Bianca Nogrady

Umbilical cord blood transplantation from unrelated donors offers a reasonable chance of cure for children with juvenile myelomonocytic leukemia, particularly in those diagnosed before age 2 years and where there is greater immunologic compatibility between donor and recipient.

A retrospective analysis of data from 110 children with juvenile myelomonocytic leukemia given single-unit, unrelated donor umbilical cord blood transplantation (UCBT) showed a 5-year disease-free survival rate of 44%, according to data published in Blood (2013;122:2135-41 [doi:10.1182/blood-2013-03-491589]).

"Our data document that a significant proportion of children with this disease, especially when receiving transplants from donors with limited HLA [human leukocyte antigens] disparity, can be cured with UCBT, thus indicating that this allograft can represent a suitable option for children with juvenile myelomonocytic leukemia lacking either a related donor or [an] unrelated donor of hematopoietic stem cells," wrote Dr. Franco Locatelli from the University of Pavia, Rome, and his colleagues.

"Compared with bone marrow transplantation, advantages of UCBT are represented by lower incidence and severity of graft-versus-host disease, easier procurement, and prompter availability of cord blood, and the possibility of using donors showing HLA disparities with the recipient," they said.

Patients’ median age at diagnosis was 1.4 years, and at transplantation was 2.2 years. While 16% of units were HLA matched with the recipient, 43% of units had one HLA disparity and 35% had two or three HLA disparities. Data on HLA compatibility were missing in 6 patients (6%).

The study found that children aged younger than 1.4 years at diagnosis had significantly better disease-free survival rates (hazard ratio, 0.42), while those who had one or no HLA disparities with the donor also had better survival rates (HR, 0.43).

Platelet recovery was achieved in 76 children, with the median time of 44 days required to reach a platelet count greater than 20 x 10⁹/L, and by day 180, the cumulative incidence of platelet recovery was 71% plus or minus 6%.

A total of 28 children underwent splenectomy before transplantation, 88 received chemotherapy, 8 were given a reduced-intensity conditioning regimen, and the remainder were treated with myeloablative regimens. Nineteen children also received total body irradiation.

Disease recurrence was the major cause of treatment failure, with a 5-year cumulative incidence of relapse of 33% in the median follow-up period of 64 months.

Twenty-four children died of transplant-attributable causes during the follow-up period, while 45 patients were diagnosed with grade II to IV acute graft-versus-host disease.

The researchers noted an increased risk of transplantation-related mortality among those with monosomy 7 karyotype, and those who did not receive cytotoxic treatment before transplantation.

The authors declared they had no financial conflicts of interest.

Umbilical cord blood transplantation from unrelated donors offers a reasonable chance of cure for children with juvenile myelomonocytic leukemia, particularly in those diagnosed before age 2 years and where there is greater immunologic compatibility between donor and recipient.

A retrospective analysis of data from 110 children with juvenile myelomonocytic leukemia given single-unit, unrelated donor umbilical cord blood transplantation (UCBT) showed a 5-year disease-free survival rate of 44%, according to data published in Blood (2013;122:2135-41 [doi:10.1182/blood-2013-03-491589]).

"Our data document that a significant proportion of children with this disease, especially when receiving transplants from donors with limited HLA [human leukocyte antigens] disparity, can be cured with UCBT, thus indicating that this allograft can represent a suitable option for children with juvenile myelomonocytic leukemia lacking either a related donor or [an] unrelated donor of hematopoietic stem cells," wrote Dr. Franco Locatelli from the University of Pavia, Rome, and his colleagues.

"Compared with bone marrow transplantation, advantages of UCBT are represented by lower incidence and severity of graft-versus-host disease, easier procurement, and prompter availability of cord blood, and the possibility of using donors showing HLA disparities with the recipient," they said.

Patients’ median age at diagnosis was 1.4 years, and at transplantation was 2.2 years. While 16% of units were HLA matched with the recipient, 43% of units had one HLA disparity and 35% had two or three HLA disparities. Data on HLA compatibility were missing in 6 patients (6%).

The study found that children aged younger than 1.4 years at diagnosis had significantly better disease-free survival rates (hazard ratio, 0.42), while those who had one or no HLA disparities with the donor also had better survival rates (HR, 0.43).

Platelet recovery was achieved in 76 children, with the median time of 44 days required to reach a platelet count greater than 20 x 10⁹/L, and by day 180, the cumulative incidence of platelet recovery was 71% plus or minus 6%.

A total of 28 children underwent splenectomy before transplantation, 88 received chemotherapy, 8 were given a reduced-intensity conditioning regimen, and the remainder were treated with myeloablative regimens. Nineteen children also received total body irradiation.

Disease recurrence was the major cause of treatment failure, with a 5-year cumulative incidence of relapse of 33% in the median follow-up period of 64 months.

Twenty-four children died of transplant-attributable causes during the follow-up period, while 45 patients were diagnosed with grade II to IV acute graft-versus-host disease.

The researchers noted an increased risk of transplantation-related mortality among those with monosomy 7 karyotype, and those who did not receive cytotoxic treatment before transplantation.

The authors declared they had no financial conflicts of interest.

Umbilical cord blood transplantation from unrelated donors offers a reasonable chance of cure for children with juvenile myelomonocytic leukemia, particularly in those diagnosed before age 2 years and where there is greater immunologic compatibility between donor and recipient.

A retrospective analysis of data from 110 children with juvenile myelomonocytic leukemia given single-unit, unrelated donor umbilical cord blood transplantation (UCBT) showed a 5-year disease-free survival rate of 44%, according to data published in Blood (2013;122:2135-41 [doi:10.1182/blood-2013-03-491589]).

"Our data document that a significant proportion of children with this disease, especially when receiving transplants from donors with limited HLA [human leukocyte antigens] disparity, can be cured with UCBT, thus indicating that this allograft can represent a suitable option for children with juvenile myelomonocytic leukemia lacking either a related donor or [an] unrelated donor of hematopoietic stem cells," wrote Dr. Franco Locatelli from the University of Pavia, Rome, and his colleagues.

