only identified 2 out of 77 patients with familial ovarian cancer to have HNPCC, but these 2 were previously unidentified and are probably unaware of their risk for colon cancer,” she added.

Dr. Rodabaugh said that she hoped the findings would lead to greater awareness of the relationship of gynecologic cancers to HNPCC.

Women who have HNPCC are known to be at risk of developing ovarian cancer, she said; it is recognized as a component of the syndrome, but not as a diagnostic criterion.

For women who have HNPCC, dealing with the risk of gynecologic cancer can be a lifelong endeavor with serious effects on quality of life, according to Dr. Chen. The primary options are:

▸ Risk-reducing surgery;

▸ An annual screening with ultrasound, CA-125 test, endometrial biopsy, and a medical examination; or

▸ An annual examination without special screening.

Dr. Chen and her associates applied a statistical model to data on cancer mortality and costs and found that risk-reducing surgery at age 30 was the most cost-effective option.

It is the most expensive option initially, but becomes less costly over time, according to Dr. Chen. By preventing cancer, the costs of annual screenings and examinations and of treating gynecologic cancers are eliminated.

Although the study's primary end point was cost-effectiveness, the calculations included survival.

Life expectancy was longest (80 years) among patients who had risk-reducing surgery, compared with 79 years in those who had annual screening, and 77 years in those who had only an annual examination.

Risk-reducing surgery at age 30 is the most cost-effective option long term, though initially, it's the most expensive. DR. CHEN

SAN DIEGO — More attention needs to be paid to the risk of hereditary colorectal cancer in women diagnosed with endometrial and ovarian cancers—and vice versa, according to studies reported at the annual meeting of the Society of Gynecologic Oncologists.

Investigators from the University of Alabama, Birmingham, urged that all endometrial cancer patients younger than 50 years be screened for hereditary nonpolyposis colorectal cancer (HNPCC) mutations.

Another group, from the Roswell Park Cancer Institute in Buffalo, N.Y., recommended that HNPCC, also known as Lynch syndrome, be considered when evaluating patients who have a family history of ovarian cancer but do not screen positive for BRCA gene mutations.

For women diagnosed with HNPCC, researchers at the University of California, San Francisco, reported that prophylactic hysterectomy with bilateral salpingo-oophorectomy would be more cost effective than annual screenings or medical examinations for gynecologic cancers.

Lynch syndrome conveys lifetime risks of 60%–80% for colon cancer, 40%–60% for endometrial cancer, and 10%–20% for ovarian cancer in women, according to Dr. Lee-May Chen, who led the California project. Although endometrial cancer is more common, she said it is usually more treatable than ovarian cancer because endometrial bleeding leads to earlier detection.

Most women known to have HNPCC are screened by colonoscopy every year or two, Dr. Chen added, but tests for gynecologic cancers are not as effective or as routine.

The Alabama investigators, in looking for HNPCC in endometrial cancer patients, used immunohistochemical staining to screen pathologic specimens from 61 women younger than 50 years who were diagnosed between 1996 and 2006. They found mutations associated with HNPCC in 21 women (34%), of whom 5 had multiple mutations.

“The rate of HNPCC in this population is considerably higher than previous reports. These women, once diagnosed [with HNPCC], can benefit from further screening,” said Dr. Kellie Matthews, a resident who was lead author of the study.

Overall, the women's risk of HNPCC was three times higher than expected, added Dr. Rodney Rocconi, a fellow in gynecologic oncology.

For women who were not obese, it was six times as high. Consequently, the investigators urged that special attention be paid to those with a body mass index less than 30, even though they recommend that all endometrial cancer patients younger than age 50 be screened for HNPCC.

The Roswell Park group looked for HNPCC mutations in 77 patients in the Gilda Radner Familial Ovarian Cancer Registry. None had tested positive for BRCA gene mutations, and none met the Amsterdam criteria for diagnosing HNPCC.

The investigators reported that two patients tested positive for mutations in the MSH2 gene, and eight others had suspicious base-pair substitutions in the MLH1 or MSH2 genes.

Had the Amsterdam criteria included a family history of ovarian cancer, 13 patients would have been recognized as being at high risk for HNPCC.

