Heidi Splete

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”

WASHINGTON — A human papillomavirus vaccine developed by Merck & Co. is 100% effective in preventing genital warts in women in addition to preventing cervical cancer, Dr. John T. Schiller reported at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The vaccine, known as Gardasil, includes HPV types 6, 11, 16, and 18. Types 16 and 18 account for about 70% of cervical cancer, and types 6 and 11 account for about 90% of genital warts, said Dr. Schiller, head of the neoplastic disease section of the National Cancer Institute, Bethesda, Md.

At 2 years of follow-up, Gardasil achieved 100% efficacy against genital warts, vulvar neoplasia, and vaginal neoplasia, in addition to the previously reported 100% efficacy against cervical intraepithelial neoplasia (CIN). The phase II Females United to Unilaterally Reduce Endo-Ectocervical Disease study (FUTURE I) included 2,717 women randomized to a vaccine group and 2,725 randomized to a placebo group. Overall, there were no cases of genital warts in the vaccine group, compared with 40 cases in the placebo group.

Dr. Schiller also shared the latest findings from the FUTURE II study, a randomized, double-blind, phase III clinical trial that included about 12,000 women aged 18–25 years. The intent-to-treat numbers in the FUTURE II study showed extremely strong protection at 2 years of follow-up—only two cases of CIN grade 2 or 3—and the vaccine was generally well tolerated. One case of CIN was associated with HPV type 16, and the other was associated with a combination of types 16 and 18. The phase III studies are ongoing, and the data remain under review, but findings similar to those from the phase II study are expected with regard to genital warts and vulvar and vaginal neoplasia.

Merck filed its Gardasil data with the Food and Drug Administration on Dec. 1, 2005, and a vaccine could be available in the United States by late summer in 2006, Dr. Schiller said. GlaxoSmithKline Inc. has stated that it will seek regulatory approval in 2006 for its vaccine, Cervarix, which immunizes against HPV 16 and 18, but that it might seek initial approval in Europe.

Once the vaccine becomes available, the top candidates for immunization will be 10- to 13-year-old girls. “They are the ideal first targets because presumably, they have not yet been exposed to sexually transmitted viruses,” Dr. Schiller said at the meeting, sponsored by the American Society for Microbiology.

But before the vaccine becomes standard for young girls, it may be used in young women because of the high demand in that population, he noted. Some adult women may not have been exposed to the oncogenic strains of HPV, and vaccination may reduce transmission to their partners as well. An HPV vaccine has yet to be tested in men, but only 10% of HPV cancers occur in men, and high vaccination coverage of women may result in sufficient herd immunity, Dr. Schiller noted.

The HPV vaccines are based on purified viruslike particles (VLPs) that consist of single proteins. They are noninfectious and nononcogenic, but they can induce high titres of neutralizing antibodies, Dr. Schiller said.

Despite the promising results, several questions about HPV vaccination remain unresolved, including effects on current cancer screening programs, public acceptance, price, and distribution to underserved populations.

“Women might think that they are protected from cervical cancer because they have the vaccine, and abandon their screening programs, which would be a disaster,” Dr. Schiller said. Vaccination would not replace the need for a pap test, he emphasized, although it might reduce the incidence of repeat pap tests resulting from unclear results.

Vaccine acceptance is another issue, but preliminary surveys of parents suggest that as many as 75% would agree to vaccination of their adolescent daughters. But the logistics of delivering three intramuscular doses of vaccine to early adolescent girls over a 6-month period may prove challenging, Dr. Schiller added.

The price of the vaccine is critical to how many women and girls receive it. It is likely to be expensive at first, “perhaps as much as $100 per dose,” Dr. Schiller said.

Price is a huge barrier to providing the HPV vaccine to the underserved women who need it most. “Cervical cancer is a disease of poverty—80% of cases occur in developing countries where women don't have access to good quality pap screening,” Dr. Schiller noted. “This vaccine will not have the impact it should if the only women who are vaccinated are those who already get good cervical cancer screening.”

Regional production might be the best way to build up the amount of the vaccine and reduce the cost. In addition, researchers continue to investigate a second-generation vaccine that could be administered orally.

