Damian McNamara

ORLANDO — The clinical benefits of gastric bypass surgery go beyond weight loss and include lowering the risk of coronary artery disease, according to the results of a study presented by D. Brandon Williams, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is among the major risk factors for coronary heart disease and stroke, and that risk may be particularly high among the morbidly obese, Dr. Williams said.

In a prospective study, Dr. Williams and coinvestigators monitored eight markers of cardiovascular risk in 222 morbidly obese patients before and after gastric bypass surgery.

The markers—which included both traditional and emerging biochemical measurements—improved up to 1 year after surgery compared with preoperative values, said Dr. Williams, a surgery resident at Stanford University Medical Center in Palo Alto, Calif.

Gastric bypass is the most common form of weight loss surgery that is performed at Stanford.

All participants had Roux-en-Y gastric bypass surgery; 99% of the procedures were laparoscopic. The mean age of the patients was 43 years, and 84% were female. At baseline, 31% of the subjects were diabetic, 50% were hypertensive, and 18% were taking lipid-lowering medication. “Patients had a high percentage of elevated risk factors,” Dr. Williams said. Only 1% had known coronary artery disease at enrollment.

Researchers measured traditional laboratory values, including total cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol, at 3 months and 6 months after surgery. But “our markers are not perfect,” Dr. Williams said. Therefore, they also assessed three emerging markers: lipoprotein (a), homocysteine, and C-reactive protein.

Total cholesterol lipids initially decreased from a mean 201 mg/dL preoperatively to 168 at 3 months and then slightly increased to 169 at 6 months after surgery. Triglycerides decreased from a mean 188 mg/dL to 129 at 3 months and 119 at 6 months. LDL cholesterol was a mean 181 mg/dL preoperatively and decreased to 112 at 3 months and 102 at 6 months.

HDL cholesterol initially dropped after surgery but then improved, Dr. Williams reported. From a baseline mean of 47 mg/dL, HDL decreased to 42 at 3 months but increased to 49 at 6 months.

Researchers observed similar improvements in the other risk factors. For example, from a preoperative value of 36 mg/L, lipoprotein (a) changed to 25 at 3 months and 30 at 6 months.

From a baseline mean of 10.8 mmol/L, homocysteine decreased to 9.9 at 3 months and 9.5 at 6 months.

The eighth indicator of risk was body mass index. The mean body mass index was 47 kg/m

Although all the markers improved postoperatively, there was “a dramatic improvement” in C-reactive protein (CRP) over time, Dr. Williams said. From a preoperative mean value of 10.7 mg/L, CRP decreased to 8.1 at 3 months and 4.2 at 6 months. A growing number of studies indicate that abnormally high levels of CRP and some other blood proteins indicate elevated cardiovascular disease risk.

“Even with low total cholesterol, CRP remains a strong cardiovascular risk factor,” Dr. Williams said.

CRP is the strongest of the biochemical risk factors followed by the total cholesterol/HDL ratio. “Combined, these two are even stronger,” he added.

A total of 80% of participants had abnormal CRP values preoperatively, indicating that the morbidly obese are extremely vulnerable to cardiac disease, according to John Morton, M.D., senior author of the study and director of bariatric surgery at Stanford.

“The new risk factors, in particular C-reactive protein, have been shown to add substantially to risk assessment,” Dr. Williams added. “About half of strokes and myocardial infarctions occur in people with normal LDL, so C-reactive protein adds to the risk assessment.”

Lipoprotein (a) is helpful because it does not simply mirror the lipid profile, he explained. Similar in structure to LDL cholesterol, lipoprotein (a) is involved in atherothrombosis, a risk factor for premature coronary artery disease.

Homocysteine measurements are useful because homocysteine is prothrombotic and an independent predictor of coronary artery disease.

A meeting attendee asked Dr. Williams if he found a correlation between the magnitude of individual weight loss and improvement in risk factors. “There was a correlation, but it was somewhat low, implying there are other factors involved,” he replied. “For example, diet and exercise can improve C-reactive protein.”

Although other weight loss strategies could lower cardiovascular risk, “the only effective and enduring long-term therapy for obesity is bariatric surgery,” Dr. Williams said.

Obesity and smoking are the primary modifiable coronary artery disease risk factors, he added. “Smoking has decreased, but obesity is on the rise.”

The study was completed in March 2005 to include a total of 371 participants and up to 12 months of follow-up data.

Updated findings still showed improvements in all eight risk factors after gastric bypass surgery, Dr. Williams said.

ORLANDO — The clinical benefits of gastric bypass surgery go beyond weight loss and include lowering the risk of coronary artery disease, according to the results of a study presented by D. Brandon Williams, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is among the major risk factors for coronary heart disease and stroke, and that risk may be particularly high among the morbidly obese, Dr. Williams said.

In a prospective study, Dr. Williams and coinvestigators monitored eight markers of cardiovascular risk in 222 morbidly obese patients before and after gastric bypass surgery.

The markers—which included both traditional and emerging biochemical measurements—improved up to 1 year after surgery compared with preoperative values, said Dr. Williams, a surgery resident at Stanford University Medical Center in Palo Alto, Calif.

Gastric bypass is the most common form of weight loss surgery that is performed at Stanford.

All participants had Roux-en-Y gastric bypass surgery; 99% of the procedures were laparoscopic. The mean age of the patients was 43 years, and 84% were female. At baseline, 31% of the subjects were diabetic, 50% were hypertensive, and 18% were taking lipid-lowering medication. “Patients had a high percentage of elevated risk factors,” Dr. Williams said. Only 1% had known coronary artery disease at enrollment.

Researchers measured traditional laboratory values, including total cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol, at 3 months and 6 months after surgery. But “our markers are not perfect,” Dr. Williams said. Therefore, they also assessed three emerging markers: lipoprotein (a), homocysteine, and C-reactive protein.

Total cholesterol lipids initially decreased from a mean 201 mg/dL preoperatively to 168 at 3 months and then slightly increased to 169 at 6 months after surgery. Triglycerides decreased from a mean 188 mg/dL to 129 at 3 months and 119 at 6 months. LDL cholesterol was a mean 181 mg/dL preoperatively and decreased to 112 at 3 months and 102 at 6 months.

HDL cholesterol initially dropped after surgery but then improved, Dr. Williams reported. From a baseline mean of 47 mg/dL, HDL decreased to 42 at 3 months but increased to 49 at 6 months.

Researchers observed similar improvements in the other risk factors. For example, from a preoperative value of 36 mg/L, lipoprotein (a) changed to 25 at 3 months and 30 at 6 months.

From a baseline mean of 10.8 mmol/L, homocysteine decreased to 9.9 at 3 months and 9.5 at 6 months.

The eighth indicator of risk was body mass index. The mean body mass index was 47 kg/m

Although all the markers improved postoperatively, there was “a dramatic improvement” in C-reactive protein (CRP) over time, Dr. Williams said. From a preoperative mean value of 10.7 mg/L, CRP decreased to 8.1 at 3 months and 4.2 at 6 months. A growing number of studies indicate that abnormally high levels of CRP and some other blood proteins indicate elevated cardiovascular disease risk.