“HNPCC should be considered in families with familial ovarian cancer if BRCA has been ruled out,” said Dr. Kerry Rodabaugh, senior author.

“We only identified 2 out of 77 patients with familial ovarian cancer to have HNPCC, but these 2 were previously unidentified and are probably unaware of their risk for colon cancer,” she added.

Dr. Rodabaugh said that she hoped the findings would lead to greater awareness of the relationship of gynecologic cancers to HNPCC.

Women who have HNPCC are known to be at risk of developing ovarian cancer, she said; it is recognized as a component of the syndrome, but not as a diagnostic criterion.

For women who have HNPCC, dealing with the risk of gynecologic cancer can be a lifelong endeavor with serious effects on quality of life, according to Dr. Chen. The primary options are:

▸ Risk-reducing surgery;

▸ An annual screening with ultrasound, CA-125 test, endometrial biopsy, and a medical examination; or

▸ An annual examination without special screening.

Dr. Chen and her associates applied a statistical model to data on cancer mortality and costs and found that risk-reducing surgery at age 30 was the most cost-effective option.

It is the most expensive option initially, but becomes less costly over time, according to Dr. Chen. By preventing cancer, the costs of annual screenings and examinations and of treating gynecologic cancers are eliminated.

Although the study's primary end point was cost-effectiveness, the calculations included survival.

Life expectancy was longest (80 years) among patients who had risk-reducing surgery, compared with 79 years in those who had annual screening, and 77 years in those who had only an annual examination.

Risk-reducing surgery at age 30 is the most cost-effective option long term, though initially, it's the most expensive. DR. CHEN

PHOENIX — An analysis of more than 350,000 reports from skin cancer screenings has identified five melanoma risk factors that can flag candidates for total skin examinations, Dr. Darrell S. Rigel reported at a clinical dermatology conference sponsored by Medicis.

The risk factors, arranged to form the acronym HARMM, are:

▸ History of previous melanoma.

▸ Age over 50 years.

▸ Regular dermatologist absent.

▸ Mole changing.

▸ Male gender.

People with four or five factors were 4.4 times more likely to have a suspected malignant melanoma than were those with one or no risk factors. (See graph.)

The study's data came from 5 years of the American Academy of Dermatology's annual National Melanoma/Skin Cancer Program, which has screened more than 1.7 million people and detected more than 171,200 suspicious lesions since its start in 1985. Dr. Rigel, a clinical professor of dermatology at New York University, New York, and his coauthors said future mass screening initiatives should focus on providing total skin examinations to people with multiple risk factors (J. Am. Acad. Dermatol. 2007 May 7 [Epub doi:10.1016/j.jaad.2007. 02.010]).

During 2001–2005, participating dermatologists identified possible melanomas in 0.9% of 364,804 people between the ages of 18 and 100 years. The screenings also found suspected actinic keratoses in 17.5% of the population and suspected nonmelanoma skin cancers in 7.6%. The prevalence of suspected melanomas did not vary much over time; the low was 0.7% in 2003 and the high 1.2% in 2002.

People who met four or five of the HARMM criteria accounted for 13.6% of those diagnosed with suspected melan- omas but only 5.8% of the population screened and they were also the least likely to receive a total skin examination: 53.7% received a full body screening, compared with 62.5% of those with one or no risk factors, 58.4% with two risk factors, and 55.9% with three risk factors.

The observed trend toward fewer thorough examinations with higher risk troubled the researchers, who said it “suggests an area where risk targeting can have an impact on patient care and mass screening cost efficacy.” Suspected melanomas, they noted, were more often found on patients who received a total skin examination (odds ratio 1.4) than on those whose examination was of a specific lesion or just the face and arms. In patients with four or five HARMM risk factors, melanoma prevalence was 2.50% with total skin examination, 2.49% when specific lesions were examined, and 1.76% with face and arm examination.

The academy is revising its screening program materials to promote the HARMM criteria, said Dr. Rigel. “It turned out the more risk factors you had, the less likely you were to have a complete physical,” he told clinicians at the conference.