"Compared with bone marrow transplantation, advantages of UCBT are represented by lower incidence and severity of graft-versus-host disease, easier procurement, and prompter availability of cord blood, and the possibility of using donors showing HLA disparities with the recipient," they said.

Patients’ median age at diagnosis was 1.4 years, and at transplantation was 2.2 years. While 16% of units were HLA matched with the recipient, 43% of units had one HLA disparity and 35% had two or three HLA disparities. Data on HLA compatibility were missing in 6 patients (6%).

The study found that children aged younger than 1.4 years at diagnosis had significantly better disease-free survival rates (hazard ratio, 0.42), while those who had one or no HLA disparities with the donor also had better survival rates (HR, 0.43).

Platelet recovery was achieved in 76 children, with the median time of 44 days required to reach a platelet count greater than 20 x 10⁹/L, and by day 180, the cumulative incidence of platelet recovery was 71% plus or minus 6%.

A total of 28 children underwent splenectomy before transplantation, 88 received chemotherapy, 8 were given a reduced-intensity conditioning regimen, and the remainder were treated with myeloablative regimens. Nineteen children also received total body irradiation.

Disease recurrence was the major cause of treatment failure, with a 5-year cumulative incidence of relapse of 33% in the median follow-up period of 64 months.

Twenty-four children died of transplant-attributable causes during the follow-up period, while 45 patients were diagnosed with grade II to IV acute graft-versus-host disease.

The researchers noted an increased risk of transplantation-related mortality among those with monosomy 7 karyotype, and those who did not receive cytotoxic treatment before transplantation.

The authors declared they had no financial conflicts of interest.

SYDNEY – The presence of subchorionic bleeding around the gestational sac does not appear to increase the risk of miscarriage, according to data from a prospective observational study.

In a study of 1,115 women in early pregnancy, 142 (13%) had documented subchorionic hematoma. The women were diagnosed either after presenting with bleeding or during a routine dating scan. Researchers looked at the outcomes of pregnancy in both groups at the end of the first trimester and the final pregnancy outcome. They found no statistically significant association between the presence of subchorionic bleeding and miscarriage, according to findings presented at the International Society on Ultrasound in Obstetrics and Gynecology world congress.

Lead author Dr. Nicole Stamatopoulos said the study came about because she observed a significant number of women attending the unit with subchorionic hematoma.

Looking at viable pregnancies that later miscarry, "we wondered if the bleeding around the gestational sac was one of the reasons why these women were miscarrying," said Dr. Stamatopoulos, a researcher at Nepean Hospital in Penrith, Sydney.

Dr. Stamatopoulos said that a diagnosis of subchorionic hematoma – which is one of the most common sonographic abnormalities with live embryos – often caused women a lot of concern, particularly when it was accompanied by vaginal bleeding.

She said the findings should offer some reassurance to these women.

"If you’ve got an embryo that’s got a heart rate, and someone’s come in with bleeding, and there is a subchorionic hematoma, I think you can reassure those women," Dr. Stamatopoulos said in an interview.

However, she said that reassurance could not necessarily be extended to women in whom a viable pregnancy was yet to be established.

The causes of subchorionic hematoma are not well understood, but the condition may result from trauma or may be related to the process of the trophoblast embedding into the uterus, Dr. Stamatopoulos said.

The next step in the study is to explore a possible relationship between the size of the hematoma and pregnancy outcomes.

"I’ve got data relating to the actual size of the subchorionic hematoma, to see whether or not, if it’s a really large one, does that increase the risk of miscarriage? Or if it’s just small, is it not a problem?" she said.

There were no relevant financial conflicts of interest declared.

SYDNEY – The presence of subchorionic bleeding around the gestational sac does not appear to increase the risk of miscarriage, according to data from a prospective observational study.

In a study of 1,115 women in early pregnancy, 142 (13%) had documented subchorionic hematoma. The women were diagnosed either after presenting with bleeding or during a routine dating scan. Researchers looked at the outcomes of pregnancy in both groups at the end of the first trimester and the final pregnancy outcome. They found no statistically significant association between the presence of subchorionic bleeding and miscarriage, according to findings presented at the International Society on Ultrasound in Obstetrics and Gynecology world congress.

Lead author Dr. Nicole Stamatopoulos said the study came about because she observed a significant number of women attending the unit with subchorionic hematoma.

Looking at viable pregnancies that later miscarry, "we wondered if the bleeding around the gestational sac was one of the reasons why these women were miscarrying," said Dr. Stamatopoulos, a researcher at Nepean Hospital in Penrith, Sydney.

Dr. Stamatopoulos said that a diagnosis of subchorionic hematoma – which is one of the most common sonographic abnormalities with live embryos – often caused women a lot of concern, particularly when it was accompanied by vaginal bleeding.

She said the findings should offer some reassurance to these women.

"If you’ve got an embryo that’s got a heart rate, and someone’s come in with bleeding, and there is a subchorionic hematoma, I think you can reassure those women," Dr. Stamatopoulos said in an interview.

However, she said that reassurance could not necessarily be extended to women in whom a viable pregnancy was yet to be established.

The causes of subchorionic hematoma are not well understood, but the condition may result from trauma or may be related to the process of the trophoblast embedding into the uterus, Dr. Stamatopoulos said.

The next step in the study is to explore a possible relationship between the size of the hematoma and pregnancy outcomes.

"I’ve got data relating to the actual size of the subchorionic hematoma, to see whether or not, if it’s a really large one, does that increase the risk of miscarriage? Or if it’s just small, is it not a problem?" she said.

There were no relevant financial conflicts of interest declared.

SYDNEY – The presence of subchorionic bleeding around the gestational sac does not appear to increase the risk of miscarriage, according to data from a prospective observational study.

In a study of 1,115 women in early pregnancy, 142 (13%) had documented subchorionic hematoma. The women were diagnosed either after presenting with bleeding or during a routine dating scan. Researchers looked at the outcomes of pregnancy in both groups at the end of the first trimester and the final pregnancy outcome. They found no statistically significant association between the presence of subchorionic bleeding and miscarriage, according to findings presented at the International Society on Ultrasound in Obstetrics and Gynecology world congress.