WASHINGTON — A human papillomavirus vaccine developed by Merck & Co. is 100% effective in preventing genital warts in women in addition to preventing cervical cancer, Dr. John T. Schiller reported at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The vaccine, known as Gardasil, includes HPV types 6, 11, 16, and 18. Types 16 and 18 account for about 70% of cervical cancer, and types 6 and 11 account for about 90% of genital warts, said Dr. Schiller, head of the neoplastic disease section of the National Cancer Institute, Bethesda, Md.

At 2 years of follow-up, Gardasil achieved 100% efficacy against genital warts, vulvar neoplasia, and vaginal neoplasia, in addition to the previously reported 100% efficacy against cervical intraepithelial neoplasia (CIN). The phase II Females United to Unilaterally Reduce Endo-Ectocervical Disease study (FUTURE I) included 2,717 women randomized to a vaccine group and 2,725 randomized to a placebo group. Overall, there were no cases of genital warts in the vaccine group, compared with 40 cases in the placebo group.

Dr. Schiller also shared the latest findings from the FUTURE II study, a randomized, double-blind, phase III clinical trial that included about 12,000 women aged 18–25 years. The intent-to-treat numbers in the FUTURE II study showed extremely strong protection at 2 years of follow-up—only two cases of CIN grade 2 or 3—and the vaccine was generally well tolerated. One case of CIN was associated with HPV type 16, and the other was associated with a combination of types 16 and 18. The phase III studies are ongoing, and the data remain under review, but findings similar to those from the phase II study are expected with regard to genital warts and vulvar and vaginal neoplasia.

Merck filed its Gardasil data with the Food and Drug Administration on Dec. 1, 2005, and a vaccine could be available in the United States by late summer in 2006, Dr. Schiller said. GlaxoSmithKline Inc. has stated that it will seek regulatory approval in 2006 for its vaccine, Cervarix, which immunizes against HPV 16 and 18, but that it might seek initial approval in Europe.

Once the vaccine becomes available, the top candidates for immunization will be 10- to 13-year-old girls. “They are the ideal first targets because presumably, they have not yet been exposed to sexually transmitted viruses,” Dr. Schiller said at the meeting, sponsored by the American Society for Microbiology.

But before the vaccine becomes standard for young girls, it may be used in young women because of the high demand in that population, he noted. Some adult women may not have been exposed to the oncogenic strains of HPV, and vaccination may reduce transmission to their partners as well. An HPV vaccine has yet to be tested in men, but only 10% of HPV cancers occur in men, and high vaccination coverage of women may result in sufficient herd immunity, Dr. Schiller noted.

The HPV vaccines are based on purified viruslike particles (VLPs) that consist of single proteins. They are noninfectious and nononcogenic, but they can induce high titres of neutralizing antibodies, Dr. Schiller said.

Despite the promising results, several questions about HPV vaccination remain unresolved, including effects on current cancer screening programs, public acceptance, price, and distribution to underserved populations.

“Women might think that they are protected from cervical cancer because they have the vaccine, and abandon their screening programs, which would be a disaster,” Dr. Schiller said. Vaccination would not replace the need for a pap test, he emphasized, although it might reduce the incidence of repeat pap tests resulting from unclear results.

Vaccine acceptance is another issue, but preliminary surveys of parents suggest that as many as 75% would agree to vaccination of their adolescent daughters. But the logistics of delivering three intramuscular doses of vaccine to early adolescent girls over a 6-month period may prove challenging, Dr. Schiller added.

The price of the vaccine is critical to how many women and girls receive it. It is likely to be expensive at first, “perhaps as much as $100 per dose,” Dr. Schiller said.

Price is a huge barrier to providing the HPV vaccine to the underserved women who need it most. “Cervical cancer is a disease of poverty—80% of cases occur in developing countries where women don't have access to good quality pap screening,” Dr. Schiller noted. “This vaccine will not have the impact it should if the only women who are vaccinated are those who already get good cervical cancer screening.”

Regional production might be the best way to build up the amount of the vaccine and reduce the cost. In addition, researchers continue to investigate a second-generation vaccine that could be administered orally.

WASHINGTON — A human papillomavirus vaccine developed by Merck & Co. is 100% effective in preventing genital warts in women in addition to preventing cervical cancer, Dr. John T. Schiller reported at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The vaccine, known as Gardasil, includes HPV types 6, 11, 16, and 18. Types 16 and 18 account for about 70% of cervical cancer, and types 6 and 11 account for about 90% of genital warts, said Dr. Schiller, head of the neoplastic disease section of the National Cancer Institute, Bethesda, Md.