“Even with low total cholesterol, CRP remains a strong cardiovascular risk factor,” Dr. Williams said.

CRP is the strongest of the biochemical risk factors followed by the total cholesterol/HDL ratio. “Combined, these two are even stronger,” he added.

A total of 80% of participants had abnormal CRP values preoperatively, indicating that the morbidly obese are extremely vulnerable to cardiac disease, according to John Morton, M.D., senior author of the study and director of bariatric surgery at Stanford.

“The new risk factors, in particular C-reactive protein, have been shown to add substantially to risk assessment,” Dr. Williams added. “About half of strokes and myocardial infarctions occur in people with normal LDL, so C-reactive protein adds to the risk assessment.”

Lipoprotein (a) is helpful because it does not simply mirror the lipid profile, he explained. Similar in structure to LDL cholesterol, lipoprotein (a) is involved in atherothrombosis, a risk factor for premature coronary artery disease.

Homocysteine measurements are useful because homocysteine is prothrombotic and an independent predictor of coronary artery disease.

A meeting attendee asked Dr. Williams if he found a correlation between the magnitude of individual weight loss and improvement in risk factors. “There was a correlation, but it was somewhat low, implying there are other factors involved,” he replied. “For example, diet and exercise can improve C-reactive protein.”

Although other weight loss strategies could lower cardiovascular risk, “the only effective and enduring long-term therapy for obesity is bariatric surgery,” Dr. Williams said.

Obesity and smoking are the primary modifiable coronary artery disease risk factors, he added. “Smoking has decreased, but obesity is on the rise.”

The study was completed in March 2005 to include a total of 371 participants and up to 12 months of follow-up data.

Updated findings still showed improvements in all eight risk factors after gastric bypass surgery, Dr. Williams said.

ORLANDO — The clinical benefits of gastric bypass surgery go beyond weight loss and include lowering the risk of coronary artery disease, according to the results of a study presented by D. Brandon Williams, M.D., at the annual meeting of the American Society for Bariatric Surgery.

Obesity is among the major risk factors for coronary heart disease and stroke, and that risk may be particularly high among the morbidly obese, Dr. Williams said.

In a prospective study, Dr. Williams and coinvestigators monitored eight markers of cardiovascular risk in 222 morbidly obese patients before and after gastric bypass surgery.

The markers—which included both traditional and emerging biochemical measurements—improved up to 1 year after surgery compared with preoperative values, said Dr. Williams, a surgery resident at Stanford University Medical Center in Palo Alto, Calif.

Gastric bypass is the most common form of weight loss surgery that is performed at Stanford.

All participants had Roux-en-Y gastric bypass surgery; 99% of the procedures were laparoscopic. The mean age of the patients was 43 years, and 84% were female. At baseline, 31% of the subjects were diabetic, 50% were hypertensive, and 18% were taking lipid-lowering medication. “Patients had a high percentage of elevated risk factors,” Dr. Williams said. Only 1% had known coronary artery disease at enrollment.

Researchers measured traditional laboratory values, including total cholesterol, triglycerides, LDL cholesterol, and HDL cholesterol, at 3 months and 6 months after surgery. But “our markers are not perfect,” Dr. Williams said. Therefore, they also assessed three emerging markers: lipoprotein (a), homocysteine, and C-reactive protein.

Total cholesterol lipids initially decreased from a mean 201 mg/dL preoperatively to 168 at 3 months and then slightly increased to 169 at 6 months after surgery. Triglycerides decreased from a mean 188 mg/dL to 129 at 3 months and 119 at 6 months. LDL cholesterol was a mean 181 mg/dL preoperatively and decreased to 112 at 3 months and 102 at 6 months.

HDL cholesterol initially dropped after surgery but then improved, Dr. Williams reported. From a baseline mean of 47 mg/dL, HDL decreased to 42 at 3 months but increased to 49 at 6 months.

Researchers observed similar improvements in the other risk factors. For example, from a preoperative value of 36 mg/L, lipoprotein (a) changed to 25 at 3 months and 30 at 6 months.

From a baseline mean of 10.8 mmol/L, homocysteine decreased to 9.9 at 3 months and 9.5 at 6 months.

The eighth indicator of risk was body mass index. The mean body mass index was 47 kg/m

Although all the markers improved postoperatively, there was “a dramatic improvement” in C-reactive protein (CRP) over time, Dr. Williams said. From a preoperative mean value of 10.7 mg/L, CRP decreased to 8.1 at 3 months and 4.2 at 6 months. A growing number of studies indicate that abnormally high levels of CRP and some other blood proteins indicate elevated cardiovascular disease risk.

“Even with low total cholesterol, CRP remains a strong cardiovascular risk factor,” Dr. Williams said.

CRP is the strongest of the biochemical risk factors followed by the total cholesterol/HDL ratio. “Combined, these two are even stronger,” he added.

A total of 80% of participants had abnormal CRP values preoperatively, indicating that the morbidly obese are extremely vulnerable to cardiac disease, according to John Morton, M.D., senior author of the study and director of bariatric surgery at Stanford.

“The new risk factors, in particular C-reactive protein, have been shown to add substantially to risk assessment,” Dr. Williams added. “About half of strokes and myocardial infarctions occur in people with normal LDL, so C-reactive protein adds to the risk assessment.”

Lipoprotein (a) is helpful because it does not simply mirror the lipid profile, he explained. Similar in structure to LDL cholesterol, lipoprotein (a) is involved in atherothrombosis, a risk factor for premature coronary artery disease.

Homocysteine measurements are useful because homocysteine is prothrombotic and an independent predictor of coronary artery disease.

A meeting attendee asked Dr. Williams if he found a correlation between the magnitude of individual weight loss and improvement in risk factors. “There was a correlation, but it was somewhat low, implying there are other factors involved,” he replied. “For example, diet and exercise can improve C-reactive protein.”

Although other weight loss strategies could lower cardiovascular risk, “the only effective and enduring long-term therapy for obesity is bariatric surgery,” Dr. Williams said.

Obesity and smoking are the primary modifiable coronary artery disease risk factors, he added. “Smoking has decreased, but obesity is on the rise.”

The study was completed in March 2005 to include a total of 371 participants and up to 12 months of follow-up data.

Updated findings still showed improvements in all eight risk factors after gastric bypass surgery, Dr. Williams said.

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders–18 million–and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents. “The average age when a young person first tries alcohol is 11–13 years. The likelihood of alcohol use and dependence can be reduced by 5% for each year onset of alcohol use is delayed,” Dr. Kessler said.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science in Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast–in the first 24–48 hours–and the “effect is rather startling,” he added.

Naltrexone blocks the euphoria experienced by alcoholics. It works best in a subpopulation of patients, and the challenge is identifying patients who will respond, Dr. Pinsky said.

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery from alcohol addiction. The surveys were supported by a grant from Forest Laboratories.

The survey found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment advisor, for example.

Although most people have heard the phrase “alcoholism is a disease,” not everyone believes it, Mr. Rivlin said. When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

Alcoholism is not the primary health concern among physicians or the general public, according to the survey. Respondents were more concerned with obesity, cancer, and heart disease, with depression, AIDS, and drug addiction also outranking alcoholism as top health priorities.