Lead author Dr. Nicole Stamatopoulos said the study came about because she observed a significant number of women attending the unit with subchorionic hematoma.

Looking at viable pregnancies that later miscarry, "we wondered if the bleeding around the gestational sac was one of the reasons why these women were miscarrying," said Dr. Stamatopoulos, a researcher at Nepean Hospital in Penrith, Sydney.

Dr. Stamatopoulos said that a diagnosis of subchorionic hematoma – which is one of the most common sonographic abnormalities with live embryos – often caused women a lot of concern, particularly when it was accompanied by vaginal bleeding.

She said the findings should offer some reassurance to these women.

"If you’ve got an embryo that’s got a heart rate, and someone’s come in with bleeding, and there is a subchorionic hematoma, I think you can reassure those women," Dr. Stamatopoulos said in an interview.

However, she said that reassurance could not necessarily be extended to women in whom a viable pregnancy was yet to be established.

The causes of subchorionic hematoma are not well understood, but the condition may result from trauma or may be related to the process of the trophoblast embedding into the uterus, Dr. Stamatopoulos said.

The next step in the study is to explore a possible relationship between the size of the hematoma and pregnancy outcomes.

"I’ve got data relating to the actual size of the subchorionic hematoma, to see whether or not, if it’s a really large one, does that increase the risk of miscarriage? Or if it’s just small, is it not a problem?" she said.

There were no relevant financial conflicts of interest declared.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Patch testing is essential in determining the substances responsible for allergic contact dermatitis but is also associated with significant challenges for both clinician and patient, according to Dr. Mark Davis and his colleagues.

"Although the results of patch testing can often be rewarding for the patient and physician, the process of patch testing can be expensive, challenging, time consuming, and frustrating," the researchers wrote. "Often, it raises more questions than answers."

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery (Semin. Cutan. Med. Surg. 2013;32:158-68), Dr. Davis and his colleagues at the Mayo Clinic in Rochester, Minn., and the University of Minnesota, Minneapolis, examined key issues with patch testing for allergic contact dermatitis and provided practical guidance on how to deal with these issues.

Allergic contact dermatitis can occur at any age, and the authors recommended that in general, everyone with recurrent or persistent dermatitis suspected of having a component of allergic contact dermatitis should be patch tested.

However, a positive patch test may contradict other evidence, such as a patient showing a positive reaction to gold sodium thiosulfate despite having always tolerated a gold ring.

Patch tests may also deliver a positive result although the patient shows no signs of dermatitis, such as a positive response to nickel, the researchers noted.

They advised against patch testing to dust mites in particular, because most patients undergoing patch testing to dust mites have positive reactions regardless of whether they have atopic dermatitis.

"Research at our institution paradoxically showed that atopic patients had fewer reactions to the dust mites than patients who were nonatopic," they said.

Determining the relevance of a positive result can be difficult. In one researcher’s reported experience, most reactions were relevant, but predicting positive relevant allergens was often complicated by the occurrence of unexpected reactions.

One common question about patch testing is how to distinguish between an irritant versus an allergic patch test reaction, the researchers noted.

"Irritant reactions occur within minutes to hours after application of the chemical, whereas allergic reactions occur over days," they noted. "Irritant patch test reactions are usually very prominent initially and then fade with time (decrescendo), whereas an allergic patch test reaction usually increases with time (crescendo)."

Another area of controversy is allergic contact dermatitis to laundry detergent, which the authors said was so rare that it had been described as an urban legend. Despite this, both patients and physicians may conclude that laundry detergent is involved when allergic contact dermatitis is diagnosed.

In addition, not all patch test results are clear, and up to 50% of reactions may be very weak. In particular, some problematic patch test results are associated with allergens such as cocamidopropyl betaine 1% aqueous (aq), benzalkonium chloride 0.1% aq, and jasmine absolute 2% pet (Dermatitis 2010;21:91-7), the researchers wrote.

Although the management of weak reactions is controversial, the researchers noted that in their own practice at the Mayo Clinic, they err on the side of caution and regard even very weak reactions as potentially relevant.

The authors had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization."

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization."

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.

"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.

Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).

Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.

Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.

There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization."

Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.

"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.

Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.

Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.

Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.

As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.

"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.

Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.

However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).

Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.

There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.

The researchers had no financial conflicts to disclose.

Mild traumatic brain injury with intracranial hemorrhage can be safely managed by an acute care surgeon without the need for an inpatient neurosurgical consultation, a retrospective analysis has found.

A study of 270 patients with mild traumatic brain injury and positive CT scan findings of intracranial hemorrhage – 90 of whom received a neurosurgical consultation and 180 of whom did not – found no neurosurgical intervention, in-hospital mortality, or 30-day readmission in either group.

A total of 8% of patients seen by acute care surgeons had a postdischarge visit to the emergency department, compared with 4% of the group who had a neurosurgical consultation (P = .5), according to data published in the July 2013 issue of the Journal of Trauma and Acute Care Surgery (2013;75:102-5 [doi:10.1097/TA.0b013e3182946667]).

The main reasons for the unplanned returns, all of which were within 12 days of initial discharge, were headache (62%) and vomiting (30%); however, all patients in both groups were discharged home from the emergency department.

Patients who saw a neurosurgeon were more likely to have a repeat head CT scan (86% vs. 20%; P less than .001) and ICU admission (44% vs. 20%; P less than .001) for further care and evaluation, compared with patients seen by an acute care surgeon.

Differences in practice also led to differences in cost, as patients in the no neurological consultation group showed significantly lower mean hospital costs than did those in the neurosurgical consultation group ($9,400 vs. $14,108; P = .01).

"Currently, the standard of practice is to consult the neurosurgical service for all head injury patients with intracranial bleeds," wrote Dr. Bellal Joseph and his associates from the University of Arizona, Tucson.

"Our study questions the clinical relevance of a small intracranial hemorrhage on head CT scan in patients who are neurologically intact and adds to the increasing evidence that small intracranial hemorrhages can be managed without obtaining a formal neurosurgical consultation because none of our study patients required a neurosurgical intervention based on the findings of initial head CT scan."