At 2 years of follow-up, Gardasil achieved 100% efficacy against genital warts, vulvar neoplasia, and vaginal neoplasia, in addition to the previously reported 100% efficacy against cervical intraepithelial neoplasia (CIN). The phase II Females United to Unilaterally Reduce Endo-Ectocervical Disease study (FUTURE I) included 2,717 women randomized to a vaccine group and 2,725 randomized to a placebo group. Overall, there were no cases of genital warts in the vaccine group, compared with 40 cases in the placebo group.

Dr. Schiller also shared the latest findings from the FUTURE II study, a randomized, double-blind, phase III clinical trial that included about 12,000 women aged 18–25 years. The intent-to-treat numbers in the FUTURE II study showed extremely strong protection at 2 years of follow-up—only two cases of CIN grade 2 or 3—and the vaccine was generally well tolerated. One case of CIN was associated with HPV type 16, and the other was associated with a combination of types 16 and 18. The phase III studies are ongoing, and the data remain under review, but findings similar to those from the phase II study are expected with regard to genital warts and vulvar and vaginal neoplasia.

Merck filed its Gardasil data with the Food and Drug Administration on Dec. 1, 2005, and a vaccine could be available in the United States by late summer in 2006, Dr. Schiller said. GlaxoSmithKline Inc. has stated that it will seek regulatory approval in 2006 for its vaccine, Cervarix, which immunizes against HPV 16 and 18, but that it might seek initial approval in Europe.

Once the vaccine becomes available, the top candidates for immunization will be 10- to 13-year-old girls. “They are the ideal first targets because presumably, they have not yet been exposed to sexually transmitted viruses,” Dr. Schiller said at the meeting, sponsored by the American Society for Microbiology.

But before the vaccine becomes standard for young girls, it may be used in young women because of the high demand in that population, he noted. Some adult women may not have been exposed to the oncogenic strains of HPV, and vaccination may reduce transmission to their partners as well. An HPV vaccine has yet to be tested in men, but only 10% of HPV cancers occur in men, and high vaccination coverage of women may result in sufficient herd immunity, Dr. Schiller noted.

The HPV vaccines are based on purified viruslike particles (VLPs) that consist of single proteins. They are noninfectious and nononcogenic, but they can induce high titres of neutralizing antibodies, Dr. Schiller said.

Despite the promising results, several questions about HPV vaccination remain unresolved, including effects on current cancer screening programs, public acceptance, price, and distribution to underserved populations.

“Women might think that they are protected from cervical cancer because they have the vaccine, and abandon their screening programs, which would be a disaster,” Dr. Schiller said. Vaccination would not replace the need for a pap test, he emphasized, although it might reduce the incidence of repeat pap tests resulting from unclear results.

Vaccine acceptance is another issue, but preliminary surveys of parents suggest that as many as 75% would agree to vaccination of their adolescent daughters. But the logistics of delivering three intramuscular doses of vaccine to early adolescent girls over a 6-month period may prove challenging, Dr. Schiller added.

The price of the vaccine is critical to how many women and girls receive it. It is likely to be expensive at first, “perhaps as much as $100 per dose,” Dr. Schiller said.

Price is a huge barrier to providing the HPV vaccine to the underserved women who need it most. “Cervical cancer is a disease of poverty—80% of cases occur in developing countries where women don't have access to good quality pap screening,” Dr. Schiller noted. “This vaccine will not have the impact it should if the only women who are vaccinated are those who already get good cervical cancer screening.”

Regional production might be the best way to build up the amount of the vaccine and reduce the cost. In addition, researchers continue to investigate a second-generation vaccine that could be administered orally.

WASHINGTON — Three clinical characteristics—arteriovenous shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C.

Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination.

Of the remaining 159 patients (7.7% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species.

Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) of bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of culture-negative patients, and 34 (44%) of bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients.

In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Three clinical characteristics—arteriovenous shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C.

Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination.

Of the remaining 159 patients (7.7% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species.

Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) of bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of culture-negative patients, and 34 (44%) of bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients.