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders–18 million–and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents. “The average age when a young person first tries alcohol is 11–13 years. The likelihood of alcohol use and dependence can be reduced by 5% for each year onset of alcohol use is delayed,” Dr. Kessler said.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science in Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast–in the first 24–48 hours–and the “effect is rather startling,” he added.

Naltrexone blocks the euphoria experienced by alcoholics. It works best in a subpopulation of patients, and the challenge is identifying patients who will respond, Dr. Pinsky said.

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery from alcohol addiction. The surveys were supported by a grant from Forest Laboratories.

The survey found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment advisor, for example.

Although most people have heard the phrase “alcoholism is a disease,” not everyone believes it, Mr. Rivlin said. When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

Alcoholism is not the primary health concern among physicians or the general public, according to the survey. Respondents were more concerned with obesity, cancer, and heart disease, with depression, AIDS, and drug addiction also outranking alcoholism as top health priorities.

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders–18 million–and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents. “The average age when a young person first tries alcohol is 11–13 years. The likelihood of alcohol use and dependence can be reduced by 5% for each year onset of alcohol use is delayed,” Dr. Kessler said.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science in Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast–in the first 24–48 hours–and the “effect is rather startling,” he added.

Naltrexone blocks the euphoria experienced by alcoholics. It works best in a subpopulation of patients, and the challenge is identifying patients who will respond, Dr. Pinsky said.

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery from alcohol addiction. The surveys were supported by a grant from Forest Laboratories.

The survey found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment advisor, for example.

Although most people have heard the phrase “alcoholism is a disease,” not everyone believes it, Mr. Rivlin said. When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

Alcoholism is not the primary health concern among physicians or the general public, according to the survey. Respondents were more concerned with obesity, cancer, and heart disease, with depression, AIDS, and drug addiction also outranking alcoholism as top health priorities.

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — A strong edematous response immediately after laser hair removal is not necessary to achieve treatment efficacy, according to a prospective study.

"There is zero need to drive patients into an intense edematous response," Albert J. Nemeth, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Nemeth conducted a study to correlate immediate postlaser response with efficacy of permanent hair removal, which he said is an area with insufficient research.

He also proposed that a less visible immediate reaction might be better for patients. "Selection of more aggressive fluences based on a perceived inadequate immediate response might cause more adverse sequelae," said Dr. Nemeth, who is in private practice in Clearwater, Fla.

Dr. Nemeth assessed 200 patients treated with the MeDioStar 810-nm power-pulsed diode laser (Asclepion Laser Technologies, Jena, Germany).

The average participant age was 36 years, 86% were female, and mean follow-up was 5 months. The majority of patients had Fitzpatrick skin types of I, II, and III.

Immediate perifollicular response and surrounding erythema were rated on a scale of 1 (very mild) to 5 (intense). Patients with a low score still had effective permanent hair reduction.

The laser features a 12-mm actively chilled handpiece with a sapphire spot. "The actively chilled handpiece is vital for epidermal protection," said Dr. Nemeth, also of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

Laser fluences were set between 10 J/cm

"I've never seen such efficacy with other lasers—I think the power pulse makes that much of a difference," he said. Dr. Nemeth disclosed no conflict of interest regarding the MeDioStar laser or its manufacturer.

Multiple treatment sessions were required. After the first treatment, there was a mean 26% reduction in hair. After the second treatment, there was a mean 47% reduction, and after a third session, 64%.

Adverse events were infrequent. These included occasional crusting, and "easily resolvable" postinflammatory hyperpigmentation in 5 out of a total of 978 treatment sessions.

"There is physician supervision without exception for every treatment session," Dr. Nemeth said. A highly trained nurse who also is a licensed electrologist performed all procedures in the study to minimize variations in treatment.

This patient is shown at baseline prior to treatment on his upper lip.

The patient is shown after receiving 810-nm MeDioStar laser hair removal. Photos courtesy Dr. Albert J. Nemeth

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Sometimes the simplest surgical strategy is the best choice for reconstruction of facial defects, according to a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

Closure of facial defects requires careful planning, which can be more challenging than the surgery for some reconstructions. "Always talk to patients about their expectations. You may have to do more complex procedures for patients with higher expectations," said Dean M. Toriumi, M.D., who is professor of facial plastic and reconstructive surgery in the department of otolaryngology-head and neck surgery, University of Illinois at Chicago.

Options from simplest to more complex include granulation as secondary intention closure, primary closure, skin grafts, and local flaps.

Secondary intention can provide a good outcome with small defects, Dr. Toriumi said. However, delayed healing, daily wound care, and visible scars are possible adverse outcomes. He recalled a middle-aged male patient with a non-hair-bearing scalp defect, who proved to be a good candidate for secondary intention, he said. "On outcome, it was really hard to detect where the lesion was located."

Primary closure is also a good choice to minimize distortion of structures adjacent to a defect, Dr. Toriumi said at the meeting.

Skin grafts are an option when there is lack of available local tissue. The technique can be simple if there is abundant donor tissue. Color mismatch, contracture, depression of the graft area, and ischemia are potential concerns, Dr. Toriumi said.

A patient was referred to Dr. Toriumi to correct a poor outcome after a nasal supratip skin graft. "It left a depression. We did a transposition flap to correct this," he explained. "She was a good candidate because it lifted her nasal tip—a benefit from this operation she did not expect.

When planning an excision, the ideal angle of a defect is about 30 degrees, because it yields less distortion than a wider cut, Dr. Toriumi said.

Some dermatologic surgeons use a fusiform incision, but removal of a "tremendous amount of normal tissue" can be problematic.

Instead, he suggested performing an M-plasty because it employs two 30-degree apices, instead of one, and shortens the overall incision. Once the M-shaped incision is made, advance the apex of the triangle (the center of the M) toward the center of the defect by 2–3 mm, Dr. Toriumi suggested.

A case where an M-plasty produced a good result was a patient with a hemangioma of the eyebrow. An M-plasty inferiorly and superiorly yielded a "reasonable reconstruction" after removal of the hemangioma. However, this technique removed the lateral brow, so hair micrografts were placed to replace the eyebrow hairs.

A more complex reconstruction might call for an advancement flap, rotation flap, or other local flap. An advancement flap is a linear configuration moved in a single direction to correct a defect. Consider wide field undermining to minimize tension on the closure, Dr. Toriumi explained.

If skin is tight, as it can be with a forehead defect, for example, consider an "H-shaped incision, to reduce pull in multiple directions," he added.

"A very important technical consideration is to preserve the blood supply to the flap," Dr. Toriumi said. "Limit the length of a flap so you don't have a problem with blood supply at the distal end."

A rotation flap may be in order for the upper or midcheek region and the scalp. "Most have some advance component—few are 100% rotation flaps," Dr. Toriumi said. A patient with recurrent squamous cell carcinoma of the upper lip fared well with a rotation flap to correct his defect.

M-plasty produced a good result after removal of a hemangioma.

Grafts were needed to replace the eyebrow hairs after the procedure. Photos courtesy Dr. Dean M. Toriumi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

ORLANDO — Maintain the "free borders" when closing a Mohs surgery defect on the face to sustain symmetry and avoid adverse outcomes, Ali Hendi, M.D., advised at the annual meeting of the Florida Society of Dermatologic Surgeons.