Of the 270 patients involved in the study, 63% were male and the mean age was 39 years. The median Glasgow Coma Scale score was 15 and median head Abbreviated Injury Scale score was 2.

Researchers said the results had already changed the practice at their institution, with acute care surgeons and neurosurgeons collaborating to develop guidelines for neurosurgical consultations in blunt head trauma.

"Based on these guidelines, the acute care surgery team at our institution now independently manages subdural hematoma or epidural hematoma of 4 mm or less as well as solitary subarachnoid hemorrhage and contusions," they reported.

However, the study’s authors said the challenge would be setting a new standard of acute care surgeons being the leading provider of care for patients with mild traumatic brain injury, and that prospective evaluation of strict guidelines could support the change in practice.

The authors declared no conflicts of interest.

Mild traumatic brain injury with intracranial hemorrhage can be safely managed by an acute care surgeon without the need for an inpatient neurosurgical consultation, a retrospective analysis has found.

A study of 270 patients with mild traumatic brain injury and positive CT scan findings of intracranial hemorrhage – 90 of whom received a neurosurgical consultation and 180 of whom did not – found no neurosurgical intervention, in-hospital mortality, or 30-day readmission in either group.

A total of 8% of patients seen by acute care surgeons had a postdischarge visit to the emergency department, compared with 4% of the group who had a neurosurgical consultation (P = .5), according to data published in the July 2013 issue of the Journal of Trauma and Acute Care Surgery (2013;75:102-5 [doi:10.1097/TA.0b013e3182946667]).

The main reasons for the unplanned returns, all of which were within 12 days of initial discharge, were headache (62%) and vomiting (30%); however, all patients in both groups were discharged home from the emergency department.

Patients who saw a neurosurgeon were more likely to have a repeat head CT scan (86% vs. 20%; P less than .001) and ICU admission (44% vs. 20%; P less than .001) for further care and evaluation, compared with patients seen by an acute care surgeon.

Differences in practice also led to differences in cost, as patients in the no neurological consultation group showed significantly lower mean hospital costs than did those in the neurosurgical consultation group ($9,400 vs. $14,108; P = .01).

"Currently, the standard of practice is to consult the neurosurgical service for all head injury patients with intracranial bleeds," wrote Dr. Bellal Joseph and his associates from the University of Arizona, Tucson.

"Our study questions the clinical relevance of a small intracranial hemorrhage on head CT scan in patients who are neurologically intact and adds to the increasing evidence that small intracranial hemorrhages can be managed without obtaining a formal neurosurgical consultation because none of our study patients required a neurosurgical intervention based on the findings of initial head CT scan."

Of the 270 patients involved in the study, 63% were male and the mean age was 39 years. The median Glasgow Coma Scale score was 15 and median head Abbreviated Injury Scale score was 2.

Researchers said the results had already changed the practice at their institution, with acute care surgeons and neurosurgeons collaborating to develop guidelines for neurosurgical consultations in blunt head trauma.

"Based on these guidelines, the acute care surgery team at our institution now independently manages subdural hematoma or epidural hematoma of 4 mm or less as well as solitary subarachnoid hemorrhage and contusions," they reported.

However, the study’s authors said the challenge would be setting a new standard of acute care surgeons being the leading provider of care for patients with mild traumatic brain injury, and that prospective evaluation of strict guidelines could support the change in practice.

The authors declared no conflicts of interest.

Mild traumatic brain injury with intracranial hemorrhage can be safely managed by an acute care surgeon without the need for an inpatient neurosurgical consultation, a retrospective analysis has found.

A study of 270 patients with mild traumatic brain injury and positive CT scan findings of intracranial hemorrhage – 90 of whom received a neurosurgical consultation and 180 of whom did not – found no neurosurgical intervention, in-hospital mortality, or 30-day readmission in either group.

A total of 8% of patients seen by acute care surgeons had a postdischarge visit to the emergency department, compared with 4% of the group who had a neurosurgical consultation (P = .5), according to data published in the July 2013 issue of the Journal of Trauma and Acute Care Surgery (2013;75:102-5 [doi:10.1097/TA.0b013e3182946667]).

The main reasons for the unplanned returns, all of which were within 12 days of initial discharge, were headache (62%) and vomiting (30%); however, all patients in both groups were discharged home from the emergency department.

Patients who saw a neurosurgeon were more likely to have a repeat head CT scan (86% vs. 20%; P less than .001) and ICU admission (44% vs. 20%; P less than .001) for further care and evaluation, compared with patients seen by an acute care surgeon.

Differences in practice also led to differences in cost, as patients in the no neurological consultation group showed significantly lower mean hospital costs than did those in the neurosurgical consultation group ($9,400 vs. $14,108; P = .01).

"Currently, the standard of practice is to consult the neurosurgical service for all head injury patients with intracranial bleeds," wrote Dr. Bellal Joseph and his associates from the University of Arizona, Tucson.

"Our study questions the clinical relevance of a small intracranial hemorrhage on head CT scan in patients who are neurologically intact and adds to the increasing evidence that small intracranial hemorrhages can be managed without obtaining a formal neurosurgical consultation because none of our study patients required a neurosurgical intervention based on the findings of initial head CT scan."

Of the 270 patients involved in the study, 63% were male and the mean age was 39 years. The median Glasgow Coma Scale score was 15 and median head Abbreviated Injury Scale score was 2.

Researchers said the results had already changed the practice at their institution, with acute care surgeons and neurosurgeons collaborating to develop guidelines for neurosurgical consultations in blunt head trauma.

"Based on these guidelines, the acute care surgery team at our institution now independently manages subdural hematoma or epidural hematoma of 4 mm or less as well as solitary subarachnoid hemorrhage and contusions," they reported.

However, the study’s authors said the challenge would be setting a new standard of acute care surgeons being the leading provider of care for patients with mild traumatic brain injury, and that prospective evaluation of strict guidelines could support the change in practice.

The authors declared no conflicts of interest.

SYDNEY, AUSTRALIA – An iPod-based program using music as reward and behavioral reinforcement can lead to significant improvements in stride length and walking speed, according to data presented at the international congress of Parkinson’s Disease and Movement Disorders.