In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Three clinical characteristics—arteriovenous shunts or grafts, history of methicillin-resistant Staphylococcus aureus, and the presence of chills—were significantly associated with S. aureus bacteremia in a study of 1,015 patients, Dr. Zeina A. Kanafani reported in a poster presented at the annual meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy.

The findings may facilitate earlier detection of infection and encourage the timely initiation of antibiotics in bacteremic patients, noted Dr. Kanafani and her colleagues at Duke University Medical Center in Durham, N.C.

Data were collected from hospitalized patients aged 18 years and older with fevers of at least 38° C who underwent blood cultures between December 2003 and December 2004. A total of 235 patients (23%) had positive blood cultures; 76 were excluded from the study due to possible culture contamination.

Of the remaining 159 patients (7.7% of the original patient population), 78 had S. aureus bacteremia; the other 81 patients grew organisms including Candida species, Enterococcus species, and Bacteroides species.

Overall, 15 (19%) of patients with S. aureus bacteremia had histories of S. aureus infection, compared with 42 (5%) of the 780 patients whose blood cultures were negative for bacteremia. In addition, 25 (32%) of bacteremia patients had an arteriovenous shunt or graft, compared with 74 (10%) of culture-negative patients, and 34 (44%) of bacteremia patients suffered from chills, compared with 126 (16%) of the culture-negative patients.

In a subgroup of 829 nonhemodialysis patients, 45 (5%) had S. aureus bacteremia, and these patients were significantly more likely to have a tunneled-cuff catheter and a history of methicillin-resistant S. aureus.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — The percentage of Staphylococcus aureus isolates resistant to methicillin was about 68% in a survey of more than 100 long-term care facilities, Susan Beekmann, R.N., M.P.H., reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This “extraordinarily high” rate was higher than the documented MRSA rates from surveys of acute care hospitals nationwide, noted Ms. Beekmann and her colleagues at the University of Iowa, Iowa City.

The multicenter, longitudinal surveillance study included 1,060 S. aureus and 1,979 Enterococcus isolates collected from long-term care facilities across the United States during three 1-year periods from 1999 to 2004, Dr. Beekmann reported. The S. aureus isolates included 325 skin or soft tissue specimens, 489 urine specimens, and 246 other specimens. The Enterococcus isolates included 81 skin or soft tissue specimens, 1,835 urine specimens, and 63 other specimens.

The MRSA rate remained fairly stable (66%–71%) throughout the study period. By contrast, the overall infection rate of vancomycin-resistant enterococcus was relatively low (5%), and ranged from 4% in 1999 to 7% in 2003. No evidence of VRE was found in any of the skin or soft tissue isolates, the investigators noted.

Only five MRSA isolates showed no coresistances to other antibiotics. An additional 22 were resistant to ciprofloxacin only; these 22 were also susceptible to clindamycin. Only two of the Enterococcus isolates were linezolid resistant, and eight were intermediate resistant to linezolid, whereas none of the S. aureus isolates was resistant to linezolid.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — The percentage of Staphylococcus aureus isolates resistant to methicillin was about 68% in a survey of more than 100 long-term care facilities, Susan Beekmann, R.N., M.P.H., reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This “extraordinarily high” rate was higher than the documented MRSA rates from surveys of acute care hospitals nationwide, noted Ms. Beekmann and her colleagues at the University of Iowa, Iowa City.

The multicenter, longitudinal surveillance study included 1,060 S. aureus and 1,979 Enterococcus isolates collected from long-term care facilities across the United States during three 1-year periods from 1999 to 2004, Dr. Beekmann reported. The S. aureus isolates included 325 skin or soft tissue specimens, 489 urine specimens, and 246 other specimens. The Enterococcus isolates included 81 skin or soft tissue specimens, 1,835 urine specimens, and 63 other specimens.

The MRSA rate remained fairly stable (66%–71%) throughout the study period. By contrast, the overall infection rate of vancomycin-resistant enterococcus was relatively low (5%), and ranged from 4% in 1999 to 7% in 2003. No evidence of VRE was found in any of the skin or soft tissue isolates, the investigators noted.