Free borders are mobile facial landmarks—the lips, eyebrows, eyelids, and nasal ala—that can be distorted during reconstructive surgery or by contraction of scars after Mohs surgery. Most free borders on the face are curved structures, adding to the correct closure challenge. If surgical closure causes tension or pulls on these focal points, the risk of facial asymmetry increases.

"If there is any deformity, that is what catches the eye," said Dr. Hendi, a dermatology surgeon at Mayo Clinic Jacksonville in Florida.

Eclabium of the lip, a permanently raised eyebrow, eyelid ectropion, corneal desiccation, and an asymmetric nasal alar flare are possible adverse outcomes.

▸ Lips. "Lips are the central point of facial anatomy. Any pull or asymmetry is very noticeable and not cosmetically acceptable," Dr. Hendi said.

Dogma among dermatologic surgeons is to not violate the vermillion border, but "that doesn't have to be the case," Dr. Hendi said. It is possible in some patients to make an incision across the vermillion and onto the mucosal lip with good outcomes.

As an example, Dr. Hendi described a patient with a Mohs defect on the chin who fared well after such an incision. "I intentionally involved the vermillion border even though I might have avoided it, because otherwise the vermillion border would be pushed up," Dr. Hendi said.

▸ Eyebrows. Dermatologic surgeons can also disobey another dogma in some cases and make an incision through the eyebrows, Dr. Hendi said. "It's better to have a shorter eyebrow than a deformed eyebrow."

Primary closure of an eyebrow defect is Dr. Hendi's first choice to avoid multiple scar lines. "It's easier on you in terms of time, and easier on patients in terms of fewer complications."

▸ Eyelids. Elderly patients can have lax eyelids and are at higher risk of ectropion after reconstruction of the upper cheek and/or lower eyelid, Dr. Hendi said. To avoid this droopy look, tension vectors of the surgical closure should be parallel to eyelid margins. A "snap back" test before surgery can help judge the laxity of the lower eyelid. "If it does not snap back, you are more likely to have ectropion."

▸ Nasal ala. Pull on the alar flare is very noticeable and should be avoided, Dr. Hendi said. A tension vector parallel to the nasal ala can be risky, he said. Perform an excision perpendicular to the alar rim because it does not pull up the nose, Dr. Hendi said.

The Mohs defect is visible after local anesthesia and before reconstruction.

The vermillion border is intentionally involved surgically to keep it from being "pushed up."

At 4 months post op, the cosmetic result shows no sign of pull or asymmetry. Photos courtesy Dr. Ali Hendi

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."

ORLANDO — Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

He suggested that dermatologic surgeons consider partial closure for:

▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."

▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."

▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.

▸ Surgical sites where complete closure might cause ischemia or necrosis.

"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.

"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.

In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.

"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.

"I let it granulate in. It was very functional, and the patient was very happy."

A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.

A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.

Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."

A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.

Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."

Low-dose fluticasone propionate significantly improved pulmonary function, controlled nocturnal symptoms, and reduced the need for supplemental albuterol, compared with montelukast in a study of children with persistent asthma.

Fluticasone was significantly more cost effective than was montelukast and earned higher satisfaction ratings among parents and physicians, reported Nancy K. Ostrom, M.D., of the Allergy and Asthma Medical Group and Research Center, San Diego, and her colleagues.

In clinical practice, either medication can be prescribed as initial controller therapy for patients, according to the investigators (J. Pediatr. 2005;147:213–20). Although adult asthma studies demonstrate safety and efficacy of each drug, comparative data in pediatric patients are limited.

The investigators randomized 172 children to 50 mcg fluticasone propionate administered via the Diskus multidose powder inhaler (GlaxoSmithKline) twice daily and 170 others to 5 mg montelukast (Singulair, Merck) once daily. Participants in the randomized, double-blind study were 6- to 12-year-old outpatients from 43 medical centers.

The study was supported by GlaxoSmithKline, a company from which Dr. Ostrom has received consultant, grant, and research support.

The mean percent increase in forced expiratory volume in one second (FEV₁) at 12 weeks in the fluticasone propionate group was 11% versus 5% in the montelukast group, a significant difference.

Also, mean total albuterol supplementation, nighttime albuterol use, and nighttime symptoms scores were significantly lower with fluticasone propionate than with montelukast.

“As a matter of company policy, Merck does not comment on competitor-initiated studies,” spokesperson Carmen L. de Gourville said when contacted for comment.

At 12 weeks, more parents were very satisfied with fluticasone propionate (58%), compared with montelukast (46%). Similarly, more physicians were very satisfied at 12 weeks with fluticasone propionate (48%), versus montelukast (29%).

Headache, upper respiratory tract infection, sore throat, fever, and cough were the most common adverse events. Incidence was similar between groups.

Low-dose fluticasone propionate significantly improved pulmonary function, controlled nocturnal symptoms, and reduced the need for supplemental albuterol, compared with montelukast in a study of children with persistent asthma.

Fluticasone was significantly more cost effective than was montelukast and earned higher satisfaction ratings among parents and physicians, reported Nancy K. Ostrom, M.D., of the Allergy and Asthma Medical Group and Research Center, San Diego, and her colleagues.

In clinical practice, either medication can be prescribed as initial controller therapy for patients, according to the investigators (J. Pediatr. 2005;147:213–20). Although adult asthma studies demonstrate safety and efficacy of each drug, comparative data in pediatric patients are limited.

The investigators randomized 172 children to 50 mcg fluticasone propionate administered via the Diskus multidose powder inhaler (GlaxoSmithKline) twice daily and 170 others to 5 mg montelukast (Singulair, Merck) once daily. Participants in the randomized, double-blind study were 6- to 12-year-old outpatients from 43 medical centers.

The study was supported by GlaxoSmithKline, a company from which Dr. Ostrom has received consultant, grant, and research support.

The mean percent increase in forced expiratory volume in one second (FEV₁) at 12 weeks in the fluticasone propionate group was 11% versus 5% in the montelukast group, a significant difference.

Also, mean total albuterol supplementation, nighttime albuterol use, and nighttime symptoms scores were significantly lower with fluticasone propionate than with montelukast.

“As a matter of company policy, Merck does not comment on competitor-initiated studies,” spokesperson Carmen L. de Gourville said when contacted for comment.

At 12 weeks, more parents were very satisfied with fluticasone propionate (58%), compared with montelukast (46%). Similarly, more physicians were very satisfied at 12 weeks with fluticasone propionate (48%), versus montelukast (29%).

Headache, upper respiratory tract infection, sore throat, fever, and cough were the most common adverse events. Incidence was similar between groups.

Low-dose fluticasone propionate significantly improved pulmonary function, controlled nocturnal symptoms, and reduced the need for supplemental albuterol, compared with montelukast in a study of children with persistent asthma.

Fluticasone was significantly more cost effective than was montelukast and earned higher satisfaction ratings among parents and physicians, reported Nancy K. Ostrom, M.D., of the Allergy and Asthma Medical Group and Research Center, San Diego, and her colleagues.