Nearly all the people who came to the annual screenings had at least one of the HARMM criteria. Three-quarters had two or more, and a third had three or more risk factors. About a third came to the screenings more than 1 year, and repeaters had a lower prevalence of suspected melanomas than did first-timers (0.85% vs. 0.97%).

History of a previous melanoma was the most ominous risk factor, with an odds ratio of 3.5 by univariate analysis. The presence of a mole that was changing was the next most serious (odds ratio 2.0).

More women were screened than men, but men were more often diagnosed with a suspected melanoma (odds ratio 1.4). This was especially true for men over 50 years of age, who made up 23.4% of the people screened and 31.6% of those in whom dermatologists suspected melanoma.

ELSEVIER GLOBAL MEDICAL NEWS

PHOENIX — An analysis of more than 350,000 reports from skin cancer screenings has identified five melanoma risk factors that can flag candidates for total skin examinations, Dr. Darrell S. Rigel reported at a clinical dermatology conference sponsored by Medicis.

The risk factors, arranged to form the acronym HARMM, are:

▸ History of previous melanoma.

▸ Age over 50 years.

▸ Regular dermatologist absent.

▸ Mole changing.

▸ Male gender.

People with four or five factors were 4.4 times more likely to have a suspected malignant melanoma than were those with one or no risk factors. (See graph.)

The study's data came from 5 years of the American Academy of Dermatology's annual National Melanoma/Skin Cancer Program, which has screened more than 1.7 million people and detected more than 171,200 suspicious lesions since its start in 1985. Dr. Rigel, a clinical professor of dermatology at New York University, New York, and his coauthors said future mass screening initiatives should focus on providing total skin examinations to people with multiple risk factors (J. Am. Acad. Dermatol. 2007 May 7 [Epub doi:10.1016/j.jaad.2007. 02.010]).

During 2001–2005, participating dermatologists identified possible melanomas in 0.9% of 364,804 people between the ages of 18 and 100 years. The screenings also found suspected actinic keratoses in 17.5% of the population and suspected nonmelanoma skin cancers in 7.6%. The prevalence of suspected melanomas did not vary much over time; the low was 0.7% in 2003 and the high 1.2% in 2002.

People who met four or five of the HARMM criteria accounted for 13.6% of those diagnosed with suspected melan- omas but only 5.8% of the population screened and they were also the least likely to receive a total skin examination: 53.7% received a full body screening, compared with 62.5% of those with one or no risk factors, 58.4% with two risk factors, and 55.9% with three risk factors.

The observed trend toward fewer thorough examinations with higher risk troubled the researchers, who said it “suggests an area where risk targeting can have an impact on patient care and mass screening cost efficacy.” Suspected melanomas, they noted, were more often found on patients who received a total skin examination (odds ratio 1.4) than on those whose examination was of a specific lesion or just the face and arms. In patients with four or five HARMM risk factors, melanoma prevalence was 2.50% with total skin examination, 2.49% when specific lesions were examined, and 1.76% with face and arm examination.

The academy is revising its screening program materials to promote the HARMM criteria, said Dr. Rigel. “It turned out the more risk factors you had, the less likely you were to have a complete physical,” he told clinicians at the conference.

Nearly all the people who came to the annual screenings had at least one of the HARMM criteria. Three-quarters had two or more, and a third had three or more risk factors. About a third came to the screenings more than 1 year, and repeaters had a lower prevalence of suspected melanomas than did first-timers (0.85% vs. 0.97%).

History of a previous melanoma was the most ominous risk factor, with an odds ratio of 3.5 by univariate analysis. The presence of a mole that was changing was the next most serious (odds ratio 2.0).

More women were screened than men, but men were more often diagnosed with a suspected melanoma (odds ratio 1.4). This was especially true for men over 50 years of age, who made up 23.4% of the people screened and 31.6% of those in whom dermatologists suspected melanoma.

ELSEVIER GLOBAL MEDICAL NEWS

PHOENIX — An analysis of more than 350,000 reports from skin cancer screenings has identified five melanoma risk factors that can flag candidates for total skin examinations, Dr. Darrell S. Rigel reported at a clinical dermatology conference sponsored by Medicis.