Only five MRSA isolates showed no coresistances to other antibiotics. An additional 22 were resistant to ciprofloxacin only; these 22 were also susceptible to clindamycin. Only two of the Enterococcus isolates were linezolid resistant, and eight were intermediate resistant to linezolid, whereas none of the S. aureus isolates was resistant to linezolid.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — The percentage of Staphylococcus aureus isolates resistant to methicillin was about 68% in a survey of more than 100 long-term care facilities, Susan Beekmann, R.N., M.P.H., reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This “extraordinarily high” rate was higher than the documented MRSA rates from surveys of acute care hospitals nationwide, noted Ms. Beekmann and her colleagues at the University of Iowa, Iowa City.

The multicenter, longitudinal surveillance study included 1,060 S. aureus and 1,979 Enterococcus isolates collected from long-term care facilities across the United States during three 1-year periods from 1999 to 2004, Dr. Beekmann reported. The S. aureus isolates included 325 skin or soft tissue specimens, 489 urine specimens, and 246 other specimens. The Enterococcus isolates included 81 skin or soft tissue specimens, 1,835 urine specimens, and 63 other specimens.

The MRSA rate remained fairly stable (66%–71%) throughout the study period. By contrast, the overall infection rate of vancomycin-resistant enterococcus was relatively low (5%), and ranged from 4% in 1999 to 7% in 2003. No evidence of VRE was found in any of the skin or soft tissue isolates, the investigators noted.

Only five MRSA isolates showed no coresistances to other antibiotics. An additional 22 were resistant to ciprofloxacin only; these 22 were also susceptible to clindamycin. Only two of the Enterococcus isolates were linezolid resistant, and eight were intermediate resistant to linezolid, whereas none of the S. aureus isolates was resistant to linezolid.

The meeting was sponsored by the American Society for Microbiology.

Vaccine Effective Against hMPV

Lower respiratory tract infections associated with human metapneumovirus were reduced by 45%, and clinical pneumonia was reduced by 55% among non-HIV-infected children who had received at least three doses of 9-valent conjugate pneumococcal vaccine, Dr. Shabir A. Madhi reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The randomized, placebo-controlled study enrolled nearly 40,000 children in South Africa between March 1998 and October 2000. The children received the first dose of vaccine at approximately 6 weeks of age and two additional doses at approximately 11 and 16 weeks of age.

In addition, lower respiratory tract infections due to hMPV and clinical pneumonia were reduced by 53% and 65%, respectively, among HIV-infected children who had been fully vaccinated, wrote Dr. Madhi of the University of the Witwatersrand, Soweto, South Africa, and associates.

Overall, 1,533 vaccinated children were hospitalized with a lower respiratory tract infection, compared with 1,643 placebo patients between January 1, 2000 and December 31, 2002. Of these, 1,306 vaccinated patients and 1,409 placebo patients were successfully tested for hMPV, which was identified in 76 (5.8%) and 126 (8.9%) cases, respectively.

Of the 189 hMPV-associated lower respiratory tract infections in which blood was cultured, only four HIV-infected children experienced episodes of Staphylococcus aureus bacteremia. One of the children had been vaccinated, and the other three were in the placebo group. The results suggest that bacterial coinfection with pneumococcus plays a role in hMPV-associated lower respiratory tract infections, and that use of the pneumococcal conjugate vaccine may prevent a significant number of these infections, the investigators said at the meeting, also sponsored by the American Society for Microbiology.

hMPV Contributes to URIs

Human metapneumovirus appeared in 5% of 2,384 nasal wash specimens from infants and children with upper respiratory tract infections, reported Dr. John V. Williams of Vanderbilt University, Nashville, Tenn., and his colleagues.

The Vanderbilt Vaccine Clinic conducted the study to evaluate the clinical characteristics of human metapneumovirus (hMPV) in otherwise healthy children over a period of 20 years (J. Infect. Dis. 2006;193:387–95). Most of the illnesses (78%) occurred between December and May of each year from January 1982 through December 2001, with 38% occurring in March and April. During the study period, 1,532 children, mean age 20 months, were followed for an average of 2.4 years.

Fifty percent of the children with upper respiratory infections (URIs) were prescribed antibiotics for acute otitis media.

Children who presented with URIs caused by hMPV were significantly less likely to be febrile, compared with children with influenza (54% vs. 85%). The mean duration of symptoms in the sick children prior to medical attention was 2.7 days for hMPV infection, compared with 3.2 days for influenza, 4.3 days for respiratory syncytial virus, and 3.8 days for parainfluenza virus. Children with URIs caused by hMPV also presented with standard symptoms including cough and rhinorrhea. However, these symptoms were not useful in diagnosis because of the overlap among the pathogens, and rapid tests are needed to distinguish hMPV from the influenza virus, respiratory syncytial virus, and parainfluenza virus.