The AmbuloSono system, developed by researchers from the University of Calgary (Alta.), uses an accelerometer to measure stride length and distance walked, and is tied to a music program that only switches on above a certain stride length. The iPod is housed in a pouch strapped above the knee and connected wirelessly to headphones.

"It uses music as a reward, so you have to walk larger steps in order to trigger the music to play, and when your step size becomes smaller, the music stops," said lead author Dr. Bin Hu of the Hotchkiss Brain Institute, University of Calgary.

In a pilot study of 42 patients with Parkinson’s disease, use of the device over a 320-day trial period was associated with significant improvements in stride length (10%-30%) and walking speed (10%-20%) over long distances. In that time, patients walked more than 3,500 km and listened to more than 700 hours of music.

Researchers also noted significant improvements in other functional domains, including arm swings, facial expression, long-term fear and anxiety of using an escalator, and activity avoidance due to depression/apathy.

"Our pilot study indicates that AmbuloSono may be a more efficient behavioral training paradigm than simple rhythmic auditory stimulation to induce functional improvements in multiple domains of motor and nonmotor functions in patients living with Parkinson’s disease," the researchers wrote.

Postural instability and gait disorders can be particularly challenging to treat in Parkinson’s patients, as they do not respond well to drugs and are associated with major functional disability, Dr. Hu said in an interview.

"This program is designed based on the mechanism of reward seeking and learning, so instead of triggering neuroregeneration, you trigger functional compensation," Dr. Hu said.

The music used in the program was chosen particularly for its saliency, to maximize the reward.

"Over time, it becomes automatic, so you essentially learn how to automatically control your walk again, but you need a reward in order to achieve that state because the brain is built in that way – when you engage in reward-seeking, the behavior becomes automatic," he said.

Dr. Hu said the improvements were sustained and patients’ gait problems were minimized to the point where their walk appeared to be relatively normal.

The study was supported by the Canadian Institutes of Health Research, Alberta Innovations Health Solutions, the Hotchkiss Brain Institute, the Parkinson’s Society of Alberta, Alberta Health Services, and the Foothills Movement Disorders Clinic. No other conflicts of interest were declared.

SYDNEY, AUSTRALIA – An iPod-based program using music as reward and behavioral reinforcement can lead to significant improvements in stride length and walking speed, according to data presented at the international congress of Parkinson’s Disease and Movement Disorders.

The AmbuloSono system, developed by researchers from the University of Calgary (Alta.), uses an accelerometer to measure stride length and distance walked, and is tied to a music program that only switches on above a certain stride length. The iPod is housed in a pouch strapped above the knee and connected wirelessly to headphones.

"It uses music as a reward, so you have to walk larger steps in order to trigger the music to play, and when your step size becomes smaller, the music stops," said lead author Dr. Bin Hu of the Hotchkiss Brain Institute, University of Calgary.

In a pilot study of 42 patients with Parkinson’s disease, use of the device over a 320-day trial period was associated with significant improvements in stride length (10%-30%) and walking speed (10%-20%) over long distances. In that time, patients walked more than 3,500 km and listened to more than 700 hours of music.

Researchers also noted significant improvements in other functional domains, including arm swings, facial expression, long-term fear and anxiety of using an escalator, and activity avoidance due to depression/apathy.

"Our pilot study indicates that AmbuloSono may be a more efficient behavioral training paradigm than simple rhythmic auditory stimulation to induce functional improvements in multiple domains of motor and nonmotor functions in patients living with Parkinson’s disease," the researchers wrote.

Postural instability and gait disorders can be particularly challenging to treat in Parkinson’s patients, as they do not respond well to drugs and are associated with major functional disability, Dr. Hu said in an interview.

"This program is designed based on the mechanism of reward seeking and learning, so instead of triggering neuroregeneration, you trigger functional compensation," Dr. Hu said.

The music used in the program was chosen particularly for its saliency, to maximize the reward.

"Over time, it becomes automatic, so you essentially learn how to automatically control your walk again, but you need a reward in order to achieve that state because the brain is built in that way – when you engage in reward-seeking, the behavior becomes automatic," he said.

Dr. Hu said the improvements were sustained and patients’ gait problems were minimized to the point where their walk appeared to be relatively normal.

The study was supported by the Canadian Institutes of Health Research, Alberta Innovations Health Solutions, the Hotchkiss Brain Institute, the Parkinson’s Society of Alberta, Alberta Health Services, and the Foothills Movement Disorders Clinic. No other conflicts of interest were declared.

SYDNEY, AUSTRALIA – An iPod-based program using music as reward and behavioral reinforcement can lead to significant improvements in stride length and walking speed, according to data presented at the international congress of Parkinson’s Disease and Movement Disorders.

The AmbuloSono system, developed by researchers from the University of Calgary (Alta.), uses an accelerometer to measure stride length and distance walked, and is tied to a music program that only switches on above a certain stride length. The iPod is housed in a pouch strapped above the knee and connected wirelessly to headphones.

"It uses music as a reward, so you have to walk larger steps in order to trigger the music to play, and when your step size becomes smaller, the music stops," said lead author Dr. Bin Hu of the Hotchkiss Brain Institute, University of Calgary.

In a pilot study of 42 patients with Parkinson’s disease, use of the device over a 320-day trial period was associated with significant improvements in stride length (10%-30%) and walking speed (10%-20%) over long distances. In that time, patients walked more than 3,500 km and listened to more than 700 hours of music.

Researchers also noted significant improvements in other functional domains, including arm swings, facial expression, long-term fear and anxiety of using an escalator, and activity avoidance due to depression/apathy.

"Our pilot study indicates that AmbuloSono may be a more efficient behavioral training paradigm than simple rhythmic auditory stimulation to induce functional improvements in multiple domains of motor and nonmotor functions in patients living with Parkinson’s disease," the researchers wrote.

Postural instability and gait disorders can be particularly challenging to treat in Parkinson’s patients, as they do not respond well to drugs and are associated with major functional disability, Dr. Hu said in an interview.

"This program is designed based on the mechanism of reward seeking and learning, so instead of triggering neuroregeneration, you trigger functional compensation," Dr. Hu said.