The risk factors, arranged to form the acronym HARMM, are:

▸ History of previous melanoma.

▸ Age over 50 years.

▸ Regular dermatologist absent.

▸ Mole changing.

▸ Male gender.

People with four or five factors were 4.4 times more likely to have a suspected malignant melanoma than were those with one or no risk factors. (See graph.)

The study's data came from 5 years of the American Academy of Dermatology's annual National Melanoma/Skin Cancer Program, which has screened more than 1.7 million people and detected more than 171,200 suspicious lesions since its start in 1985. Dr. Rigel, a clinical professor of dermatology at New York University, New York, and his coauthors said future mass screening initiatives should focus on providing total skin examinations to people with multiple risk factors (J. Am. Acad. Dermatol. 2007 May 7 [Epub doi:10.1016/j.jaad.2007. 02.010]).

During 2001–2005, participating dermatologists identified possible melanomas in 0.9% of 364,804 people between the ages of 18 and 100 years. The screenings also found suspected actinic keratoses in 17.5% of the population and suspected nonmelanoma skin cancers in 7.6%. The prevalence of suspected melanomas did not vary much over time; the low was 0.7% in 2003 and the high 1.2% in 2002.

People who met four or five of the HARMM criteria accounted for 13.6% of those diagnosed with suspected melan- omas but only 5.8% of the population screened and they were also the least likely to receive a total skin examination: 53.7% received a full body screening, compared with 62.5% of those with one or no risk factors, 58.4% with two risk factors, and 55.9% with three risk factors.

The observed trend toward fewer thorough examinations with higher risk troubled the researchers, who said it “suggests an area where risk targeting can have an impact on patient care and mass screening cost efficacy.” Suspected melanomas, they noted, were more often found on patients who received a total skin examination (odds ratio 1.4) than on those whose examination was of a specific lesion or just the face and arms. In patients with four or five HARMM risk factors, melanoma prevalence was 2.50% with total skin examination, 2.49% when specific lesions were examined, and 1.76% with face and arm examination.

The academy is revising its screening program materials to promote the HARMM criteria, said Dr. Rigel. “It turned out the more risk factors you had, the less likely you were to have a complete physical,” he told clinicians at the conference.

Nearly all the people who came to the annual screenings had at least one of the HARMM criteria. Three-quarters had two or more, and a third had three or more risk factors. About a third came to the screenings more than 1 year, and repeaters had a lower prevalence of suspected melanomas than did first-timers (0.85% vs. 0.97%).

History of a previous melanoma was the most ominous risk factor, with an odds ratio of 3.5 by univariate analysis. The presence of a mole that was changing was the next most serious (odds ratio 2.0).

More women were screened than men, but men were more often diagnosed with a suspected melanoma (odds ratio 1.4). This was especially true for men over 50 years of age, who made up 23.4% of the people screened and 31.6% of those in whom dermatologists suspected melanoma.

ELSEVIER GLOBAL MEDICAL NEWS

SANTA FE, N.M. – Patients who attack mental health professionals in hospital settings are rarely prosecuted and usually cannot be sued for civil damages, Ralph J. Slovenko, Ph.D., advised at the annual meeting of the American College of Forensic Psychiatry.

“More often than not there is almost a wooden response from prosecutors in cases where a patient has been involuntarily committed or is in a prison facility,” said Dr. Slovenko, a professor of law and psychiatry at Wayne State University in Detroit.

No national reporting system keeps track of violent attacks in psychiatric hospitals or nonpsychiatric hospitals, Dr. Slovenko said, but a several indicators suggest violence against clinical and nonclinical staff is extensive.

He quoted U.S. Department of Justice National Crime Victimization data as ranking mental health professionals seventh in a list of occupations most at risk of violent crimes in the workplace. Mental health custodial workers also placed in the top 10.

“In U.S. public-sector hospitals, the risk of injury to staff is higher than the risk of injury from all causes combined in construction, agriculture, mining, manufacture, and transportation,” he said.

About half of the forensic psychiatrists at the meeting raised their hands when he asked whether they had been attacked in hospital settings. Roughly a quarter of the audience indicated that patients had attacked them outside of hospitals.

Authorities usually take the position that it would be inconsistent to prosecute a person who has already been hospitalized for reason of mental illness, Dr. Slovenko said. He cited a Colorado ruling that a person found insane cannot be deemed sane if that person were not released from the hospital before the attack.

Even in cases in which a nurse is battered against a wall and severely injured, hospitals are reluctant to file a complaint, he added, “Particularly private hospitals; they feel their reputation will be besmirched.”

In one case in which authorities did try to use a disorderly conduct statute against a patient, Dr. Slovenko said a New Jersey court ruled that it did not apply. The court held that to convict a mentally ill person for displaying symptoms of mental illness in the hospital where he was being treated for that illness could not be justified constitutionally or morally.

Pennsylvania authorities prosecuted a patient for “tearing up his room and causing a disturbance” in another case cited by Dr. Slovenko. The man then sued the hospital “for failure to prevent him from getting himself in such trouble.” The courts found for the hospital on “the well-known principle that one cannot benefit from his own wrongful act, and therefore he could not have action for damages.”

A hospital can be held responsible for the premature release of a violent patient, Dr. Slovenko said. It also is responsible for the safety of staff, patients, and visitors on its premises. A New York court did not hold a hospital liable when a discharged patient returned and killed a psychologist, however, because the hospital had a large security force that the patient managed to evade.

“When we have attacks in hospitals, overcrowding or understaffing is no defense,” Dr. Slovenko said, noting that the presence of security guards has been shown to reduce the frequency of attacks.

Workers' compensation often is the only claim open to the mental health worker injured in an attack, Dr. Slovenko concluded. The situation is analogous to “the Fireman's Rule” in tort law, he said. A firefighter is expected to face danger as part of his job. For this, he is entitled to pay and workers' compensation. He cannot sue the owner of a burning building for injuries sustained in firefighting.

“The same idea applies when a patient injures a member of the staff or others,” Dr. Slovenko advised. “You are limited to [workers'] compensation.”

SANTA FE, N.M. – Patients who attack mental health professionals in hospital settings are rarely prosecuted and usually cannot be sued for civil damages, Ralph J. Slovenko, Ph.D., advised at the annual meeting of the American College of Forensic Psychiatry.

“More often than not there is almost a wooden response from prosecutors in cases where a patient has been involuntarily committed or is in a prison facility,” said Dr. Slovenko, a professor of law and psychiatry at Wayne State University in Detroit.

No national reporting system keeps track of violent attacks in psychiatric hospitals or nonpsychiatric hospitals, Dr. Slovenko said, but a several indicators suggest violence against clinical and nonclinical staff is extensive.

He quoted U.S. Department of Justice National Crime Victimization data as ranking mental health professionals seventh in a list of occupations most at risk of violent crimes in the workplace. Mental health custodial workers also placed in the top 10.

“In U.S. public-sector hospitals, the risk of injury to staff is higher than the risk of injury from all causes combined in construction, agriculture, mining, manufacture, and transportation,” he said.

About half of the forensic psychiatrists at the meeting raised their hands when he asked whether they had been attacked in hospital settings. Roughly a quarter of the audience indicated that patients had attacked them outside of hospitals.

Authorities usually take the position that it would be inconsistent to prosecute a person who has already been hospitalized for reason of mental illness, Dr. Slovenko said. He cited a Colorado ruling that a person found insane cannot be deemed sane if that person were not released from the hospital before the attack.

Even in cases in which a nurse is battered against a wall and severely injured, hospitals are reluctant to file a complaint, he added, “Particularly private hospitals; they feel their reputation will be besmirched.”

In one case in which authorities did try to use a disorderly conduct statute against a patient, Dr. Slovenko said a New Jersey court ruled that it did not apply. The court held that to convict a mentally ill person for displaying symptoms of mental illness in the hospital where he was being treated for that illness could not be justified constitutionally or morally.

Pennsylvania authorities prosecuted a patient for “tearing up his room and causing a disturbance” in another case cited by Dr. Slovenko. The man then sued the hospital “for failure to prevent him from getting himself in such trouble.” The courts found for the hospital on “the well-known principle that one cannot benefit from his own wrongful act, and therefore he could not have action for damages.”