Predictive Model of Lyme Meningitis

Three conditions—the presence of cranial neuritis, a long-lasting headache, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients.

Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% in LM patients vs. 58% in AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

Vaccine Effective Against hMPV

Lower respiratory tract infections associated with human metapneumovirus were reduced by 45%, and clinical pneumonia was reduced by 55% among non-HIV-infected children who had received at least three doses of 9-valent conjugate pneumococcal vaccine, Dr. Shabir A. Madhi reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The randomized, placebo-controlled study enrolled nearly 40,000 children in South Africa between March 1998 and October 2000. The children received the first dose of vaccine at approximately 6 weeks of age and two additional doses at approximately 11 and 16 weeks of age.

In addition, lower respiratory tract infections due to hMPV and clinical pneumonia were reduced by 53% and 65%, respectively, among HIV-infected children who had been fully vaccinated, wrote Dr. Madhi of the University of the Witwatersrand, Soweto, South Africa, and associates.

Overall, 1,533 vaccinated children were hospitalized with a lower respiratory tract infection, compared with 1,643 placebo patients between January 1, 2000 and December 31, 2002. Of these, 1,306 vaccinated patients and 1,409 placebo patients were successfully tested for hMPV, which was identified in 76 (5.8%) and 126 (8.9%) cases, respectively.

Of the 189 hMPV-associated lower respiratory tract infections in which blood was cultured, only four HIV-infected children experienced episodes of Staphylococcus aureus bacteremia. One of the children had been vaccinated, and the other three were in the placebo group. The results suggest that bacterial coinfection with pneumococcus plays a role in hMPV-associated lower respiratory tract infections, and that use of the pneumococcal conjugate vaccine may prevent a significant number of these infections, the investigators said at the meeting, also sponsored by the American Society for Microbiology.

hMPV Contributes to URIs

Human metapneumovirus appeared in 5% of 2,384 nasal wash specimens from infants and children with upper respiratory tract infections, reported Dr. John V. Williams of Vanderbilt University, Nashville, Tenn., and his colleagues.

The Vanderbilt Vaccine Clinic conducted the study to evaluate the clinical characteristics of human metapneumovirus (hMPV) in otherwise healthy children over a period of 20 years (J. Infect. Dis. 2006;193:387–95). Most of the illnesses (78%) occurred between December and May of each year from January 1982 through December 2001, with 38% occurring in March and April. During the study period, 1,532 children, mean age 20 months, were followed for an average of 2.4 years.

Fifty percent of the children with upper respiratory infections (URIs) were prescribed antibiotics for acute otitis media.

Children who presented with URIs caused by hMPV were significantly less likely to be febrile, compared with children with influenza (54% vs. 85%). The mean duration of symptoms in the sick children prior to medical attention was 2.7 days for hMPV infection, compared with 3.2 days for influenza, 4.3 days for respiratory syncytial virus, and 3.8 days for parainfluenza virus. Children with URIs caused by hMPV also presented with standard symptoms including cough and rhinorrhea. However, these symptoms were not useful in diagnosis because of the overlap among the pathogens, and rapid tests are needed to distinguish hMPV from the influenza virus, respiratory syncytial virus, and parainfluenza virus.

Predictive Model of Lyme Meningitis

Three conditions—the presence of cranial neuritis, a long-lasting headache, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients.

Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% in LM patients vs. 58% in AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

Vaccine Effective Against hMPV

Lower respiratory tract infections associated with human metapneumovirus were reduced by 45%, and clinical pneumonia was reduced by 55% among non-HIV-infected children who had received at least three doses of 9-valent conjugate pneumococcal vaccine, Dr. Shabir A. Madhi reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The randomized, placebo-controlled study enrolled nearly 40,000 children in South Africa between March 1998 and October 2000. The children received the first dose of vaccine at approximately 6 weeks of age and two additional doses at approximately 11 and 16 weeks of age.