In clinical practice, either medication can be prescribed as initial controller therapy for patients, according to the investigators (J. Pediatr. 2005;147:213–20). Although adult asthma studies demonstrate safety and efficacy of each drug, comparative data in pediatric patients are limited.

The investigators randomized 172 children to 50 mcg fluticasone propionate administered via the Diskus multidose powder inhaler (GlaxoSmithKline) twice daily and 170 others to 5 mg montelukast (Singulair, Merck) once daily. Participants in the randomized, double-blind study were 6- to 12-year-old outpatients from 43 medical centers.

The study was supported by GlaxoSmithKline, a company from which Dr. Ostrom has received consultant, grant, and research support.

The mean percent increase in forced expiratory volume in one second (FEV₁) at 12 weeks in the fluticasone propionate group was 11% versus 5% in the montelukast group, a significant difference.

Also, mean total albuterol supplementation, nighttime albuterol use, and nighttime symptoms scores were significantly lower with fluticasone propionate than with montelukast.

“As a matter of company policy, Merck does not comment on competitor-initiated studies,” spokesperson Carmen L. de Gourville said when contacted for comment.

At 12 weeks, more parents were very satisfied with fluticasone propionate (58%), compared with montelukast (46%). Similarly, more physicians were very satisfied at 12 weeks with fluticasone propionate (48%), versus montelukast (29%).

Headache, upper respiratory tract infection, sore throat, fever, and cough were the most common adverse events. Incidence was similar between groups.

NEW ORLEANS — Specific sexually transmitted diseases are associated with prostate cancer, most significantly so, according to a metaanalysis.

Prostate cancer is the most common cancer in American men and is estimated to account for one-third of all new cases of cancer in men this year. It is the second leading cause of cancer-related death in this group and will be responsible for an estimated 30,000 deaths this year, according to the American Cancer Society.

Sexually transmitted diseases (STDs) cause inflammation of the prostate, which might increase the risk for malignancy, Marcia L. Taylor, M.D., said at the annual conference of the Society of Teachers of Family Medicine.

A previous metaanalysis of 17 case-control studies showed an association (odds ratio 1.44) between and increased risk of prostate cancer and history of any STD infection in men (Epidemiology 2002;13:72–9). “But there were study limitations,” said Dr. Taylor of the Medical University of South Carolina. The researchers, for example, did not include human papillomavirus (HPV) or a subgroup analysis of specific STDs.

To determine more specific associations, Dr. Taylor and her colleagues performed a Medline search of published reports from 1966 to August 2004. They found 29 case-control studies that demonstrated an association between prostate cancer and any STD or gonorrhea, syphilis, or HPV.

There was a statistically significant association between any STD and an increased risk of prostate cancer (OR 1.48) based on 6,022 cases in the 29 studies. Similarly, researchers found a statistically significant association between gonorrhea and prostate cancer (OR 1.39), based on 2,241 cases in 11 studies; and between HPV and prostate cancer (OR 1.52), based on 2,305 cases in 10 studies.

The association between syphilis and prostate cancer, based on 2,254 cases in seven case-control studies, did not reach statistical significance (OR 1.42).

Some studies included in the metaanalysis controlled for confounding variables, and some did not. Researchers, for example, did not account for exposure to multiple STDs or patients with asymptomatic infection.

Recall bias is another possible limitation. “Most used patient history for documentation of STDs, and not all patients may have been forthcoming,” Dr. Taylor reported.

NEW ORLEANS — Specific sexually transmitted diseases are associated with prostate cancer, most significantly so, according to a metaanalysis.

Prostate cancer is the most common cancer in American men and is estimated to account for one-third of all new cases of cancer in men this year. It is the second leading cause of cancer-related death in this group and will be responsible for an estimated 30,000 deaths this year, according to the American Cancer Society.

Sexually transmitted diseases (STDs) cause inflammation of the prostate, which might increase the risk for malignancy, Marcia L. Taylor, M.D., said at the annual conference of the Society of Teachers of Family Medicine.

A previous metaanalysis of 17 case-control studies showed an association (odds ratio 1.44) between and increased risk of prostate cancer and history of any STD infection in men (Epidemiology 2002;13:72–9). “But there were study limitations,” said Dr. Taylor of the Medical University of South Carolina. The researchers, for example, did not include human papillomavirus (HPV) or a subgroup analysis of specific STDs.

To determine more specific associations, Dr. Taylor and her colleagues performed a Medline search of published reports from 1966 to August 2004. They found 29 case-control studies that demonstrated an association between prostate cancer and any STD or gonorrhea, syphilis, or HPV.

There was a statistically significant association between any STD and an increased risk of prostate cancer (OR 1.48) based on 6,022 cases in the 29 studies. Similarly, researchers found a statistically significant association between gonorrhea and prostate cancer (OR 1.39), based on 2,241 cases in 11 studies; and between HPV and prostate cancer (OR 1.52), based on 2,305 cases in 10 studies.

The association between syphilis and prostate cancer, based on 2,254 cases in seven case-control studies, did not reach statistical significance (OR 1.42).

Some studies included in the metaanalysis controlled for confounding variables, and some did not. Researchers, for example, did not account for exposure to multiple STDs or patients with asymptomatic infection.

Recall bias is another possible limitation. “Most used patient history for documentation of STDs, and not all patients may have been forthcoming,” Dr. Taylor reported.

NEW ORLEANS — Specific sexually transmitted diseases are associated with prostate cancer, most significantly so, according to a metaanalysis.

Prostate cancer is the most common cancer in American men and is estimated to account for one-third of all new cases of cancer in men this year. It is the second leading cause of cancer-related death in this group and will be responsible for an estimated 30,000 deaths this year, according to the American Cancer Society.

Sexually transmitted diseases (STDs) cause inflammation of the prostate, which might increase the risk for malignancy, Marcia L. Taylor, M.D., said at the annual conference of the Society of Teachers of Family Medicine.

A previous metaanalysis of 17 case-control studies showed an association (odds ratio 1.44) between and increased risk of prostate cancer and history of any STD infection in men (Epidemiology 2002;13:72–9). “But there were study limitations,” said Dr. Taylor of the Medical University of South Carolina. The researchers, for example, did not include human papillomavirus (HPV) or a subgroup analysis of specific STDs.

To determine more specific associations, Dr. Taylor and her colleagues performed a Medline search of published reports from 1966 to August 2004. They found 29 case-control studies that demonstrated an association between prostate cancer and any STD or gonorrhea, syphilis, or HPV.

There was a statistically significant association between any STD and an increased risk of prostate cancer (OR 1.48) based on 6,022 cases in the 29 studies. Similarly, researchers found a statistically significant association between gonorrhea and prostate cancer (OR 1.39), based on 2,241 cases in 11 studies; and between HPV and prostate cancer (OR 1.52), based on 2,305 cases in 10 studies.

The association between syphilis and prostate cancer, based on 2,254 cases in seven case-control studies, did not reach statistical significance (OR 1.42).

Some studies included in the metaanalysis controlled for confounding variables, and some did not. Researchers, for example, did not account for exposure to multiple STDs or patients with asymptomatic infection.

Recall bias is another possible limitation. “Most used patient history for documentation of STDs, and not all patients may have been forthcoming,” Dr. Taylor reported.

For most pediatric patients with high blood sugar, the distinction between type 1 and type 2 diabetes is straightforward. However, there can be an overlap and patients who fit criteria for both conditions, making diagnosis and management more challenging.

Michelle Ditto is a California teenager and avid dancer diagnosed with type 2 diabetes 4 years ago, at age 11. “It was kind of scary,” she said. “Type 2 kinda runs in my family,” Michelle said in an interview. Her grandmother and an uncle not related by blood have type 2 diabetes, “so I knew what it was.”

About 1½ years ago, Michelle switched physicians and had some blood tests. Results showed she had two of the three antibodies indicative of type 1 diabetes. “It was a shock.”

Her dual diagnosis puts Michelle in a unique position to compare type 1 and type 2 diabetes.

“To me it just seems like there is more medication [with type 1], more insulin, more shots, so more inconvenience from my point of view as a kid,” she said. “I have to bring my kit and my insulin to school now. As a kid it's a big deal.”

“You can have a genetic predisposition to type 2 diabetes, be Hispanic and overweight, and yet develop type 1 autoimmune type. That is where diagnosis gets difficult,” Susan Clark, M.D., director of endocrinology at Children's Hospital of Orange County, Orange, Calif., told this newspaper. “That is probably 5% or less of all cases, but that overlap is there.”

“The overlap is certainly more common now than in the past because of the obesity epidemic,” Floyd L. Culler, M.D., professor of pediatrics at the University of California, Irvine, said in an interview.

The growing obesity epidemic in the United States is driving an increased incidence of type 2 diabetes among children and adolescents. That may be intuitive, but there is also a suggestion that the growing number of overweight pediatric patients contributes to increased incidence of type 1 incidence as well.

“There has been a 3%–4% increase per year in the last few years in incidence of type 1 diabetes. Some have hypothesized that it may also be related to obesity,” Francine R. Kaufman, M.D., head of the Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, California, said in an interview. “If you are overweight, it might accelerate destruction of the β-cells.”

She is author of a book titled, “Diabesity: The Obesity-Diabetes Epidemic That Threatens America—And What We Must Do to Stop It (Bantam, March 2005).

To further complicate diagnosis, there are some patients with diabetes who do not fit criteria for type 1 or type 2, Dr. Culler said. “The more you know the more you find patients who don't fit in a category.” Maturity-onset diabetes of the young (MODY), a subtype of non-insulin dependent diabetes mellitus, is an example.

Type 1 diabetes is an autoimmune disorder; the immune system attacks the pancreas and the cells that make insulin. With type 2 diabetes these cells become resistant to insulin, so insulin does not work well. “Early in the disease [type 2], they have high insulin levels, which leads to physical symptoms, such as a little fat around the middle and acanthosis nigricans,” Dr. Clark said.

Comorbidities are another distinction. For example, people with type 1 diabetes can have other autoimmune conditions such as autoimmune thyroid disease or celiac disease. “In type 2 diabetes, you see more diseases associated with insulin resistance, such as polycystic ovarian syndrome,” Dr. Kaufman said.

Children with type 1 diabetes generally experience a faster onset than do those with type 2 diabetes. In addition, pediatric patients with type 1 diabetes are generally younger than are those with type 2.

Other clues can aid diagnosis. “Ethnicity is a big difference. Type 1 diabetes is primarily a Caucasian disease, and type 2 diabetes pretty much affects everyone else,” Dr. Kaufman said. For example, type 2 is more common among American Indian, Hispanic, Asian, or Pacific Islander patients.

“My first recommendation to primary care physicians is to recognize abnormal weight gain early and aggressively intervene,” Dr. Clark said. “No. 2 is with a child of any age who is drinking and urinating a lot and gaining weight, to think diabetes.”

Her third recommendation is to address lifestyle issues with all children, whether an overweight patient has diabetes or not. “Every pediatrician can talk to patients and families about this, even during a short visit.”

“It's best to have a healthy lifestyle for either kind [of diabetes], and appropriate portions of the right foods. There are benefits to having an ideal body weight,” Dr. Kaufman said.

Monitoring the number of calories a child eats matters, Dr. Culler said. “Just to say you eat certain kinds of foods is not a solution to long-term weight loss.” He recommends a low-calorie, low-fat diet with enough fruits and vegetables to keep the child healthy.

To address excess weight and lower the risk for diabetes, exercise is also important. Maximum health effects are seen with a combination of diet and exercise. “The benefit of exercise is through metabolic effects on how you burn calories,” Dr. Culler said. “It's hard to exercise yourself thin. You can only burn a few hundred calories at a time, even in kids who are very active.”

Despite differences between type 1 and type 2 diabetes, all children with diabetes share some common issues. Challenges for children include medication compliance, glucose monitoring, and managing their condition when their routine changes. There is a loss of normalcy and children with diabetes can face discrimination at school, Dr. Kaufman said. “These are huge challenges.”

For most pediatric patients with high blood sugar, the distinction between type 1 and type 2 diabetes is straightforward. However, there can be an overlap and patients who fit criteria for both conditions, making diagnosis and management more challenging.

Michelle Ditto is a California teenager and avid dancer diagnosed with type 2 diabetes 4 years ago, at age 11. “It was kind of scary,” she said. “Type 2 kinda runs in my family,” Michelle said in an interview. Her grandmother and an uncle not related by blood have type 2 diabetes, “so I knew what it was.”

About 1½ years ago, Michelle switched physicians and had some blood tests. Results showed she had two of the three antibodies indicative of type 1 diabetes. “It was a shock.”

Her dual diagnosis puts Michelle in a unique position to compare type 1 and type 2 diabetes.

“To me it just seems like there is more medication [with type 1], more insulin, more shots, so more inconvenience from my point of view as a kid,” she said. “I have to bring my kit and my insulin to school now. As a kid it's a big deal.”

“You can have a genetic predisposition to type 2 diabetes, be Hispanic and overweight, and yet develop type 1 autoimmune type. That is where diagnosis gets difficult,” Susan Clark, M.D., director of endocrinology at Children's Hospital of Orange County, Orange, Calif., told this newspaper. “That is probably 5% or less of all cases, but that overlap is there.”

“The overlap is certainly more common now than in the past because of the obesity epidemic,” Floyd L. Culler, M.D., professor of pediatrics at the University of California, Irvine, said in an interview.

The growing obesity epidemic in the United States is driving an increased incidence of type 2 diabetes among children and adolescents. That may be intuitive, but there is also a suggestion that the growing number of overweight pediatric patients contributes to increased incidence of type 1 incidence as well.

“There has been a 3%–4% increase per year in the last few years in incidence of type 1 diabetes. Some have hypothesized that it may also be related to obesity,” Francine R. Kaufman, M.D., head of the Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, California, said in an interview. “If you are overweight, it might accelerate destruction of the β-cells.”

She is author of a book titled, “Diabesity: The Obesity-Diabetes Epidemic That Threatens America—And What We Must Do to Stop It (Bantam, March 2005).

To further complicate diagnosis, there are some patients with diabetes who do not fit criteria for type 1 or type 2, Dr. Culler said. “The more you know the more you find patients who don't fit in a category.” Maturity-onset diabetes of the young (MODY), a subtype of non-insulin dependent diabetes mellitus, is an example.

Type 1 diabetes is an autoimmune disorder; the immune system attacks the pancreas and the cells that make insulin. With type 2 diabetes these cells become resistant to insulin, so insulin does not work well. “Early in the disease [type 2], they have high insulin levels, which leads to physical symptoms, such as a little fat around the middle and acanthosis nigricans,” Dr. Clark said.

Comorbidities are another distinction. For example, people with type 1 diabetes can have other autoimmune conditions such as autoimmune thyroid disease or celiac disease. “In type 2 diabetes, you see more diseases associated with insulin resistance, such as polycystic ovarian syndrome,” Dr. Kaufman said.

Children with type 1 diabetes generally experience a faster onset than do those with type 2 diabetes. In addition, pediatric patients with type 1 diabetes are generally younger than are those with type 2.

Other clues can aid diagnosis. “Ethnicity is a big difference. Type 1 diabetes is primarily a Caucasian disease, and type 2 diabetes pretty much affects everyone else,” Dr. Kaufman said. For example, type 2 is more common among American Indian, Hispanic, Asian, or Pacific Islander patients.

“My first recommendation to primary care physicians is to recognize abnormal weight gain early and aggressively intervene,” Dr. Clark said. “No. 2 is with a child of any age who is drinking and urinating a lot and gaining weight, to think diabetes.”

Her third recommendation is to address lifestyle issues with all children, whether an overweight patient has diabetes or not. “Every pediatrician can talk to patients and families about this, even during a short visit.”

“It's best to have a healthy lifestyle for either kind [of diabetes], and appropriate portions of the right foods. There are benefits to having an ideal body weight,” Dr. Kaufman said.

Monitoring the number of calories a child eats matters, Dr. Culler said. “Just to say you eat certain kinds of foods is not a solution to long-term weight loss.” He recommends a low-calorie, low-fat diet with enough fruits and vegetables to keep the child healthy.

To address excess weight and lower the risk for diabetes, exercise is also important. Maximum health effects are seen with a combination of diet and exercise. “The benefit of exercise is through metabolic effects on how you burn calories,” Dr. Culler said. “It's hard to exercise yourself thin. You can only burn a few hundred calories at a time, even in kids who are very active.”

Despite differences between type 1 and type 2 diabetes, all children with diabetes share some common issues. Challenges for children include medication compliance, glucose monitoring, and managing their condition when their routine changes. There is a loss of normalcy and children with diabetes can face discrimination at school, Dr. Kaufman said. “These are huge challenges.”

For most pediatric patients with high blood sugar, the distinction between type 1 and type 2 diabetes is straightforward. However, there can be an overlap and patients who fit criteria for both conditions, making diagnosis and management more challenging.

Michelle Ditto is a California teenager and avid dancer diagnosed with type 2 diabetes 4 years ago, at age 11. “It was kind of scary,” she said. “Type 2 kinda runs in my family,” Michelle said in an interview. Her grandmother and an uncle not related by blood have type 2 diabetes, “so I knew what it was.”

About 1½ years ago, Michelle switched physicians and had some blood tests. Results showed she had two of the three antibodies indicative of type 1 diabetes. “It was a shock.”

Her dual diagnosis puts Michelle in a unique position to compare type 1 and type 2 diabetes.

“To me it just seems like there is more medication [with type 1], more insulin, more shots, so more inconvenience from my point of view as a kid,” she said. “I have to bring my kit and my insulin to school now. As a kid it's a big deal.”

“You can have a genetic predisposition to type 2 diabetes, be Hispanic and overweight, and yet develop type 1 autoimmune type. That is where diagnosis gets difficult,” Susan Clark, M.D., director of endocrinology at Children's Hospital of Orange County, Orange, Calif., told this newspaper. “That is probably 5% or less of all cases, but that overlap is there.”

“The overlap is certainly more common now than in the past because of the obesity epidemic,” Floyd L. Culler, M.D., professor of pediatrics at the University of California, Irvine, said in an interview.

The growing obesity epidemic in the United States is driving an increased incidence of type 2 diabetes among children and adolescents. That may be intuitive, but there is also a suggestion that the growing number of overweight pediatric patients contributes to increased incidence of type 1 incidence as well.

“There has been a 3%–4% increase per year in the last few years in incidence of type 1 diabetes. Some have hypothesized that it may also be related to obesity,” Francine R. Kaufman, M.D., head of the Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, California, said in an interview. “If you are overweight, it might accelerate destruction of the β-cells.”

She is author of a book titled, “Diabesity: The Obesity-Diabetes Epidemic That Threatens America—And What We Must Do to Stop It (Bantam, March 2005).

To further complicate diagnosis, there are some patients with diabetes who do not fit criteria for type 1 or type 2, Dr. Culler said. “The more you know the more you find patients who don't fit in a category.” Maturity-onset diabetes of the young (MODY), a subtype of non-insulin dependent diabetes mellitus, is an example.

Type 1 diabetes is an autoimmune disorder; the immune system attacks the pancreas and the cells that make insulin. With type 2 diabetes these cells become resistant to insulin, so insulin does not work well. “Early in the disease [type 2], they have high insulin levels, which leads to physical symptoms, such as a little fat around the middle and acanthosis nigricans,” Dr. Clark said.

Comorbidities are another distinction. For example, people with type 1 diabetes can have other autoimmune conditions such as autoimmune thyroid disease or celiac disease. “In type 2 diabetes, you see more diseases associated with insulin resistance, such as polycystic ovarian syndrome,” Dr. Kaufman said.

Children with type 1 diabetes generally experience a faster onset than do those with type 2 diabetes. In addition, pediatric patients with type 1 diabetes are generally younger than are those with type 2.

Other clues can aid diagnosis. “Ethnicity is a big difference. Type 1 diabetes is primarily a Caucasian disease, and type 2 diabetes pretty much affects everyone else,” Dr. Kaufman said. For example, type 2 is more common among American Indian, Hispanic, Asian, or Pacific Islander patients.

“My first recommendation to primary care physicians is to recognize abnormal weight gain early and aggressively intervene,” Dr. Clark said. “No. 2 is with a child of any age who is drinking and urinating a lot and gaining weight, to think diabetes.”

Her third recommendation is to address lifestyle issues with all children, whether an overweight patient has diabetes or not. “Every pediatrician can talk to patients and families about this, even during a short visit.”

“It's best to have a healthy lifestyle for either kind [of diabetes], and appropriate portions of the right foods. There are benefits to having an ideal body weight,” Dr. Kaufman said.

Monitoring the number of calories a child eats matters, Dr. Culler said. “Just to say you eat certain kinds of foods is not a solution to long-term weight loss.” He recommends a low-calorie, low-fat diet with enough fruits and vegetables to keep the child healthy.

To address excess weight and lower the risk for diabetes, exercise is also important. Maximum health effects are seen with a combination of diet and exercise. “The benefit of exercise is through metabolic effects on how you burn calories,” Dr. Culler said. “It's hard to exercise yourself thin. You can only burn a few hundred calories at a time, even in kids who are very active.”

Despite differences between type 1 and type 2 diabetes, all children with diabetes share some common issues. Challenges for children include medication compliance, glucose monitoring, and managing their condition when their routine changes. There is a loss of normalcy and children with diabetes can face discrimination at school, Dr. Kaufman said. “These are huge challenges.”

ORLANDO — African American women in general lose less weight after gastric bypass surgery than do white women, but the reasons are unknown. A recent study found that diet, eating behavior, and psychosocial status do not explain the disparity, but changes in fat mass seem to be the key.

“We know that African American women are generally more obese overall,” Cynthia K. Buffington, Ph.D., said in an interview at a poster presentation during the annual meeting of the American Society for Bariatric Surgery.

Dr. Buffington and her associates compared morbidly obese African American and white women with no significant differences in preoperative body mass index, ideal body weight, or fat mass.

The study included 39 African American women with a mean BMI of 51 kg/m

Investigators also compared 39 of the African Americans to a subgroup of 39 whites matched for preoperative weight (a mean 143 kg). One year later, the African American women lost 62% of their excess weight to a mean of 94 kg, whereas the white women lost 80% of excess weight to a mean of 78 kg.

In the full cohort, the investigators determined psychosocial status using the Minnesota Multiphasic Personality Inventory-2 and the Millon Behavioral Medicine Diagnostic instruments. African American women had fewer psychosocial issues than did white women in the study, perhaps because obesity is more culturally accepted in the African American community, Dr. Buffington said.

“African American women are more self-confident and have fewer psychosocial issues related to their obesity,” said Dr. Buffington, director of research at U.S. Bariatric in Fort Lauderdale, Fla.

Specifically, African American women demonstrated significantly less depression, emotional instability, introversion, inhibition, and feelings of isolation or dejection; fewer adjustment problems; and better social adjustment than did white women in the study.

Dr. Buffington and her associates assessed patient diet histories and scores on eating-behavior questionnaires.

The reserchers found no significant differences in macronutrient intake or eating behaviors such as binge eating, food cravings, or eating control to explain the reduced effectiveness of surgery in African Americans.

“Both groups were consuming large amounts of calories, but there were no differences in carbohydrates or proteins,” Dr. Buffington said.

“Both were consuming high amounts of fat, but there were no differences between groups.”

African Americans had a 47% change in fat mass 1 year after surgery that was far less than the 63% change for whites, Dr. Buffington said. “This was strongly correlated to total weight loss.”

“We think it means there is a biological basis for surgery not to induce as much fat loss in a morbidly obese population of African Americans versus [whites],” Dr. Buffington said. She said other investigators are finding reduced oxidation of fat in the muscle of African American females.

ORLANDO — African American women in general lose less weight after gastric bypass surgery than do white women, but the reasons are unknown. A recent study found that diet, eating behavior, and psychosocial status do not explain the disparity, but changes in fat mass seem to be the key.

“We know that African American women are generally more obese overall,” Cynthia K. Buffington, Ph.D., said in an interview at a poster presentation during the annual meeting of the American Society for Bariatric Surgery.

Dr. Buffington and her associates compared morbidly obese African American and white women with no significant differences in preoperative body mass index, ideal body weight, or fat mass.

The study included 39 African American women with a mean BMI of 51 kg/m

Investigators also compared 39 of the African Americans to a subgroup of 39 whites matched for preoperative weight (a mean 143 kg). One year later, the African American women lost 62% of their excess weight to a mean of 94 kg, whereas the white women lost 80% of excess weight to a mean of 78 kg.

In the full cohort, the investigators determined psychosocial status using the Minnesota Multiphasic Personality Inventory-2 and the Millon Behavioral Medicine Diagnostic instruments. African American women had fewer psychosocial issues than did white women in the study, perhaps because obesity is more culturally accepted in the African American community, Dr. Buffington said.

“African American women are more self-confident and have fewer psychosocial issues related to their obesity,” said Dr. Buffington, director of research at U.S. Bariatric in Fort Lauderdale, Fla.

Specifically, African American women demonstrated significantly less depression, emotional instability, introversion, inhibition, and feelings of isolation or dejection; fewer adjustment problems; and better social adjustment than did white women in the study.

Dr. Buffington and her associates assessed patient diet histories and scores on eating-behavior questionnaires.

The reserchers found no significant differences in macronutrient intake or eating behaviors such as binge eating, food cravings, or eating control to explain the reduced effectiveness of surgery in African Americans.

“Both groups were consuming large amounts of calories, but there were no differences in carbohydrates or proteins,” Dr. Buffington said.

“Both were consuming high amounts of fat, but there were no differences between groups.”

African Americans had a 47% change in fat mass 1 year after surgery that was far less than the 63% change for whites, Dr. Buffington said. “This was strongly correlated to total weight loss.”

“We think it means there is a biological basis for surgery not to induce as much fat loss in a morbidly obese population of African Americans versus [whites],” Dr. Buffington said. She said other investigators are finding reduced oxidation of fat in the muscle of African American females.

ORLANDO — African American women in general lose less weight after gastric bypass surgery than do white women, but the reasons are unknown. A recent study found that diet, eating behavior, and psychosocial status do not explain the disparity, but changes in fat mass seem to be the key.

“We know that African American women are generally more obese overall,” Cynthia K. Buffington, Ph.D., said in an interview at a poster presentation during the annual meeting of the American Society for Bariatric Surgery.

Dr. Buffington and her associates compared morbidly obese African American and white women with no significant differences in preoperative body mass index, ideal body weight, or fat mass.

The study included 39 African American women with a mean BMI of 51 kg/m

Investigators also compared 39 of the African Americans to a subgroup of 39 whites matched for preoperative weight (a mean 143 kg). One year later, the African American women lost 62% of their excess weight to a mean of 94 kg, whereas the white women lost 80% of excess weight to a mean of 78 kg.

In the full cohort, the investigators determined psychosocial status using the Minnesota Multiphasic Personality Inventory-2 and the Millon Behavioral Medicine Diagnostic instruments. African American women had fewer psychosocial issues than did white women in the study, perhaps because obesity is more culturally accepted in the African American community, Dr. Buffington said.

“African American women are more self-confident and have fewer psychosocial issues related to their obesity,” said Dr. Buffington, director of research at U.S. Bariatric in Fort Lauderdale, Fla.

Specifically, African American women demonstrated significantly less depression, emotional instability, introversion, inhibition, and feelings of isolation or dejection; fewer adjustment problems; and better social adjustment than did white women in the study.

Dr. Buffington and her associates assessed patient diet histories and scores on eating-behavior questionnaires.

The reserchers found no significant differences in macronutrient intake or eating behaviors such as binge eating, food cravings, or eating control to explain the reduced effectiveness of surgery in African Americans.

“Both groups were consuming large amounts of calories, but there were no differences in carbohydrates or proteins,” Dr. Buffington said.

“Both were consuming high amounts of fat, but there were no differences between groups.”

African Americans had a 47% change in fat mass 1 year after surgery that was far less than the 63% change for whites, Dr. Buffington said. “This was strongly correlated to total weight loss.”

“We think it means there is a biological basis for surgery not to induce as much fat loss in a morbidly obese population of African Americans versus [whites],” Dr. Buffington said. She said other investigators are finding reduced oxidation of fat in the muscle of African American females.