A hospital can be held responsible for the premature release of a violent patient, Dr. Slovenko said. It also is responsible for the safety of staff, patients, and visitors on its premises. A New York court did not hold a hospital liable when a discharged patient returned and killed a psychologist, however, because the hospital had a large security force that the patient managed to evade.

“When we have attacks in hospitals, overcrowding or understaffing is no defense,” Dr. Slovenko said, noting that the presence of security guards has been shown to reduce the frequency of attacks.

Workers' compensation often is the only claim open to the mental health worker injured in an attack, Dr. Slovenko concluded. The situation is analogous to “the Fireman's Rule” in tort law, he said. A firefighter is expected to face danger as part of his job. For this, he is entitled to pay and workers' compensation. He cannot sue the owner of a burning building for injuries sustained in firefighting.

“The same idea applies when a patient injures a member of the staff or others,” Dr. Slovenko advised. “You are limited to [workers'] compensation.”

SANTA FE, N.M. – Patients who attack mental health professionals in hospital settings are rarely prosecuted and usually cannot be sued for civil damages, Ralph J. Slovenko, Ph.D., advised at the annual meeting of the American College of Forensic Psychiatry.

“More often than not there is almost a wooden response from prosecutors in cases where a patient has been involuntarily committed or is in a prison facility,” said Dr. Slovenko, a professor of law and psychiatry at Wayne State University in Detroit.

No national reporting system keeps track of violent attacks in psychiatric hospitals or nonpsychiatric hospitals, Dr. Slovenko said, but a several indicators suggest violence against clinical and nonclinical staff is extensive.

He quoted U.S. Department of Justice National Crime Victimization data as ranking mental health professionals seventh in a list of occupations most at risk of violent crimes in the workplace. Mental health custodial workers also placed in the top 10.

“In U.S. public-sector hospitals, the risk of injury to staff is higher than the risk of injury from all causes combined in construction, agriculture, mining, manufacture, and transportation,” he said.

About half of the forensic psychiatrists at the meeting raised their hands when he asked whether they had been attacked in hospital settings. Roughly a quarter of the audience indicated that patients had attacked them outside of hospitals.

Authorities usually take the position that it would be inconsistent to prosecute a person who has already been hospitalized for reason of mental illness, Dr. Slovenko said. He cited a Colorado ruling that a person found insane cannot be deemed sane if that person were not released from the hospital before the attack.

Even in cases in which a nurse is battered against a wall and severely injured, hospitals are reluctant to file a complaint, he added, “Particularly private hospitals; they feel their reputation will be besmirched.”

In one case in which authorities did try to use a disorderly conduct statute against a patient, Dr. Slovenko said a New Jersey court ruled that it did not apply. The court held that to convict a mentally ill person for displaying symptoms of mental illness in the hospital where he was being treated for that illness could not be justified constitutionally or morally.

Pennsylvania authorities prosecuted a patient for “tearing up his room and causing a disturbance” in another case cited by Dr. Slovenko. The man then sued the hospital “for failure to prevent him from getting himself in such trouble.” The courts found for the hospital on “the well-known principle that one cannot benefit from his own wrongful act, and therefore he could not have action for damages.”

A hospital can be held responsible for the premature release of a violent patient, Dr. Slovenko said. It also is responsible for the safety of staff, patients, and visitors on its premises. A New York court did not hold a hospital liable when a discharged patient returned and killed a psychologist, however, because the hospital had a large security force that the patient managed to evade.

“When we have attacks in hospitals, overcrowding or understaffing is no defense,” Dr. Slovenko said, noting that the presence of security guards has been shown to reduce the frequency of attacks.

Workers' compensation often is the only claim open to the mental health worker injured in an attack, Dr. Slovenko concluded. The situation is analogous to “the Fireman's Rule” in tort law, he said. A firefighter is expected to face danger as part of his job. For this, he is entitled to pay and workers' compensation. He cannot sue the owner of a burning building for injuries sustained in firefighting.

“The same idea applies when a patient injures a member of the staff or others,” Dr. Slovenko advised. “You are limited to [workers'] compensation.”