In addition, lower respiratory tract infections due to hMPV and clinical pneumonia were reduced by 53% and 65%, respectively, among HIV-infected children who had been fully vaccinated, wrote Dr. Madhi of the University of the Witwatersrand, Soweto, South Africa, and associates.

Overall, 1,533 vaccinated children were hospitalized with a lower respiratory tract infection, compared with 1,643 placebo patients between January 1, 2000 and December 31, 2002. Of these, 1,306 vaccinated patients and 1,409 placebo patients were successfully tested for hMPV, which was identified in 76 (5.8%) and 126 (8.9%) cases, respectively.

Of the 189 hMPV-associated lower respiratory tract infections in which blood was cultured, only four HIV-infected children experienced episodes of Staphylococcus aureus bacteremia. One of the children had been vaccinated, and the other three were in the placebo group. The results suggest that bacterial coinfection with pneumococcus plays a role in hMPV-associated lower respiratory tract infections, and that use of the pneumococcal conjugate vaccine may prevent a significant number of these infections, the investigators said at the meeting, also sponsored by the American Society for Microbiology.

hMPV Contributes to URIs

Human metapneumovirus appeared in 5% of 2,384 nasal wash specimens from infants and children with upper respiratory tract infections, reported Dr. John V. Williams of Vanderbilt University, Nashville, Tenn., and his colleagues.

The Vanderbilt Vaccine Clinic conducted the study to evaluate the clinical characteristics of human metapneumovirus (hMPV) in otherwise healthy children over a period of 20 years (J. Infect. Dis. 2006;193:387–95). Most of the illnesses (78%) occurred between December and May of each year from January 1982 through December 2001, with 38% occurring in March and April. During the study period, 1,532 children, mean age 20 months, were followed for an average of 2.4 years.

Fifty percent of the children with upper respiratory infections (URIs) were prescribed antibiotics for acute otitis media.

Children who presented with URIs caused by hMPV were significantly less likely to be febrile, compared with children with influenza (54% vs. 85%). The mean duration of symptoms in the sick children prior to medical attention was 2.7 days for hMPV infection, compared with 3.2 days for influenza, 4.3 days for respiratory syncytial virus, and 3.8 days for parainfluenza virus. Children with URIs caused by hMPV also presented with standard symptoms including cough and rhinorrhea. However, these symptoms were not useful in diagnosis because of the overlap among the pathogens, and rapid tests are needed to distinguish hMPV from the influenza virus, respiratory syncytial virus, and parainfluenza virus.

Predictive Model of Lyme Meningitis

Three conditions—the presence of cranial neuritis, a long-lasting headache, and a predominance of cerebral spinal fluid mononuclear cells—can predict Lyme meningitis in children aged 2–13 years, said Dr. Robert A. Avery of the Alfred I. duPont Hospital for Children in Wilmington, Del., and his colleagues.

Data from a study of 27 children with Lyme meningitis (LM) and 148 children with aseptic meningitis (AM) provide the first model to distinguish between the two conditions in areas where Lyme disease is endemic (Pediatrics 2006;117:1–7).

Overall, 16 of the 27 (59%) patients with LM experienced headaches longer than 3 days' duration, compared with 37 of 148 (25%) patients with AM. The average duration of headache was 7.5 days among LM patients vs. 2.8 days among AM patients.

In addition, 15 (56%) of the LM patients had cranial neuritis, compared with 5 (3%) of the AM patients.

Finally, the average percentage of mononuclear cells in samples of cerebrospinal fluid was 87% in LM patients vs. 58% in AM patients, and 19 (70%) of the LM patients had CSF mononuclear cell levels greater than 86% compared with 42 (28%) of the AM patients.

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

PTSD and Asthma

Adolescents with asthma who have experienced a life-threatening event–as well as their parents–are significantly more likely to experience posttraumatic stress symptoms than are adolescents with less severe asthma or healthy controls, reported Emily Millikan Kean, Ph.D., of the Children's Hospital, Denver, and her associates.

Events related to severe asthma attacks–such as ambulance rides and invasive procedures, as well as lingering feelings about the possibility of death even after the events resolve–may make children and adolescents with asthma, and their parents, vulnerable to posttraumatic stress disorder (PTSD), the researchers noted.

Their study of three groups of adolescents aged 12–18 years included 49 adolescents who had experienced a life-threatening episode, 71 who had asthma but had not experienced a severe episode, and 80 healthy controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:78–86).