The music used in the program was chosen particularly for its saliency, to maximize the reward.

"Over time, it becomes automatic, so you essentially learn how to automatically control your walk again, but you need a reward in order to achieve that state because the brain is built in that way – when you engage in reward-seeking, the behavior becomes automatic," he said.

Dr. Hu said the improvements were sustained and patients’ gait problems were minimized to the point where their walk appeared to be relatively normal.

The study was supported by the Canadian Institutes of Health Research, Alberta Innovations Health Solutions, the Hotchkiss Brain Institute, the Parkinson’s Society of Alberta, Alberta Health Services, and the Foothills Movement Disorders Clinic. No other conflicts of interest were declared.

Postoperative postural hypotension or adrenal insufficiency in patients with inflammatory bowel disease can be effectively prevented with low-dose rather than high-dose steroids, according to data published in the June 14 online issue of Annals of Surgery [doi: 10.1097/SLA.b013e318297adca].

"Corticosteroid-treated patients undergoing major colorectal surgery are commonly prescribed high-dose steroids to prevent perioperative adrenal insufficiency and cardiovascular collapse," wrote Dr. Karen Zaghiyan and her colleagues from Cedars-Sinai Medical Center, Los Angeles. "There is little evidence to support this practice."

A randomized, single-blinded noninferiority trial in 92 steroid-treated inflammatory bowel disease (IBD) patients undergoing major colorectal surgery showed that 96% of patients randomized to low-dose steroids and 95% of patients randomized to high-dose steroids did not exhibit postural hypotension on the first day after surgery (noninferiority 95% confidence interval, –0.08 to 0.09; P = .007).

"Because reports of postoperative adrenal insufficiency and hemodynamic collapse have implicated the first 24 hours after surgery as the most susceptible, and postural hypotension is likely to be a more reliable indicator of hemodynamic instability than supine hypotension, our primary endpoint was clinically meaningful," the researchers reported.

Patients were randomized to receive either 100 mg of IV hydrocortisone at the time of incision and three times daily for the first postoperative day, then tapered, or to low-dose IV hydrocortisone equivalent to presurgical oral dosing, followed by taper.

The primary outcome was the absence of postural hypotension on postoperative day 1, defined as a decrease in systolic blood pressure by 20 mm Hg after sitting from a supine position.

"We found no significant difference in perioperative factors, including operative time, intraoperative blood loss, volume of intravenous fluids administered, number of patients requiring intravenous fluid boluses, or blood transfusions between our two patient groups," the researchers reported.

The investigators also found no significant differences in other outcomes such as surgical or medical complications, length of postoperative stay, fatigue, nausea, and pain, although there was an insignificant trend toward more infectious complications in the high-dose steroid group.

The practice of administering high doses of corticosteroids perioperatively was sparked in the 1950s by two incidences of postoperative cardiovascular collapse and death in patients whose preoperative corticosteroids were discontinued before surgery, the authors said.

"However, high-dose corticosteroids are not without consequence and have been associated with various postoperative complications, including wound infection and anastomotic dehiscence," the authors reported.

Some studies had already suggested that steroid-treated patients undergoing surgery could remain on their baseline corticosteroid dose perioperatively; however, these studies were mostly focused on organ transplant recipients or included patients taking low maintenance doses of corticosteroids undergoing minor or moderate surgical procedures.

"Patients with IBD represent a unique study cohort because they are frequently taking high doses of steroids for a prolonged period of time, and surgery in these patients often involves major stress," the researchers reported.

"Although we recently published our retrospective data to suggest safety of low-dose steroids in steroid-treated IBD patients undergoing major colorectal surgery, this is the first prospective study to evaluate the role of stress-dose steroids in patients undergoing major abdominal and pelvic surgery," the investigators wrote.

There were no conflicts of interest declared.

Postoperative postural hypotension or adrenal insufficiency in patients with inflammatory bowel disease can be effectively prevented with low-dose rather than high-dose steroids, according to data published in the June 14 online issue of Annals of Surgery [doi: 10.1097/SLA.b013e318297adca].

"Corticosteroid-treated patients undergoing major colorectal surgery are commonly prescribed high-dose steroids to prevent perioperative adrenal insufficiency and cardiovascular collapse," wrote Dr. Karen Zaghiyan and her colleagues from Cedars-Sinai Medical Center, Los Angeles. "There is little evidence to support this practice."

A randomized, single-blinded noninferiority trial in 92 steroid-treated inflammatory bowel disease (IBD) patients undergoing major colorectal surgery showed that 96% of patients randomized to low-dose steroids and 95% of patients randomized to high-dose steroids did not exhibit postural hypotension on the first day after surgery (noninferiority 95% confidence interval, –0.08 to 0.09; P = .007).

"Because reports of postoperative adrenal insufficiency and hemodynamic collapse have implicated the first 24 hours after surgery as the most susceptible, and postural hypotension is likely to be a more reliable indicator of hemodynamic instability than supine hypotension, our primary endpoint was clinically meaningful," the researchers reported.

Patients were randomized to receive either 100 mg of IV hydrocortisone at the time of incision and three times daily for the first postoperative day, then tapered, or to low-dose IV hydrocortisone equivalent to presurgical oral dosing, followed by taper.

The primary outcome was the absence of postural hypotension on postoperative day 1, defined as a decrease in systolic blood pressure by 20 mm Hg after sitting from a supine position.

"We found no significant difference in perioperative factors, including operative time, intraoperative blood loss, volume of intravenous fluids administered, number of patients requiring intravenous fluid boluses, or blood transfusions between our two patient groups," the researchers reported.

The investigators also found no significant differences in other outcomes such as surgical or medical complications, length of postoperative stay, fatigue, nausea, and pain, although there was an insignificant trend toward more infectious complications in the high-dose steroid group.

The practice of administering high doses of corticosteroids perioperatively was sparked in the 1950s by two incidences of postoperative cardiovascular collapse and death in patients whose preoperative corticosteroids were discontinued before surgery, the authors said.

"However, high-dose corticosteroids are not without consequence and have been associated with various postoperative complications, including wound infection and anastomotic dehiscence," the authors reported.

Some studies had already suggested that steroid-treated patients undergoing surgery could remain on their baseline corticosteroid dose perioperatively; however, these studies were mostly focused on organ transplant recipients or included patients taking low maintenance doses of corticosteroids undergoing minor or moderate surgical procedures.

"Patients with IBD represent a unique study cohort because they are frequently taking high doses of steroids for a prolonged period of time, and surgery in these patients often involves major stress," the researchers reported.

"Although we recently published our retrospective data to suggest safety of low-dose steroids in steroid-treated IBD patients undergoing major colorectal surgery, this is the first prospective study to evaluate the role of stress-dose steroids in patients undergoing major abdominal and pelvic surgery," the investigators wrote.

There were no conflicts of interest declared.

Postoperative postural hypotension or adrenal insufficiency in patients with inflammatory bowel disease can be effectively prevented with low-dose rather than high-dose steroids, according to data published in the June 14 online issue of Annals of Surgery [doi: 10.1097/SLA.b013e318297adca].

"Corticosteroid-treated patients undergoing major colorectal surgery are commonly prescribed high-dose steroids to prevent perioperative adrenal insufficiency and cardiovascular collapse," wrote Dr. Karen Zaghiyan and her colleagues from Cedars-Sinai Medical Center, Los Angeles. "There is little evidence to support this practice."

A randomized, single-blinded noninferiority trial in 92 steroid-treated inflammatory bowel disease (IBD) patients undergoing major colorectal surgery showed that 96% of patients randomized to low-dose steroids and 95% of patients randomized to high-dose steroids did not exhibit postural hypotension on the first day after surgery (noninferiority 95% confidence interval, –0.08 to 0.09; P = .007).

"Because reports of postoperative adrenal insufficiency and hemodynamic collapse have implicated the first 24 hours after surgery as the most susceptible, and postural hypotension is likely to be a more reliable indicator of hemodynamic instability than supine hypotension, our primary endpoint was clinically meaningful," the researchers reported.

Patients were randomized to receive either 100 mg of IV hydrocortisone at the time of incision and three times daily for the first postoperative day, then tapered, or to low-dose IV hydrocortisone equivalent to presurgical oral dosing, followed by taper.

The primary outcome was the absence of postural hypotension on postoperative day 1, defined as a decrease in systolic blood pressure by 20 mm Hg after sitting from a supine position.

"We found no significant difference in perioperative factors, including operative time, intraoperative blood loss, volume of intravenous fluids administered, number of patients requiring intravenous fluid boluses, or blood transfusions between our two patient groups," the researchers reported.

The investigators also found no significant differences in other outcomes such as surgical or medical complications, length of postoperative stay, fatigue, nausea, and pain, although there was an insignificant trend toward more infectious complications in the high-dose steroid group.

The practice of administering high doses of corticosteroids perioperatively was sparked in the 1950s by two incidences of postoperative cardiovascular collapse and death in patients whose preoperative corticosteroids were discontinued before surgery, the authors said.

"However, high-dose corticosteroids are not without consequence and have been associated with various postoperative complications, including wound infection and anastomotic dehiscence," the authors reported.

Some studies had already suggested that steroid-treated patients undergoing surgery could remain on their baseline corticosteroid dose perioperatively; however, these studies were mostly focused on organ transplant recipients or included patients taking low maintenance doses of corticosteroids undergoing minor or moderate surgical procedures.

"Patients with IBD represent a unique study cohort because they are frequently taking high doses of steroids for a prolonged period of time, and surgery in these patients often involves major stress," the researchers reported.

"Although we recently published our retrospective data to suggest safety of low-dose steroids in steroid-treated IBD patients undergoing major colorectal surgery, this is the first prospective study to evaluate the role of stress-dose steroids in patients undergoing major abdominal and pelvic surgery," the investigators wrote.

There were no conflicts of interest declared.

Chronic obstructive pulmonary disease was associated with an increased risk of cerebral microbleeds – a marker of cerebral small vessel disease – independent of factors such as age, sex, smoking status, and cholesterol levels, according to a prospective, population-based cohort study.

"Depression, postural instability, cognitive and functional impairment are known consequences of cerebral small-vessel disease, and are frequently described extrapulmonary manifestations in patients with COPD," wrote Dr. Lies Lahousse from Ghent University Hospital, Belgium, and colleagues. "However, it is unclear whether COPD is associated with incident cerebral small-vessel disease."

Patients with COPD had a significantly higher prevalence of cerebral microbleeds, compared with patients with normal lung function, even after accounting for age, sex, smoking status, atherosclerotic macroangiopathy, antithrombotic use, total cholesterol, triglycerides, and serum creatinine (odds ratio, 1.7; 95% confidence interval, 1.15-2.47; P = .007).

Patients with COPD also had a more than threefold increase in the prevalence of microbleeds in deep or infratentorial locations (OR, 3.3; 95% CI, 1.97-5.53; P less than .001), according to data published online July 19 in the American Journal of Respiratory and Critical Care Medicine.

When a longitudinal analysis was conducted in patients without microbleed at baseline, COPD independently predicted a sevenfold increase in risk of deep or infratentorial microbleeds (OR, 7.1; 95% CI, 2.1-24.5; P = .002) over a median time interval of 3.42 years.

"Our results are in line with two previous cross-sectional studies that showed that patients with COPD had a significantly increased volume of cerebral white matter lesions, which is another marker of cerebral small vessel disease, and known to be associated with microbleeds in a deep or infratentorial region," Dr. Lahousse and associates said.

Although the increased incidence of microbleeds in patients with COPD was independent of smoking status, the researchers did find a significantly higher prevalence of cerebral microbleeds among individuals who had smoked.

The study involved 165 patients with COPD and 645 patients without COPD who were enrolled in the Rotterdam Scan Study, a population-based cohort study using MRI scan to examine age-related brain changes.

Previous research had shown an increased prevalence of atherosclerotic macroangiopathy in patients with COPD, but that was taken into account in the analysis.

The authors therefore suggested that COPD may affect large and small blood vessels, and that stiffening of arteries and arterioles may be the result of systemic inflammation in COPD as well as hypoxia caused by airflow limitation.

"Although severity of airflow limitation may not entirely reflect disease activity, our results suggest that cerebral small vessel disease is more present in COPD patients with more severe airflow limitation," the investigators noted.

Given the potential cognitive and functional consequences of microbleeds, the study authors suggested that the results could help with identification of vulnerable patient groups and point to the need for more research into preventive strategies.

The study was funded by the Fund for Scientific Research Flanders project and the Netherlands Organization for Scientific Research.

Chronic obstructive pulmonary disease was associated with an increased risk of cerebral microbleeds – a marker of cerebral small vessel disease – independent of factors such as age, sex, smoking status, and cholesterol levels, according to a prospective, population-based cohort study.

"Depression, postural instability, cognitive and functional impairment are known consequences of cerebral small-vessel disease, and are frequently described extrapulmonary manifestations in patients with COPD," wrote Dr. Lies Lahousse from Ghent University Hospital, Belgium, and colleagues. "However, it is unclear whether COPD is associated with incident cerebral small-vessel disease."

Patients with COPD had a significantly higher prevalence of cerebral microbleeds, compared with patients with normal lung function, even after accounting for age, sex, smoking status, atherosclerotic macroangiopathy, antithrombotic use, total cholesterol, triglycerides, and serum creatinine (odds ratio, 1.7; 95% confidence interval, 1.15-2.47; P = .007).

Patients with COPD also had a more than threefold increase in the prevalence of microbleeds in deep or infratentorial locations (OR, 3.3; 95% CI, 1.97-5.53; P less than .001), according to data published online July 19 in the American Journal of Respiratory and Critical Care Medicine.

When a longitudinal analysis was conducted in patients without microbleed at baseline, COPD independently predicted a sevenfold increase in risk of deep or infratentorial microbleeds (OR, 7.1; 95% CI, 2.1-24.5; P = .002) over a median time interval of 3.42 years.

"Our results are in line with two previous cross-sectional studies that showed that patients with COPD had a significantly increased volume of cerebral white matter lesions, which is another marker of cerebral small vessel disease, and known to be associated with microbleeds in a deep or infratentorial region," Dr. Lahousse and associates said.

Although the increased incidence of microbleeds in patients with COPD was independent of smoking status, the researchers did find a significantly higher prevalence of cerebral microbleeds among individuals who had smoked.

The study involved 165 patients with COPD and 645 patients without COPD who were enrolled in the Rotterdam Scan Study, a population-based cohort study using MRI scan to examine age-related brain changes.

Previous research had shown an increased prevalence of atherosclerotic macroangiopathy in patients with COPD, but that was taken into account in the analysis.

The authors therefore suggested that COPD may affect large and small blood vessels, and that stiffening of arteries and arterioles may be the result of systemic inflammation in COPD as well as hypoxia caused by airflow limitation.

"Although severity of airflow limitation may not entirely reflect disease activity, our results suggest that cerebral small vessel disease is more present in COPD patients with more severe airflow limitation," the investigators noted.

Given the potential cognitive and functional consequences of microbleeds, the study authors suggested that the results could help with identification of vulnerable patient groups and point to the need for more research into preventive strategies.

The study was funded by the Fund for Scientific Research Flanders project and the Netherlands Organization for Scientific Research.

Chronic obstructive pulmonary disease was associated with an increased risk of cerebral microbleeds – a marker of cerebral small vessel disease – independent of factors such as age, sex, smoking status, and cholesterol levels, according to a prospective, population-based cohort study.

"Depression, postural instability, cognitive and functional impairment are known consequences of cerebral small-vessel disease, and are frequently described extrapulmonary manifestations in patients with COPD," wrote Dr. Lies Lahousse from Ghent University Hospital, Belgium, and colleagues. "However, it is unclear whether COPD is associated with incident cerebral small-vessel disease."

Patients with COPD had a significantly higher prevalence of cerebral microbleeds, compared with patients with normal lung function, even after accounting for age, sex, smoking status, atherosclerotic macroangiopathy, antithrombotic use, total cholesterol, triglycerides, and serum creatinine (odds ratio, 1.7; 95% confidence interval, 1.15-2.47; P = .007).

Patients with COPD also had a more than threefold increase in the prevalence of microbleeds in deep or infratentorial locations (OR, 3.3; 95% CI, 1.97-5.53; P less than .001), according to data published online July 19 in the American Journal of Respiratory and Critical Care Medicine.

When a longitudinal analysis was conducted in patients without microbleed at baseline, COPD independently predicted a sevenfold increase in risk of deep or infratentorial microbleeds (OR, 7.1; 95% CI, 2.1-24.5; P = .002) over a median time interval of 3.42 years.

"Our results are in line with two previous cross-sectional studies that showed that patients with COPD had a significantly increased volume of cerebral white matter lesions, which is another marker of cerebral small vessel disease, and known to be associated with microbleeds in a deep or infratentorial region," Dr. Lahousse and associates said.

Although the increased incidence of microbleeds in patients with COPD was independent of smoking status, the researchers did find a significantly higher prevalence of cerebral microbleeds among individuals who had smoked.

The study involved 165 patients with COPD and 645 patients without COPD who were enrolled in the Rotterdam Scan Study, a population-based cohort study using MRI scan to examine age-related brain changes.

Previous research had shown an increased prevalence of atherosclerotic macroangiopathy in patients with COPD, but that was taken into account in the analysis.

The authors therefore suggested that COPD may affect large and small blood vessels, and that stiffening of arteries and arterioles may be the result of systemic inflammation in COPD as well as hypoxia caused by airflow limitation.

"Although severity of airflow limitation may not entirely reflect disease activity, our results suggest that cerebral small vessel disease is more present in COPD patients with more severe airflow limitation," the investigators noted.

Given the potential cognitive and functional consequences of microbleeds, the study authors suggested that the results could help with identification of vulnerable patient groups and point to the need for more research into preventive strategies.

The study was funded by the Fund for Scientific Research Flanders project and the Netherlands Organization for Scientific Research.