Overall, 20% of the adolescents with life-threatening events met the criteria for PTSD, compared with 11% of those with mild asthma and 8% of controls.

The adolescents completed three measures: the UCLA PTSD Reaction Index for DSM-IV, the Multidimensional Anxiety Scale for Children, and the Reynolds Depression Inventory-2. Parents also completed several measures, including the Brief Symptom Inventory.

Predictably, the parents of children who had experienced life-threatening events were significantly more likely to meet criteria for PTSD (29%), compared with the parents of adolescents with nonsevere asthma (14%) and the parents of controls (2%).

Substance Abuse and Suicide

Substance abuse within 48 hours of suicide was far more common among white adolescents than African American adolescents in an investigation of 75 cases, wrote Dr. Steven J. Garlow of Emory University, Atlanta, and his colleagues.

The researchers reviewed the medical examiner's records for 49 African American and 26 white adolescents aged 19 years and younger in Fulton County, Ga., from January 1989 to December 2003 (J. Psychiatr. Res. 2005[Epub doi:10.1016/j.jpsychires.08.008]).

About 82% of the African American teens tested negative for cocaine and alcohol, compared with 58% of the white teens. Only 9% of African American teens had used cocaine prior to death, compared with 28% of the white teens, and 9% of African American teens had used alcohol prior to death, compared with 21% of white teens.

When the data were analyzed along gender lines, white males had the highest detectable levels of alcohol use (22%), which was more than double the incidence among African American males (10%). Only one of the white females and none of the African American females showed signs of alcohol use prior to death.

Whites had higher rates of alcohol and cocaine use, but African American adolescents had slightly higher rates of completed suicides than did white adolescents (5.5 vs. 4.2 per 100,000 teens per year). In addition, African American teens had a significantly higher rate of firearm use in suicides, compared with white teens.

OCD Often Cormorbid With ADHD

More than 25% of children and adolescents with obsessive-compulsive disorder had comorbid attention-deficit hyperactivity disorder in a consecutive study of 94 patients, reported Dr. Gabriele Masi and her associates at the Scientific Institute of Child Neurology and Psychiatry in Calambrone, Pisa (Italy).

Overall, 88% of the 24 comorbid patients were male, and the average age of onset of obsessive-compulsive disorder (OCD) was slightly higher among patients with comorbid attention-deficit hyperactivity disorder (ADHD). Several disruptive behavior disorders–oppositional defiant disorder, bipolar disorder, and tic disorder–were significantly more common among comorbid patients.

The 3-year study included 65 males and 29 females aged 8–18 years. All of the patients were undergoing treatment for OCD with serotonin reuptake inhibitors, such as fluoxetine and sertraline (Zoloft), but none was being treated for ADHD with psychostimulants (Compr. Psychiatry 2006;47:42–7). In patients with comorbid ADHD, functional baseline impairment was higher, and improvement in symptoms after 6 months of follow-up was lower. Patients with co-occurring OCD-ADHD were more frequently male (88% vs. 62%). No significant differences were seen between patients with and without comorbid ADHD with regard to OCD behaviors involving ordering, aggression, contamination, and hoarding. The study results suggest a need for ADHD screening in all children and adolescents with OCD, the investigators wrote.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

WASHINGTON – Pubertal changes were more likely to trigger body dissatisfaction in white girls than in African American girls in a study of 331 girls, reported Tiffany Floyd, Ph.D., in a poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Previous studies have shown that body dissatisfaction during puberty is more common among girls than among boys–because pubertal changes conflict with the idealized image of the thin female–and that this increase in body dissatisfaction may promote depression. However, additional research has shown that larger female body types are more desirable and acceptable among African Americans than they are among whites, wrote Dr. Floyd, of City College, New York, and her colleagues.

The study included girls in grades 4 through 9, with an average age of 12 years. Approximately 50% of the girls were African American.

Overall, white girls reported significantly more body dissatisfaction than did African American girls. Although pubertal status did not directly predict depression in either group, pubertal status significantly predicted body dissatisfaction among white girls in a linear regression analysis, which in turn predicted depressive symptoms.

Pubertal status failed to predict body dissatisfaction among African American girls, but body dissatisfaction significantly predicted depressive symptoms independently of pubertal status.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI