Damian McNamara

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

MIAMI BEACH — Topical imiquimod shows promise for clearing superficial hemangiomas in young infants, according to a small study.

Although most superficial hemangiomas involute spontaneously by the time a child reaches age 4 or 5 years, they can leave behind significant scars, atrophic changes, or deformities. Topical imiquimod (Aldara) may be an option to speed up involution and minimize changes to the skin, Brian Berman, M.D., a coauthor of the study (J. Am. Acad. Dermatol. 2004;51:639–42), said at a seminar sponsored by the Skin Disease Education Foundation.

Other treatment options include cryosurgery, radiation, laser therapy, corticosteroids, and interferon. Although imiquimod and interferon are both im-mune response modifiers, imiquimod is applied locally and thus does not carry the same risk of systemic toxicity, said Dr. Berman, professor of dermatology at the University of Miami. Dr. Berman is a consultant for and on the speaker's bureau of 3M, maker of imiquimod.

Dr. Berman and his colleagues enrolled 10 infants aged 3–7 months with superficial hemangiomas. Participants were treated with imiquimod five times a week up to 16 weeks. One child dropped out after 3 weeks because of inflammation that developed at the treatment site; the study results included nine infants.

Follow-up was between 7 and 9 months after cessation of therapy. “Nine children experienced no systemic effects, no recurrences, no scarring,” Dr. Berman said at the seminar. The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

Four participants had complete resolution of their hemangioma, and three others had greater than 75% resolution at 16 weeks. Another participant showed moderate improvement (judged in the 50%-74% range), but was lost to follow-up after 10 weeks.

There was a treatment failure in the only infant who did not have an inflammatory response to treatment. This child may not have responded because of a receptor deficiency or poor compliance, Dr. Berman said.

“The obvious answer is the child did not use the cream, but the child may be part of the small percentage of the population that has deficient or nonfunctioning Toll-like receptor 7.” The receptor is required for imiquimod activity.

MIAMI BEACH — Topical imiquimod shows promise for clearing superficial hemangiomas in young infants, according to a small study.

Although most superficial hemangiomas involute spontaneously by the time a child reaches age 4 or 5 years, they can leave behind significant scars, atrophic changes, or deformities. Topical imiquimod (Aldara) may be an option to speed up involution and minimize changes to the skin, Brian Berman, M.D., a coauthor of the study (J. Am. Acad. Dermatol. 2004;51:639–42), said at a seminar sponsored by the Skin Disease Education Foundation.

Other treatment options include cryosurgery, radiation, laser therapy, corticosteroids, and interferon. Although imiquimod and interferon are both im-mune response modifiers, imiquimod is applied locally and thus does not carry the same risk of systemic toxicity, said Dr. Berman, professor of dermatology at the University of Miami. Dr. Berman is a consultant for and on the speaker's bureau of 3M, maker of imiquimod.

Dr. Berman and his colleagues enrolled 10 infants aged 3–7 months with superficial hemangiomas. Participants were treated with imiquimod five times a week up to 16 weeks. One child dropped out after 3 weeks because of inflammation that developed at the treatment site; the study results included nine infants.

Follow-up was between 7 and 9 months after cessation of therapy. “Nine children experienced no systemic effects, no recurrences, no scarring,” Dr. Berman said at the seminar. The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

Four participants had complete resolution of their hemangioma, and three others had greater than 75% resolution at 16 weeks. Another participant showed moderate improvement (judged in the 50%-74% range), but was lost to follow-up after 10 weeks.

There was a treatment failure in the only infant who did not have an inflammatory response to treatment. This child may not have responded because of a receptor deficiency or poor compliance, Dr. Berman said.

“The obvious answer is the child did not use the cream, but the child may be part of the small percentage of the population that has deficient or nonfunctioning Toll-like receptor 7.” The receptor is required for imiquimod activity.

MIAMI BEACH — Topical imiquimod shows promise for clearing superficial hemangiomas in young infants, according to a small study.

Although most superficial hemangiomas involute spontaneously by the time a child reaches age 4 or 5 years, they can leave behind significant scars, atrophic changes, or deformities. Topical imiquimod (Aldara) may be an option to speed up involution and minimize changes to the skin, Brian Berman, M.D., a coauthor of the study (J. Am. Acad. Dermatol. 2004;51:639–42), said at a seminar sponsored by the Skin Disease Education Foundation.

Other treatment options include cryosurgery, radiation, laser therapy, corticosteroids, and interferon. Although imiquimod and interferon are both im-mune response modifiers, imiquimod is applied locally and thus does not carry the same risk of systemic toxicity, said Dr. Berman, professor of dermatology at the University of Miami. Dr. Berman is a consultant for and on the speaker's bureau of 3M, maker of imiquimod.

Dr. Berman and his colleagues enrolled 10 infants aged 3–7 months with superficial hemangiomas. Participants were treated with imiquimod five times a week up to 16 weeks. One child dropped out after 3 weeks because of inflammation that developed at the treatment site; the study results included nine infants.

Follow-up was between 7 and 9 months after cessation of therapy. “Nine children experienced no systemic effects, no recurrences, no scarring,” Dr. Berman said at the seminar. The Skin Disease Education Foundation and this newspaper are wholly owned subsidiaries of Elsevier.

Four participants had complete resolution of their hemangioma, and three others had greater than 75% resolution at 16 weeks. Another participant showed moderate improvement (judged in the 50%-74% range), but was lost to follow-up after 10 weeks.

There was a treatment failure in the only infant who did not have an inflammatory response to treatment. This child may not have responded because of a receptor deficiency or poor compliance, Dr. Berman said.

“The obvious answer is the child did not use the cream, but the child may be part of the small percentage of the population that has deficient or nonfunctioning Toll-like receptor 7.” The receptor is required for imiquimod activity.

MIAMI BEACH — Although considered rare in skin of color, rosacea may actually be unrecognized or misdiagnosed in this population, according to a presentation at a seminar sponsored by the Skin Disease Education Foundation.

Rosacea can occur in all skin types. In particular, a combination of three racial phenotypes—African, Native American, and white—are common to most African Americans. “So … rosacea should not be considered rare in this population,” said Valerie D. Callender, M.D., of Howard University, Washington.

Rosacea is likely the same in patients with lighter and darker skin types in terms of its pathophysiology, but there are clinical differences. Flushing episodes are probably less common, and both erythema and telangiectasias are more difficult to appreciate in darker skin.

There may be less actinic damage in darker skin, but additional research is needed for confirmation. Early or mild cases are undiagnosed and underreported, Dr. Callender noted in her presentation.

“Clinical signs are less apparent—we need to look for erythema in patients with ethnic skin to treat rosacea early,” she said.

Rosacea is easier to diagnose in the lightest skin types (Fitzpatrick skin types I and II). Even individuals with lighter skin do not always have the major components of rosacea simultaneously: inflammatory effects, sebaceous effects, ocular effects, and vascular effects. Because patients with skin of color make up an estimated 33% of the U.S. population, a figure that is expected to grow to 47% by the year 2059, physicians are more likely to encounter rosacea in the darkest skin types (Fitzpatrick skin types IV through VI).

The National Rosacea Society developed a classification system for the condition (J. Am. Acad. Dermatol. 2002;46:584–7). More studies are needed to determine the true incidence of rosacea in darker skin types, said Dr. Callender, who is in private practice in Mitchellville, Md.

Treatment options for rosacea in skin of color include topical and oral agents, although a combination approach is best, Dr. Callender said. “Topical is definitely first line, but most of us use oral antibiotics for some patients.”

Recommended topical agents are sulfacetamide-sulfur, clindamycin, erythromycin, metronidazole, azelaic acid, and retinoids.

Recommended oral antibiotics include tetracycline, minocycline, and doxycycline, as well as submicrobial doses of doxycycline. Submicrobial use of doxycycline is off label, pending Food and Drug Administration approval.

Lasers can be used to treat rhinophyma and light sources to treat telangiectasias. Dr. Callender suggested sunscreens or sunblocks with an SPF of 15 or higher. She also recommended gentle skin care regimens and camouflaging makeup for these patients.

In addition, the use of a 4% hydroquinone combination product to treat postinflammatory hyperpigmentation that can develop from inflammatory lesions is “a major difference in treatment for skin of color patients.”

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Rosacea can occur in all skin types, such as in this 36-year-old African American woman. Multiple erythematous papules, pustules, and post- inflammatory hyperpigmented macules can be seen on her face. Courtesy Dr. Valerie D. Callender

MIAMI BEACH — Although considered rare in skin of color, rosacea may actually be unrecognized or misdiagnosed in this population, according to a presentation at a seminar sponsored by the Skin Disease Education Foundation.

Rosacea can occur in all skin types. In particular, a combination of three racial phenotypes—African, Native American, and white—are common to most African Americans. “So … rosacea should not be considered rare in this population,” said Valerie D. Callender, M.D., of Howard University, Washington.

Rosacea is likely the same in patients with lighter and darker skin types in terms of its pathophysiology, but there are clinical differences. Flushing episodes are probably less common, and both erythema and telangiectasias are more difficult to appreciate in darker skin.

There may be less actinic damage in darker skin, but additional research is needed for confirmation. Early or mild cases are undiagnosed and underreported, Dr. Callender noted in her presentation.

“Clinical signs are less apparent—we need to look for erythema in patients with ethnic skin to treat rosacea early,” she said.

Rosacea is easier to diagnose in the lightest skin types (Fitzpatrick skin types I and II). Even individuals with lighter skin do not always have the major components of rosacea simultaneously: inflammatory effects, sebaceous effects, ocular effects, and vascular effects. Because patients with skin of color make up an estimated 33% of the U.S. population, a figure that is expected to grow to 47% by the year 2059, physicians are more likely to encounter rosacea in the darkest skin types (Fitzpatrick skin types IV through VI).

The National Rosacea Society developed a classification system for the condition (J. Am. Acad. Dermatol. 2002;46:584–7). More studies are needed to determine the true incidence of rosacea in darker skin types, said Dr. Callender, who is in private practice in Mitchellville, Md.

Treatment options for rosacea in skin of color include topical and oral agents, although a combination approach is best, Dr. Callender said. “Topical is definitely first line, but most of us use oral antibiotics for some patients.”

Recommended topical agents are sulfacetamide-sulfur, clindamycin, erythromycin, metronidazole, azelaic acid, and retinoids.

Recommended oral antibiotics include tetracycline, minocycline, and doxycycline, as well as submicrobial doses of doxycycline. Submicrobial use of doxycycline is off label, pending Food and Drug Administration approval.

Lasers can be used to treat rhinophyma and light sources to treat telangiectasias. Dr. Callender suggested sunscreens or sunblocks with an SPF of 15 or higher. She also recommended gentle skin care regimens and camouflaging makeup for these patients.

In addition, the use of a 4% hydroquinone combination product to treat postinflammatory hyperpigmentation that can develop from inflammatory lesions is “a major difference in treatment for skin of color patients.”

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Rosacea can occur in all skin types, such as in this 36-year-old African American woman. Multiple erythematous papules, pustules, and post- inflammatory hyperpigmented macules can be seen on her face. Courtesy Dr. Valerie D. Callender

MIAMI BEACH — Although considered rare in skin of color, rosacea may actually be unrecognized or misdiagnosed in this population, according to a presentation at a seminar sponsored by the Skin Disease Education Foundation.

Rosacea can occur in all skin types. In particular, a combination of three racial phenotypes—African, Native American, and white—are common to most African Americans. “So … rosacea should not be considered rare in this population,” said Valerie D. Callender, M.D., of Howard University, Washington.

Rosacea is likely the same in patients with lighter and darker skin types in terms of its pathophysiology, but there are clinical differences. Flushing episodes are probably less common, and both erythema and telangiectasias are more difficult to appreciate in darker skin.

There may be less actinic damage in darker skin, but additional research is needed for confirmation. Early or mild cases are undiagnosed and underreported, Dr. Callender noted in her presentation.

“Clinical signs are less apparent—we need to look for erythema in patients with ethnic skin to treat rosacea early,” she said.

Rosacea is easier to diagnose in the lightest skin types (Fitzpatrick skin types I and II). Even individuals with lighter skin do not always have the major components of rosacea simultaneously: inflammatory effects, sebaceous effects, ocular effects, and vascular effects. Because patients with skin of color make up an estimated 33% of the U.S. population, a figure that is expected to grow to 47% by the year 2059, physicians are more likely to encounter rosacea in the darkest skin types (Fitzpatrick skin types IV through VI).

The National Rosacea Society developed a classification system for the condition (J. Am. Acad. Dermatol. 2002;46:584–7). More studies are needed to determine the true incidence of rosacea in darker skin types, said Dr. Callender, who is in private practice in Mitchellville, Md.

Treatment options for rosacea in skin of color include topical and oral agents, although a combination approach is best, Dr. Callender said. “Topical is definitely first line, but most of us use oral antibiotics for some patients.”

Recommended topical agents are sulfacetamide-sulfur, clindamycin, erythromycin, metronidazole, azelaic acid, and retinoids.

Recommended oral antibiotics include tetracycline, minocycline, and doxycycline, as well as submicrobial doses of doxycycline. Submicrobial use of doxycycline is off label, pending Food and Drug Administration approval.

Lasers can be used to treat rhinophyma and light sources to treat telangiectasias. Dr. Callender suggested sunscreens or sunblocks with an SPF of 15 or higher. She also recommended gentle skin care regimens and camouflaging makeup for these patients.

In addition, the use of a 4% hydroquinone combination product to treat postinflammatory hyperpigmentation that can develop from inflammatory lesions is “a major difference in treatment for skin of color patients.”

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

Rosacea can occur in all skin types, such as in this 36-year-old African American woman. Multiple erythematous papules, pustules, and post- inflammatory hyperpigmented macules can be seen on her face. Courtesy Dr. Valerie D. Callender

MIAMI BEACH, FLA. — Want to confirm a suspected case of malaria?

You can e-mail a digital image to the Centers for Disease Control and Prevention for telediagnosis, and if necessary download guidelines for treatment from its new malaria Web site, Phuc Nguyen-Dinh, M.D., said at the annual meeting of the American Society of Tropical Medicine & Hygiene.

In less than 1 year, the CDC's online malaria initiative (www.cdc.gov/malaria

“Now information is downloadable from the Web site. We believe it is more accurate to print the guidelines than to get information over the telephone. Plus, with the Web site we can update the information as needed,” said Dr. Nguyen-Dinh, medical officer in the division of parasitic diseases at the Centers for Disease Control and Prevention, Atlanta.

The response to the Web site has been positive, Dr. Nguyen-Dinh said. The clinical guidelines are especially useful, according to 430 physicians surveyed through the Infectious Diseases Society of America's Emerging Infections Network. The site features prevention information with a link to the CDC's travelers' information site. It also features interactive training for recognition of malaria.

“We know there is a need in the United States for better diagnosis,” said Stephanie Johnson, MBA, CDC researcher in the Division of Parasitic Diseases. In 2002–2003, the CDC received 188 requests for telediagnosis, of which 79 were for suspected malaria. If the telediagnosis is malaria, the CDC requests the sender submit samples for verification.

Images of other suspected parasitic infections can be e-mailed to the CDC's Laboratory Identification of Parasites of Public Health Concern program (www.dpd.cdc.gov/dpdx

The CDC malaria hotline, 770–488-7788, operates Monday through Friday, 8 a.m. to 4:30 p.m. EST; the after-hours emergency number is 770-488-7100.

MIAMI BEACH, FLA. — Want to confirm a suspected case of malaria?

You can e-mail a digital image to the Centers for Disease Control and Prevention for telediagnosis, and if necessary download guidelines for treatment from its new malaria Web site, Phuc Nguyen-Dinh, M.D., said at the annual meeting of the American Society of Tropical Medicine & Hygiene.

In less than 1 year, the CDC's online malaria initiative (www.cdc.gov/malaria

“Now information is downloadable from the Web site. We believe it is more accurate to print the guidelines than to get information over the telephone. Plus, with the Web site we can update the information as needed,” said Dr. Nguyen-Dinh, medical officer in the division of parasitic diseases at the Centers for Disease Control and Prevention, Atlanta.

The response to the Web site has been positive, Dr. Nguyen-Dinh said. The clinical guidelines are especially useful, according to 430 physicians surveyed through the Infectious Diseases Society of America's Emerging Infections Network. The site features prevention information with a link to the CDC's travelers' information site. It also features interactive training for recognition of malaria.

“We know there is a need in the United States for better diagnosis,” said Stephanie Johnson, MBA, CDC researcher in the Division of Parasitic Diseases. In 2002–2003, the CDC received 188 requests for telediagnosis, of which 79 were for suspected malaria. If the telediagnosis is malaria, the CDC requests the sender submit samples for verification.

Images of other suspected parasitic infections can be e-mailed to the CDC's Laboratory Identification of Parasites of Public Health Concern program (www.dpd.cdc.gov/dpdx

The CDC malaria hotline, 770–488-7788, operates Monday through Friday, 8 a.m. to 4:30 p.m. EST; the after-hours emergency number is 770-488-7100.

MIAMI BEACH, FLA. — Want to confirm a suspected case of malaria?

You can e-mail a digital image to the Centers for Disease Control and Prevention for telediagnosis, and if necessary download guidelines for treatment from its new malaria Web site, Phuc Nguyen-Dinh, M.D., said at the annual meeting of the American Society of Tropical Medicine & Hygiene.

In less than 1 year, the CDC's online malaria initiative (www.cdc.gov/malaria

“Now information is downloadable from the Web site. We believe it is more accurate to print the guidelines than to get information over the telephone. Plus, with the Web site we can update the information as needed,” said Dr. Nguyen-Dinh, medical officer in the division of parasitic diseases at the Centers for Disease Control and Prevention, Atlanta.

The response to the Web site has been positive, Dr. Nguyen-Dinh said. The clinical guidelines are especially useful, according to 430 physicians surveyed through the Infectious Diseases Society of America's Emerging Infections Network. The site features prevention information with a link to the CDC's travelers' information site. It also features interactive training for recognition of malaria.

“We know there is a need in the United States for better diagnosis,” said Stephanie Johnson, MBA, CDC researcher in the Division of Parasitic Diseases. In 2002–2003, the CDC received 188 requests for telediagnosis, of which 79 were for suspected malaria. If the telediagnosis is malaria, the CDC requests the sender submit samples for verification.

Images of other suspected parasitic infections can be e-mailed to the CDC's Laboratory Identification of Parasites of Public Health Concern program (www.dpd.cdc.gov/dpdx

The CDC malaria hotline, 770–488-7788, operates Monday through Friday, 8 a.m. to 4:30 p.m. EST; the after-hours emergency number is 770-488-7100.

MIAMI BEACH — Accelerated immunizations for pediatric travelers can optimize disease prevention before international travel, Elizabeth D. Barnett, M.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hepatitis A, typhoid fever, yellow fever, Japanese encephalitis, meningococcal infection, and rabies infection are some of the leading concerns for pediatric travelers, according to Dr. Barnett, director of the International Clinic, Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center.

The good news is that most traveling children have already received vaccines for hepatitis B and pneumococcal disease.

Age is important in terms of immune system maturation. For example, efficacy of polysaccharide vaccines will be limited until age 2 years because of impaired T-cell function. “The solution is development of conjugate vaccines,” Dr. Barnett said. In addition, maternal antibodies can impair response to some vaccines in very young infants, such as the measles, mumps, and rubella (MMR) and hepatitis A vaccines. “Balance the lower age limit of the vaccine with risk of disease and vaccine efficacy.”

If travel to a measles-endemic area is planned, consider giving MMR beginning at 6 months of age, Dr. Barnett suggested. If the patient is traveling to a region where a polio outbreak is possible, he or she should receive a full course of polio vaccination beforehand.

Dr. Barnett made some specific recommendations:

▸ Hepatitis A. Hepatitis A vaccine should be given 2-4 weeks prior to departure for children traveling to all international destinations except Australia, Canada, Japan, New Zealand, Western Europe, and Scandinavia. Children at least 1 year old can receive the vaccine; the only option for younger travelers is immune globulin. “If the time to departure is short, consider giving immune globulin and vaccine at the same time as MMR or varicella vaccines at different sites,” Dr. Barnett said. However, there is a theoretical risk that immune globulin may impair vaccine activity for weeks or months, so the ideal situation is to give the vaccine first, followed at least 2 weeks later by the immune globulin.

“The benefit really outweighs the risks with hepatitis A vaccine,” Dr. Barnett said.

▸ Typhoid. Vaccination is indicated for travel to areas where exposure to contaminated food or water is possible. Risk is not dictated by length of trip but by behaviors and exposure. The vaccine's efficacy is limited compared to hepatitis A, Dr. Barnett said. “We generally tell patients the efficacy is 65%-85%.”

For infants under 2 years, there are only food and water precautions. From ages 2-5 years, the same precautions plus a polysaccharide vaccine are recommended. For children 6 years and older, the parenteral polysaccharide vaccine, Ty21a oral vaccine, and food and water precautions are recommended. Adverse events with the parenteral vaccine include local reactions (7%), headache (1.5%-3%), and fever (0%-1%).

Dr. Barnett said, “In most settings, the benefit for typhoid vaccine is there, limited by incomplete vaccine efficacy.”

▸ Yellow fever. Vaccination for yellow fever is only a consideration for travel to Africa and South America. There are an estimated 0.4-4.3 cases of yellow fever per million U.S. travelers to endemic areas. The vaccine is very efficacious, with a single vaccination usually providing lifetime coverage.

“Encephalitis is a rare adverse event following yellow fever vaccine, occurring primarily in infants,” Dr. Barnett said. “The vaccine, therefore, is absolutely contraindicated in infants under 6 months.”

“The bottom line is, those who are at risk for yellow fever going to high transmission areas, and who cannot guarantee mosquito protection, should receive yellow fever vaccine unless there are specific contraindications,” Dr. Barnett said.

▸ Japanese encephalitis. There is an effective vaccine, and it is indicated for some travel to higher-risk areas, Dr. Barnett said. “We have to again balance risks and benefits.” The risk is greater in rural farming areas, during transmission season, and during outbreaks.

▸ Meningococcal infection. Sub-Saharan Africa has frequent epidemics and outbreaks. “The overall risk of disease for travelers to sub-Saharan Africa is very low, but the vaccine is safe, effective in children over 2, and offers some protection at home,” Dr. Barnett said. Although conjugate vaccines are available in Canada and Europe, only polysaccharide vaccines are available in the United States. With polysaccharide vaccines, there is superior efficacy in children aged 2 years and older.

▸ Rabies. Although the benefits of prophylaxis are greatest for travel to high-risk areas and areas far from medical care, and for travel of long duration, “I believe we should be discussing prevention with all families traveling to a destination that is not rabies-free,” Dr. Barnett said.

It is very important to tell families that additional doses are required after exposure. “We call it pre-exposure prophylaxis, we do not call it a vaccine, because medical care should still be sought if [a person is] bitten,” she emphasized.

MIAMI BEACH — Accelerated immunizations for pediatric travelers can optimize disease prevention before international travel, Elizabeth D. Barnett, M.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hepatitis A, typhoid fever, yellow fever, Japanese encephalitis, meningococcal infection, and rabies infection are some of the leading concerns for pediatric travelers, according to Dr. Barnett, director of the International Clinic, Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center.

The good news is that most traveling children have already received vaccines for hepatitis B and pneumococcal disease.

Age is important in terms of immune system maturation. For example, efficacy of polysaccharide vaccines will be limited until age 2 years because of impaired T-cell function. “The solution is development of conjugate vaccines,” Dr. Barnett said. In addition, maternal antibodies can impair response to some vaccines in very young infants, such as the measles, mumps, and rubella (MMR) and hepatitis A vaccines. “Balance the lower age limit of the vaccine with risk of disease and vaccine efficacy.”

If travel to a measles-endemic area is planned, consider giving MMR beginning at 6 months of age, Dr. Barnett suggested. If the patient is traveling to a region where a polio outbreak is possible, he or she should receive a full course of polio vaccination beforehand.

Dr. Barnett made some specific recommendations:

▸ Hepatitis A. Hepatitis A vaccine should be given 2-4 weeks prior to departure for children traveling to all international destinations except Australia, Canada, Japan, New Zealand, Western Europe, and Scandinavia. Children at least 1 year old can receive the vaccine; the only option for younger travelers is immune globulin. “If the time to departure is short, consider giving immune globulin and vaccine at the same time as MMR or varicella vaccines at different sites,” Dr. Barnett said. However, there is a theoretical risk that immune globulin may impair vaccine activity for weeks or months, so the ideal situation is to give the vaccine first, followed at least 2 weeks later by the immune globulin.

“The benefit really outweighs the risks with hepatitis A vaccine,” Dr. Barnett said.

▸ Typhoid. Vaccination is indicated for travel to areas where exposure to contaminated food or water is possible. Risk is not dictated by length of trip but by behaviors and exposure. The vaccine's efficacy is limited compared to hepatitis A, Dr. Barnett said. “We generally tell patients the efficacy is 65%-85%.”

For infants under 2 years, there are only food and water precautions. From ages 2-5 years, the same precautions plus a polysaccharide vaccine are recommended. For children 6 years and older, the parenteral polysaccharide vaccine, Ty21a oral vaccine, and food and water precautions are recommended. Adverse events with the parenteral vaccine include local reactions (7%), headache (1.5%-3%), and fever (0%-1%).

Dr. Barnett said, “In most settings, the benefit for typhoid vaccine is there, limited by incomplete vaccine efficacy.”

▸ Yellow fever. Vaccination for yellow fever is only a consideration for travel to Africa and South America. There are an estimated 0.4-4.3 cases of yellow fever per million U.S. travelers to endemic areas. The vaccine is very efficacious, with a single vaccination usually providing lifetime coverage.

“Encephalitis is a rare adverse event following yellow fever vaccine, occurring primarily in infants,” Dr. Barnett said. “The vaccine, therefore, is absolutely contraindicated in infants under 6 months.”

“The bottom line is, those who are at risk for yellow fever going to high transmission areas, and who cannot guarantee mosquito protection, should receive yellow fever vaccine unless there are specific contraindications,” Dr. Barnett said.

▸ Japanese encephalitis. There is an effective vaccine, and it is indicated for some travel to higher-risk areas, Dr. Barnett said. “We have to again balance risks and benefits.” The risk is greater in rural farming areas, during transmission season, and during outbreaks.

▸ Meningococcal infection. Sub-Saharan Africa has frequent epidemics and outbreaks. “The overall risk of disease for travelers to sub-Saharan Africa is very low, but the vaccine is safe, effective in children over 2, and offers some protection at home,” Dr. Barnett said. Although conjugate vaccines are available in Canada and Europe, only polysaccharide vaccines are available in the United States. With polysaccharide vaccines, there is superior efficacy in children aged 2 years and older.

▸ Rabies. Although the benefits of prophylaxis are greatest for travel to high-risk areas and areas far from medical care, and for travel of long duration, “I believe we should be discussing prevention with all families traveling to a destination that is not rabies-free,” Dr. Barnett said.

It is very important to tell families that additional doses are required after exposure. “We call it pre-exposure prophylaxis, we do not call it a vaccine, because medical care should still be sought if [a person is] bitten,” she emphasized.

MIAMI BEACH — Accelerated immunizations for pediatric travelers can optimize disease prevention before international travel, Elizabeth D. Barnett, M.D., said at the annual meeting of the American Society of Tropical Medicine and Hygiene.

Hepatitis A, typhoid fever, yellow fever, Japanese encephalitis, meningococcal infection, and rabies infection are some of the leading concerns for pediatric travelers, according to Dr. Barnett, director of the International Clinic, Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center.

The good news is that most traveling children have already received vaccines for hepatitis B and pneumococcal disease.

Age is important in terms of immune system maturation. For example, efficacy of polysaccharide vaccines will be limited until age 2 years because of impaired T-cell function. “The solution is development of conjugate vaccines,” Dr. Barnett said. In addition, maternal antibodies can impair response to some vaccines in very young infants, such as the measles, mumps, and rubella (MMR) and hepatitis A vaccines. “Balance the lower age limit of the vaccine with risk of disease and vaccine efficacy.”

If travel to a measles-endemic area is planned, consider giving MMR beginning at 6 months of age, Dr. Barnett suggested. If the patient is traveling to a region where a polio outbreak is possible, he or she should receive a full course of polio vaccination beforehand.

Dr. Barnett made some specific recommendations:

▸ Hepatitis A. Hepatitis A vaccine should be given 2-4 weeks prior to departure for children traveling to all international destinations except Australia, Canada, Japan, New Zealand, Western Europe, and Scandinavia. Children at least 1 year old can receive the vaccine; the only option for younger travelers is immune globulin. “If the time to departure is short, consider giving immune globulin and vaccine at the same time as MMR or varicella vaccines at different sites,” Dr. Barnett said. However, there is a theoretical risk that immune globulin may impair vaccine activity for weeks or months, so the ideal situation is to give the vaccine first, followed at least 2 weeks later by the immune globulin.

“The benefit really outweighs the risks with hepatitis A vaccine,” Dr. Barnett said.

▸ Typhoid. Vaccination is indicated for travel to areas where exposure to contaminated food or water is possible. Risk is not dictated by length of trip but by behaviors and exposure. The vaccine's efficacy is limited compared to hepatitis A, Dr. Barnett said. “We generally tell patients the efficacy is 65%-85%.”

For infants under 2 years, there are only food and water precautions. From ages 2-5 years, the same precautions plus a polysaccharide vaccine are recommended. For children 6 years and older, the parenteral polysaccharide vaccine, Ty21a oral vaccine, and food and water precautions are recommended. Adverse events with the parenteral vaccine include local reactions (7%), headache (1.5%-3%), and fever (0%-1%).

Dr. Barnett said, “In most settings, the benefit for typhoid vaccine is there, limited by incomplete vaccine efficacy.”

▸ Yellow fever. Vaccination for yellow fever is only a consideration for travel to Africa and South America. There are an estimated 0.4-4.3 cases of yellow fever per million U.S. travelers to endemic areas. The vaccine is very efficacious, with a single vaccination usually providing lifetime coverage.

“Encephalitis is a rare adverse event following yellow fever vaccine, occurring primarily in infants,” Dr. Barnett said. “The vaccine, therefore, is absolutely contraindicated in infants under 6 months.”

“The bottom line is, those who are at risk for yellow fever going to high transmission areas, and who cannot guarantee mosquito protection, should receive yellow fever vaccine unless there are specific contraindications,” Dr. Barnett said.

▸ Japanese encephalitis. There is an effective vaccine, and it is indicated for some travel to higher-risk areas, Dr. Barnett said. “We have to again balance risks and benefits.” The risk is greater in rural farming areas, during transmission season, and during outbreaks.

▸ Meningococcal infection. Sub-Saharan Africa has frequent epidemics and outbreaks. “The overall risk of disease for travelers to sub-Saharan Africa is very low, but the vaccine is safe, effective in children over 2, and offers some protection at home,” Dr. Barnett said. Although conjugate vaccines are available in Canada and Europe, only polysaccharide vaccines are available in the United States. With polysaccharide vaccines, there is superior efficacy in children aged 2 years and older.

▸ Rabies. Although the benefits of prophylaxis are greatest for travel to high-risk areas and areas far from medical care, and for travel of long duration, “I believe we should be discussing prevention with all families traveling to a destination that is not rabies-free,” Dr. Barnett said.

It is very important to tell families that additional doses are required after exposure. “We call it pre-exposure prophylaxis, we do not call it a vaccine, because medical care should still be sought if [a person is] bitten,” she emphasized.

MIAMI BEACH — Diagnosis of a newborn urinary tract infection is challenging, but identification is crucial to prevent potentially serious complications, according to a review of recent literature.

Although urinary tract infections (UTIs) are common in newborns—with an estimated 4 million cases in the United States—clinical questions remain. What is the true incidence of complications if left untreated, which are the more serious or long-term consequences, and what is the best approach to treatment?

“UTIs remain a classic type of bad problem. We need to keep abreast of them. If you see a febrile infant, you should always think UTI,” Thomas E. Wiswell, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

He estimated that up to 10% of the 4 million newborns, or 300,000-400,000, have a febrile UTI at some time during the first 2 years of life.

“Unfortunately, as we deal with this in infants, the signs can be misleading or general and we may not think of this diagnosis. Know they may be more prone for kidney injury, and follow them for that,” Dr. Wiswell advised.

Almost all infants with a UTI in the first year of life have pyelonephritis. These patients are at greatest risk for renal scarring and permanent injury. An estimated 35%-64% of newborns with a UTI experience renal scarring. There is a significant correlation between the severity of scarring and higher nighttime systolic and diastolic blood pressures in children (J. Pediatr. 2003;142:117-22).

This hypertension occurs in about 1% of children with a UTI and may persist into adulthood. “We may think we've treated the UTI completely, but as adults the internist is treating something that stems from a UTI when [the patient was] young,” said Dr. Wiswell, attending neonatologist at Florida Hospital Center for Neonatal Care, Orlando.

Effects of minor renal scarring are less well known, but advances in technetium-99m dimercaptosuccinic acid (DMSA) imaging may help, Dr. Wiswell said. “We pick up a lot more [minor] scarring with our modern day DMSA scanning versus traditional intravenous pyelogram imaging studies. But we've only done DMSAs for about a decade, and we need long-term follow-up to see if these smaller scars worsen over time.”

A less common, but more severe, complication is end-stage renal disease, which occurs in 0.2% of newborns with a UTI. These newborns are also at higher risk for systemic bacteremia and vesicoureteral reflux. For example, in a study of 71 newborn infants treated for UTI, 15% had vesicoureteral reflux (Pediatr. Int. 2004;46:21-5).

Several recent studies address the importance of taking a urine culture at the appropriate time. For example, in a study of 538 premature infants born with sepsis, none of the 349 urine cultures taken in the first 24 hours after birth were positive (Pediatr. Infect. Dis. J. 2003;22:805-8). The babies were an average of 28.5 weeks' gestation and had an average birth weight of 1,072 g. However, cultures in 189 symptomatic infants 6 days or older showed 25% had a UTI, and of these, 38% had concomitant bacteremia.

“So there is little benefit of doing a urine culture on the first day of life with a baby with sepsis,” Dr. Wiswell said. “It is of extreme importance, however, a few days later.”

The mean time for fever resolution was 4-8 hours after start of treatment in an investigation of 128 infants 60 days old or younger with febrile UTI (Pediatr. Emerg. Care 2004;20:85-8). All had repeat cultures at 48 hours, and none were positive. Other researchers assessed the clinical course of 364 children admitted to the hospital for a UTI (Arch. Pediatr. Adolesc. Med. 2003;157:1237-40). Almost one-third, 32%, had a fever that persisted more than 48 hours, and 90% were afebrile by 80 hours. None of the 291 follow-up cultures were positive.

“From these two studies, it seems follow-up cultures are of no utility,” Dr. Wiswell commented.

Breast-feeding may have a transient but significant protective effect against UTIs, according to another study (Acta Paediatr. 2004;93:164-8). The prospective case control study compared 200 children with their first febrile UTI to 336 controls. Dr. Wiswell said, “They concluded breast-feeding significantly lowered risk of UTI, with strongest effect in the first months after birth. The protection was no longer present after 7 months of age.”

There is still uncertainty about whether long-term, low-dose antibiotics prevent recurrent UTIs in susceptible children (Cochrane Database Syst. Rev. 2001;4:CD001534). There is no consensus in the literature about traditional long-course antibiotics versus short-course therapy in upper UTIs. For eradication of lower UTIs, however, a Cochrane Collaboration Systematic Review indicates a 2- to 4-day course of oral antibiotics is as effective as 7- to 14-day therapy (Cochrane Database Syst. Rev 2003;1:CD003966).

Until larger and more rigorous trials are completed, questions will remain about UTIs in newborns, Dr. Wiswell said.

MIAMI BEACH — Diagnosis of a newborn urinary tract infection is challenging, but identification is crucial to prevent potentially serious complications, according to a review of recent literature.

Although urinary tract infections (UTIs) are common in newborns—with an estimated 4 million cases in the United States—clinical questions remain. What is the true incidence of complications if left untreated, which are the more serious or long-term consequences, and what is the best approach to treatment?

“UTIs remain a classic type of bad problem. We need to keep abreast of them. If you see a febrile infant, you should always think UTI,” Thomas E. Wiswell, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

He estimated that up to 10% of the 4 million newborns, or 300,000-400,000, have a febrile UTI at some time during the first 2 years of life.

“Unfortunately, as we deal with this in infants, the signs can be misleading or general and we may not think of this diagnosis. Know they may be more prone for kidney injury, and follow them for that,” Dr. Wiswell advised.

Almost all infants with a UTI in the first year of life have pyelonephritis. These patients are at greatest risk for renal scarring and permanent injury. An estimated 35%-64% of newborns with a UTI experience renal scarring. There is a significant correlation between the severity of scarring and higher nighttime systolic and diastolic blood pressures in children (J. Pediatr. 2003;142:117-22).

This hypertension occurs in about 1% of children with a UTI and may persist into adulthood. “We may think we've treated the UTI completely, but as adults the internist is treating something that stems from a UTI when [the patient was] young,” said Dr. Wiswell, attending neonatologist at Florida Hospital Center for Neonatal Care, Orlando.

Effects of minor renal scarring are less well known, but advances in technetium-99m dimercaptosuccinic acid (DMSA) imaging may help, Dr. Wiswell said. “We pick up a lot more [minor] scarring with our modern day DMSA scanning versus traditional intravenous pyelogram imaging studies. But we've only done DMSAs for about a decade, and we need long-term follow-up to see if these smaller scars worsen over time.”

A less common, but more severe, complication is end-stage renal disease, which occurs in 0.2% of newborns with a UTI. These newborns are also at higher risk for systemic bacteremia and vesicoureteral reflux. For example, in a study of 71 newborn infants treated for UTI, 15% had vesicoureteral reflux (Pediatr. Int. 2004;46:21-5).

Several recent studies address the importance of taking a urine culture at the appropriate time. For example, in a study of 538 premature infants born with sepsis, none of the 349 urine cultures taken in the first 24 hours after birth were positive (Pediatr. Infect. Dis. J. 2003;22:805-8). The babies were an average of 28.5 weeks' gestation and had an average birth weight of 1,072 g. However, cultures in 189 symptomatic infants 6 days or older showed 25% had a UTI, and of these, 38% had concomitant bacteremia.

“So there is little benefit of doing a urine culture on the first day of life with a baby with sepsis,” Dr. Wiswell said. “It is of extreme importance, however, a few days later.”

The mean time for fever resolution was 4-8 hours after start of treatment in an investigation of 128 infants 60 days old or younger with febrile UTI (Pediatr. Emerg. Care 2004;20:85-8). All had repeat cultures at 48 hours, and none were positive. Other researchers assessed the clinical course of 364 children admitted to the hospital for a UTI (Arch. Pediatr. Adolesc. Med. 2003;157:1237-40). Almost one-third, 32%, had a fever that persisted more than 48 hours, and 90% were afebrile by 80 hours. None of the 291 follow-up cultures were positive.

“From these two studies, it seems follow-up cultures are of no utility,” Dr. Wiswell commented.

Breast-feeding may have a transient but significant protective effect against UTIs, according to another study (Acta Paediatr. 2004;93:164-8). The prospective case control study compared 200 children with their first febrile UTI to 336 controls. Dr. Wiswell said, “They concluded breast-feeding significantly lowered risk of UTI, with strongest effect in the first months after birth. The protection was no longer present after 7 months of age.”

There is still uncertainty about whether long-term, low-dose antibiotics prevent recurrent UTIs in susceptible children (Cochrane Database Syst. Rev. 2001;4:CD001534). There is no consensus in the literature about traditional long-course antibiotics versus short-course therapy in upper UTIs. For eradication of lower UTIs, however, a Cochrane Collaboration Systematic Review indicates a 2- to 4-day course of oral antibiotics is as effective as 7- to 14-day therapy (Cochrane Database Syst. Rev 2003;1:CD003966).

Until larger and more rigorous trials are completed, questions will remain about UTIs in newborns, Dr. Wiswell said.

MIAMI BEACH — Diagnosis of a newborn urinary tract infection is challenging, but identification is crucial to prevent potentially serious complications, according to a review of recent literature.

Although urinary tract infections (UTIs) are common in newborns—with an estimated 4 million cases in the United States—clinical questions remain. What is the true incidence of complications if left untreated, which are the more serious or long-term consequences, and what is the best approach to treatment?

“UTIs remain a classic type of bad problem. We need to keep abreast of them. If you see a febrile infant, you should always think UTI,” Thomas E. Wiswell, M.D., said at a pediatric update sponsored by Miami Children's Hospital.

He estimated that up to 10% of the 4 million newborns, or 300,000-400,000, have a febrile UTI at some time during the first 2 years of life.

“Unfortunately, as we deal with this in infants, the signs can be misleading or general and we may not think of this diagnosis. Know they may be more prone for kidney injury, and follow them for that,” Dr. Wiswell advised.

Almost all infants with a UTI in the first year of life have pyelonephritis. These patients are at greatest risk for renal scarring and permanent injury. An estimated 35%-64% of newborns with a UTI experience renal scarring. There is a significant correlation between the severity of scarring and higher nighttime systolic and diastolic blood pressures in children (J. Pediatr. 2003;142:117-22).

This hypertension occurs in about 1% of children with a UTI and may persist into adulthood. “We may think we've treated the UTI completely, but as adults the internist is treating something that stems from a UTI when [the patient was] young,” said Dr. Wiswell, attending neonatologist at Florida Hospital Center for Neonatal Care, Orlando.

Effects of minor renal scarring are less well known, but advances in technetium-99m dimercaptosuccinic acid (DMSA) imaging may help, Dr. Wiswell said. “We pick up a lot more [minor] scarring with our modern day DMSA scanning versus traditional intravenous pyelogram imaging studies. But we've only done DMSAs for about a decade, and we need long-term follow-up to see if these smaller scars worsen over time.”

A less common, but more severe, complication is end-stage renal disease, which occurs in 0.2% of newborns with a UTI. These newborns are also at higher risk for systemic bacteremia and vesicoureteral reflux. For example, in a study of 71 newborn infants treated for UTI, 15% had vesicoureteral reflux (Pediatr. Int. 2004;46:21-5).

Several recent studies address the importance of taking a urine culture at the appropriate time. For example, in a study of 538 premature infants born with sepsis, none of the 349 urine cultures taken in the first 24 hours after birth were positive (Pediatr. Infect. Dis. J. 2003;22:805-8). The babies were an average of 28.5 weeks' gestation and had an average birth weight of 1,072 g. However, cultures in 189 symptomatic infants 6 days or older showed 25% had a UTI, and of these, 38% had concomitant bacteremia.

“So there is little benefit of doing a urine culture on the first day of life with a baby with sepsis,” Dr. Wiswell said. “It is of extreme importance, however, a few days later.”

The mean time for fever resolution was 4-8 hours after start of treatment in an investigation of 128 infants 60 days old or younger with febrile UTI (Pediatr. Emerg. Care 2004;20:85-8). All had repeat cultures at 48 hours, and none were positive. Other researchers assessed the clinical course of 364 children admitted to the hospital for a UTI (Arch. Pediatr. Adolesc. Med. 2003;157:1237-40). Almost one-third, 32%, had a fever that persisted more than 48 hours, and 90% were afebrile by 80 hours. None of the 291 follow-up cultures were positive.

“From these two studies, it seems follow-up cultures are of no utility,” Dr. Wiswell commented.

Breast-feeding may have a transient but significant protective effect against UTIs, according to another study (Acta Paediatr. 2004;93:164-8). The prospective case control study compared 200 children with their first febrile UTI to 336 controls. Dr. Wiswell said, “They concluded breast-feeding significantly lowered risk of UTI, with strongest effect in the first months after birth. The protection was no longer present after 7 months of age.”

There is still uncertainty about whether long-term, low-dose antibiotics prevent recurrent UTIs in susceptible children (Cochrane Database Syst. Rev. 2001;4:CD001534). There is no consensus in the literature about traditional long-course antibiotics versus short-course therapy in upper UTIs. For eradication of lower UTIs, however, a Cochrane Collaboration Systematic Review indicates a 2- to 4-day course of oral antibiotics is as effective as 7- to 14-day therapy (Cochrane Database Syst. Rev 2003;1:CD003966).

Until larger and more rigorous trials are completed, questions will remain about UTIs in newborns, Dr. Wiswell said.

MIAMI — The blades roared overhead as the Miami-Dade rescue helicopter approached the rooftop of University of Miami/Jackson Memorial Hospital shortly after dark.

Through the rain, emergency medical technicians rushed a pregnant woman injured in a car crash on Interstate 95. Doctors delivered the distressed baby via emergency cesarean section. An ob.gyn. administered oxygen, and the hypoxic newborn's color turned from blue to pink.

But these moments of high medical drama were not real. “Give the mother a fatal heart rhythm, and let's see how they respond,” said Chris Gallagher, M.D., of the department of anesthesiology at the University of Miami. He was addressing a technician in a control room separated from the activity in the emergency room by a one-way mirror.

The large crowd attending the grand opening of the University of Miami/Jackson Memorial Hospital Center for Patient Safety gathered closer around extra video monitors that had been set up so they could watch the simulated emergency unfold. The “bloody” actress on the gurney was deftly switched for one of the new, state-of-the-art mannequins in residence at the new center. After the crew had stabilized both the mother and baby mannequins, they gathered around a conference table on the hospital's renovated fourth floor for a debriefing of their performance.

The emergency scenario was staged as a kickoff for the first patient safety center of its kind in the United States, one that combines simulation with elements of engineering, ergonomic design, and high-tech monitoring and recording. Akin to a flight simulator for airline pilots, the emergency care component of the Center for Patient Safety challenges physicians and other health care workers in a realistic but safe environment where no patient is harmed.

The 2,000-square-foot simulation facility will be used to provide courses to enhance clinical, communication, and teamwork skills for health care professionals at all levels of training. The simulation facility currently trains medical students and anesthesiology residents. Courses are planned for multidisciplinary team training of residents and nurses in internal medicine, pediatrics, emergency medicine, obstetrics, and other specialties.

“It's a dream come true after 10 years,” said Paul Barach, M.D., director of the Center for Patient Safety.

The center is innovative for bringing together all of the major elements of patient safety. “I'm most proud of the integration,” said Dr. Barach, also of the department of anesthesiology at the university.

Although other institutions in the United States have some features of the program, he said, only the University of Miami center combines skill assessments simulation, an investigative team to debrief participants, a human factors and usability lab, and a strategy for promoting patient safety policies in Miami, the state of Florida, and, eventually, nationwide.

The center's immediate goals include developing and disseminating training programs for physicians, nurses, pharmacists, and risk managers; enhancing research on patient safety; and working with medical device companies to use better design and ergonomics to make their products safer.

Backed by an initial $5 million in funds from federal, state, and private sources, the center has 18 projects underway. (For more details, visit www.patientsafety.med.miami.edu

Dr. Barach's drive to establish the center stemmed in part from a medical error he experienced as a medical student. “I was told to do a central line procedure, but not told how to do it. The intern just told me to do it. I was just out of the military and did not question orders,” he said. “The patient suffered a hemothorax, was intubated, went to the ICU, and she died 4 days later.” The experience “haunted me for years.”

Although the mannequins are the focal point in each of the five skills assessment areas—three exam rooms, an operating room, and a room that can function as an ICU, emergency room, or ward room, “the focus is not on simulation, the focus is on the patient,” John C. Nelson, M.D., president of the American Medical Association, said during the opening celebration.

“Patient safety has to be much more on the minds of all of us,” Dr. Nelson said. “This is what our patients expect and our profession demands.”

Patient-centered goals of the center staff include developing better ways to disclose medical errors to patients and their families. Another goal is to identify the factors that patients consider when choosing a hospital, and how these may differ by cultural or ethnic identity, Dr. Barach explained.

“Despite our best intentions, we make mistakes,” Dr. Gallagher said. The intention of the center directors is to solve problems, not to point fingers or assign blame when a medical error occurs. “The debriefing is really the heart of the simulation. It is where we try to make sense of what happened in the ICU or emergency room chaos.” Participants review recorded actions, discuss what happened, suggest what they would do differently in the future, and, if an error occurs, explain how they would inform a patient or family.

“At the end of the day, all this is about is changing the culture to help people to do the right thing,” Dr. Barach said.

The University of Miami added a 4-year curriculum on patient safety for medical students. The simulation challenges are designed to be relatively simple for students but are more complicated for experienced physicians, Dr. Barach said. “The long-term goals are to get the center to be a vital part of the community. We want to get throughput from medical students, practicing physicians, and nurses. We also want patient safety to become part of the certification process.”

MIAMI — The blades roared overhead as the Miami-Dade rescue helicopter approached the rooftop of University of Miami/Jackson Memorial Hospital shortly after dark.

Through the rain, emergency medical technicians rushed a pregnant woman injured in a car crash on Interstate 95. Doctors delivered the distressed baby via emergency cesarean section. An ob.gyn. administered oxygen, and the hypoxic newborn's color turned from blue to pink.

But these moments of high medical drama were not real. “Give the mother a fatal heart rhythm, and let's see how they respond,” said Chris Gallagher, M.D., of the department of anesthesiology at the University of Miami. He was addressing a technician in a control room separated from the activity in the emergency room by a one-way mirror.

The large crowd attending the grand opening of the University of Miami/Jackson Memorial Hospital Center for Patient Safety gathered closer around extra video monitors that had been set up so they could watch the simulated emergency unfold. The “bloody” actress on the gurney was deftly switched for one of the new, state-of-the-art mannequins in residence at the new center. After the crew had stabilized both the mother and baby mannequins, they gathered around a conference table on the hospital's renovated fourth floor for a debriefing of their performance.

The emergency scenario was staged as a kickoff for the first patient safety center of its kind in the United States, one that combines simulation with elements of engineering, ergonomic design, and high-tech monitoring and recording. Akin to a flight simulator for airline pilots, the emergency care component of the Center for Patient Safety challenges physicians and other health care workers in a realistic but safe environment where no patient is harmed.

The 2,000-square-foot simulation facility will be used to provide courses to enhance clinical, communication, and teamwork skills for health care professionals at all levels of training. The simulation facility currently trains medical students and anesthesiology residents. Courses are planned for multidisciplinary team training of residents and nurses in internal medicine, pediatrics, emergency medicine, obstetrics, and other specialties.

“It's a dream come true after 10 years,” said Paul Barach, M.D., director of the Center for Patient Safety.

The center is innovative for bringing together all of the major elements of patient safety. “I'm most proud of the integration,” said Dr. Barach, also of the department of anesthesiology at the university.

Although other institutions in the United States have some features of the program, he said, only the University of Miami center combines skill assessments simulation, an investigative team to debrief participants, a human factors and usability lab, and a strategy for promoting patient safety policies in Miami, the state of Florida, and, eventually, nationwide.

The center's immediate goals include developing and disseminating training programs for physicians, nurses, pharmacists, and risk managers; enhancing research on patient safety; and working with medical device companies to use better design and ergonomics to make their products safer.

Backed by an initial $5 million in funds from federal, state, and private sources, the center has 18 projects underway. (For more details, visit www.patientsafety.med.miami.edu

Dr. Barach's drive to establish the center stemmed in part from a medical error he experienced as a medical student. “I was told to do a central line procedure, but not told how to do it. The intern just told me to do it. I was just out of the military and did not question orders,” he said. “The patient suffered a hemothorax, was intubated, went to the ICU, and she died 4 days later.” The experience “haunted me for years.”

Although the mannequins are the focal point in each of the five skills assessment areas—three exam rooms, an operating room, and a room that can function as an ICU, emergency room, or ward room, “the focus is not on simulation, the focus is on the patient,” John C. Nelson, M.D., president of the American Medical Association, said during the opening celebration.

“Patient safety has to be much more on the minds of all of us,” Dr. Nelson said. “This is what our patients expect and our profession demands.”

Patient-centered goals of the center staff include developing better ways to disclose medical errors to patients and their families. Another goal is to identify the factors that patients consider when choosing a hospital, and how these may differ by cultural or ethnic identity, Dr. Barach explained.

“Despite our best intentions, we make mistakes,” Dr. Gallagher said. The intention of the center directors is to solve problems, not to point fingers or assign blame when a medical error occurs. “The debriefing is really the heart of the simulation. It is where we try to make sense of what happened in the ICU or emergency room chaos.” Participants review recorded actions, discuss what happened, suggest what they would do differently in the future, and, if an error occurs, explain how they would inform a patient or family.

“At the end of the day, all this is about is changing the culture to help people to do the right thing,” Dr. Barach said.

The University of Miami added a 4-year curriculum on patient safety for medical students. The simulation challenges are designed to be relatively simple for students but are more complicated for experienced physicians, Dr. Barach said. “The long-term goals are to get the center to be a vital part of the community. We want to get throughput from medical students, practicing physicians, and nurses. We also want patient safety to become part of the certification process.”

MIAMI — The blades roared overhead as the Miami-Dade rescue helicopter approached the rooftop of University of Miami/Jackson Memorial Hospital shortly after dark.

Through the rain, emergency medical technicians rushed a pregnant woman injured in a car crash on Interstate 95. Doctors delivered the distressed baby via emergency cesarean section. An ob.gyn. administered oxygen, and the hypoxic newborn's color turned from blue to pink.

But these moments of high medical drama were not real. “Give the mother a fatal heart rhythm, and let's see how they respond,” said Chris Gallagher, M.D., of the department of anesthesiology at the University of Miami. He was addressing a technician in a control room separated from the activity in the emergency room by a one-way mirror.

The large crowd attending the grand opening of the University of Miami/Jackson Memorial Hospital Center for Patient Safety gathered closer around extra video monitors that had been set up so they could watch the simulated emergency unfold. The “bloody” actress on the gurney was deftly switched for one of the new, state-of-the-art mannequins in residence at the new center. After the crew had stabilized both the mother and baby mannequins, they gathered around a conference table on the hospital's renovated fourth floor for a debriefing of their performance.

The emergency scenario was staged as a kickoff for the first patient safety center of its kind in the United States, one that combines simulation with elements of engineering, ergonomic design, and high-tech monitoring and recording. Akin to a flight simulator for airline pilots, the emergency care component of the Center for Patient Safety challenges physicians and other health care workers in a realistic but safe environment where no patient is harmed.

The 2,000-square-foot simulation facility will be used to provide courses to enhance clinical, communication, and teamwork skills for health care professionals at all levels of training. The simulation facility currently trains medical students and anesthesiology residents. Courses are planned for multidisciplinary team training of residents and nurses in internal medicine, pediatrics, emergency medicine, obstetrics, and other specialties.

“It's a dream come true after 10 years,” said Paul Barach, M.D., director of the Center for Patient Safety.

The center is innovative for bringing together all of the major elements of patient safety. “I'm most proud of the integration,” said Dr. Barach, also of the department of anesthesiology at the university.

Although other institutions in the United States have some features of the program, he said, only the University of Miami center combines skill assessments simulation, an investigative team to debrief participants, a human factors and usability lab, and a strategy for promoting patient safety policies in Miami, the state of Florida, and, eventually, nationwide.

The center's immediate goals include developing and disseminating training programs for physicians, nurses, pharmacists, and risk managers; enhancing research on patient safety; and working with medical device companies to use better design and ergonomics to make their products safer.

Backed by an initial $5 million in funds from federal, state, and private sources, the center has 18 projects underway. (For more details, visit www.patientsafety.med.miami.edu

Dr. Barach's drive to establish the center stemmed in part from a medical error he experienced as a medical student. “I was told to do a central line procedure, but not told how to do it. The intern just told me to do it. I was just out of the military and did not question orders,” he said. “The patient suffered a hemothorax, was intubated, went to the ICU, and she died 4 days later.” The experience “haunted me for years.”

Although the mannequins are the focal point in each of the five skills assessment areas—three exam rooms, an operating room, and a room that can function as an ICU, emergency room, or ward room, “the focus is not on simulation, the focus is on the patient,” John C. Nelson, M.D., president of the American Medical Association, said during the opening celebration.

“Patient safety has to be much more on the minds of all of us,” Dr. Nelson said. “This is what our patients expect and our profession demands.”

Patient-centered goals of the center staff include developing better ways to disclose medical errors to patients and their families. Another goal is to identify the factors that patients consider when choosing a hospital, and how these may differ by cultural or ethnic identity, Dr. Barach explained.

“Despite our best intentions, we make mistakes,” Dr. Gallagher said. The intention of the center directors is to solve problems, not to point fingers or assign blame when a medical error occurs. “The debriefing is really the heart of the simulation. It is where we try to make sense of what happened in the ICU or emergency room chaos.” Participants review recorded actions, discuss what happened, suggest what they would do differently in the future, and, if an error occurs, explain how they would inform a patient or family.

“At the end of the day, all this is about is changing the culture to help people to do the right thing,” Dr. Barach said.

The University of Miami added a 4-year curriculum on patient safety for medical students. The simulation challenges are designed to be relatively simple for students but are more complicated for experienced physicians, Dr. Barach said. “The long-term goals are to get the center to be a vital part of the community. We want to get throughput from medical students, practicing physicians, and nurses. We also want patient safety to become part of the certification process.”

FORT MYERS, FLA. — Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have comorbid conditions, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained.

“It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said. “We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

If there was not a 50% improvement in depression scores, it was a red flag. The PEARLS staff would then consult with the patient's primary care physician about initiation or adjustment of medication. “I ended up calling 52 people, mostly providers, about drug therapy and other patient factors,” Dr. Ciechanowski said.

FORT MYERS, FLA. — Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have comorbid conditions, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained.

“It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said. “We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

If there was not a 50% improvement in depression scores, it was a red flag. The PEARLS staff would then consult with the patient's primary care physician about initiation or adjustment of medication. “I ended up calling 52 people, mostly providers, about drug therapy and other patient factors,” Dr. Ciechanowski said.

FORT MYERS, FLA. — Home visits and follow-up telephone calls improved elderly depression in a program that used existing community services for seniors in Seattle, according to a presentation at the annual meeting of the Academy of Psychosomatic Medicine.

Rates of depression are higher in older adults who are socially isolated, have comorbid conditions, or are homebound. About one-fifth to one-sixth of elderly individuals in the United States have clinically significant depression. They are more likely to have minor depression or dysthymia, compared with their younger counterparts.

A 12-month, randomized, controlled trial showed the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) effectively improved depression among older adults at higher risk, specifically those who are physically impaired, socially isolated, and/or of lower socioeconomic status.

“It is home based, so in a way it is a systematized, stylized way to do house calls, but a postmodern version done by social workers, not doctors,” Paul Ciechanowski, M.D., explained.

“It's amazing how much extra information you get by observing and visiting patients in their own homes,” said Dr. Ciechanowski of the University of Washington, Seattle. The university runs PEARLS in collaboration with Senior Services Seattle/King County, Aging and Disability Services, and Public Health Seattle King County. The study was funded by the Centers for Disease Control and Prevention.

There were 138 participants, 99 referred from agencies and 39 who were self-referred. About half were diagnosed with dysthymia, the other half with minor depression. The mean age was 73 years, 79% were female, and the majority had a mean annual income of less than $10,000. At baseline, 35% were taking antidepressants. People were excluded if they had major depression or another psychiatric disorder, substance abuse, or a cognitive disorder.

After randomization, there were 66 patients in a routine care group and 72 in an intervention group. Routine care included referral and communication between the patient's primary care physician, the community agency social worker, and University of Washington researchers.

The intervention included a mean of 6.6 1-hour problem-solving treatment (PST) sessions in the home over 19 weeks. PST is effective, nonpsychiatric, and consistent with other modern self-management strategies in medical disease, Dr. Ciechanowski said. “We define and break down problems, establish realistic goals, and take small, incremental steps. They begin to feel empowered.”

The intervention also included one or more of the following: problem-solving counseling sessions, social activation, physical activity, and/or prescription of antidepressants.

If there was not a 50% improvement in depression scores, it was a red flag. The PEARLS staff would then consult with the patient's primary care physician about initiation or adjustment of medication. “I ended up calling 52 people, mostly providers, about drug therapy and other patient factors,” Dr. Ciechanowski said.

KEY BISCAYNE, FLA. — The 71-year-old woman's laboratory findings included a hemoglobin of 9.8 g/dL, an erythrocyte sedimentation rate of 94 mm/hr, and a fasting blood sugar level of 163 mg/dL. Her total serum protein was 4.2 g/dL (normal range, 6-8 g/dL), and her plasma glucagon was 405 pg/mL (normal range, 50-200 pg/mL).

Histology showed significant changes in upper skin strata, spongiosis, minor blister formations, and significant parakeratosis.

Abdominal CT scan and abdominal sonogram were negative. “I almost had to beg one of my surgeons to do a laparotomy,” Paul R. Vandersteen, M.D., said at the annual meeting of the Noah Worcester Dermatological Society. Endoscopy showed a large encapsulated tumor, 5 by 4 by 3 cm, at the head of the pancreas. There were no metastases.

Her diagnosis was glucagonoma syndrome, a rare α-cell tumor of the pancreas; there are only about 400 reported cases. The syndrome typically arises in a person's fifth decade. “What is striking in the [two] patients I've seen … is the significant pain, similar to a burn,” said Dr. Vandersteen, a dermatologist at MeritCare Medical Group in Fargo, N.D.

Necrolytic migratory erythema (NME) is the hallmark sign and the overall incidence of NME is 57% and up to 77% at initial presentation. It typically appears periorally or perinasally, as well as on the lower abdomen, perineum, genitals, and lower extremities. Generally, the erythematous patch follows a 7- to 14-day cycle during which it blisters centrally, erodes and crusts over, and heals with hyperpigmentation.

Glucagonoma is also known as the 4D syndrome, for dermatitis, diabetes, depression, and deep venous thrombosis. In addition to NME and diabetes mellitus, the most common presenting symptoms are weight loss, cheilosis, stomatitis, diarrhea, weakness, and mental changes. Laboratory signs include hypoaminoacidemia and hypoproteinemia, said Dr. Vandersteen, who is also a clinical professor of medicine at the University of North Dakota, Grand Forks.

The differential diagnosis includes acrodermatitis enteropathica, essential fatty acid deficiency, annular chronic lupus erythematosus, adverse drug reactions, contact dermatitis, and various vitamin deficiencies.

Imaging is helpful for diagnosis, particularly endoscopic ultrasonography and abdominal CT scans, “but remember, ours was negative,” Dr. Vandersteen said. Other imaging modalities are less useful, such as angiography, transabdominal ultrasound, or somatostatin receptor scintigraphy.

Treatment was a partial pancreatectomy. Postoperatively, the patient developed another deep venous thrombosis. Her glucagon level decreased significantly to 126 pg/mL at 4 days. Her NME gradually resolved over the following month.

Seven years after initial presentation the patient had pancreatic surgery. Mean survival is 3-7 years, but some live up to 20 years. Another 7 years later, she was hospitalized and a large mass was detected. Dr. Vandersteen said, “They decided to do nothing; she went home and succumbed 2 days later.”

KEY BISCAYNE, FLA. — The 71-year-old woman's laboratory findings included a hemoglobin of 9.8 g/dL, an erythrocyte sedimentation rate of 94 mm/hr, and a fasting blood sugar level of 163 mg/dL. Her total serum protein was 4.2 g/dL (normal range, 6-8 g/dL), and her plasma glucagon was 405 pg/mL (normal range, 50-200 pg/mL).

Histology showed significant changes in upper skin strata, spongiosis, minor blister formations, and significant parakeratosis.

Abdominal CT scan and abdominal sonogram were negative. “I almost had to beg one of my surgeons to do a laparotomy,” Paul R. Vandersteen, M.D., said at the annual meeting of the Noah Worcester Dermatological Society. Endoscopy showed a large encapsulated tumor, 5 by 4 by 3 cm, at the head of the pancreas. There were no metastases.

Her diagnosis was glucagonoma syndrome, a rare α-cell tumor of the pancreas; there are only about 400 reported cases. The syndrome typically arises in a person's fifth decade. “What is striking in the [two] patients I've seen … is the significant pain, similar to a burn,” said Dr. Vandersteen, a dermatologist at MeritCare Medical Group in Fargo, N.D.

Necrolytic migratory erythema (NME) is the hallmark sign and the overall incidence of NME is 57% and up to 77% at initial presentation. It typically appears periorally or perinasally, as well as on the lower abdomen, perineum, genitals, and lower extremities. Generally, the erythematous patch follows a 7- to 14-day cycle during which it blisters centrally, erodes and crusts over, and heals with hyperpigmentation.

Glucagonoma is also known as the 4D syndrome, for dermatitis, diabetes, depression, and deep venous thrombosis. In addition to NME and diabetes mellitus, the most common presenting symptoms are weight loss, cheilosis, stomatitis, diarrhea, weakness, and mental changes. Laboratory signs include hypoaminoacidemia and hypoproteinemia, said Dr. Vandersteen, who is also a clinical professor of medicine at the University of North Dakota, Grand Forks.

The differential diagnosis includes acrodermatitis enteropathica, essential fatty acid deficiency, annular chronic lupus erythematosus, adverse drug reactions, contact dermatitis, and various vitamin deficiencies.

Imaging is helpful for diagnosis, particularly endoscopic ultrasonography and abdominal CT scans, “but remember, ours was negative,” Dr. Vandersteen said. Other imaging modalities are less useful, such as angiography, transabdominal ultrasound, or somatostatin receptor scintigraphy.

Treatment was a partial pancreatectomy. Postoperatively, the patient developed another deep venous thrombosis. Her glucagon level decreased significantly to 126 pg/mL at 4 days. Her NME gradually resolved over the following month.

Seven years after initial presentation the patient had pancreatic surgery. Mean survival is 3-7 years, but some live up to 20 years. Another 7 years later, she was hospitalized and a large mass was detected. Dr. Vandersteen said, “They decided to do nothing; she went home and succumbed 2 days later.”

KEY BISCAYNE, FLA. — The 71-year-old woman's laboratory findings included a hemoglobin of 9.8 g/dL, an erythrocyte sedimentation rate of 94 mm/hr, and a fasting blood sugar level of 163 mg/dL. Her total serum protein was 4.2 g/dL (normal range, 6-8 g/dL), and her plasma glucagon was 405 pg/mL (normal range, 50-200 pg/mL).

Histology showed significant changes in upper skin strata, spongiosis, minor blister formations, and significant parakeratosis.

Abdominal CT scan and abdominal sonogram were negative. “I almost had to beg one of my surgeons to do a laparotomy,” Paul R. Vandersteen, M.D., said at the annual meeting of the Noah Worcester Dermatological Society. Endoscopy showed a large encapsulated tumor, 5 by 4 by 3 cm, at the head of the pancreas. There were no metastases.

Her diagnosis was glucagonoma syndrome, a rare α-cell tumor of the pancreas; there are only about 400 reported cases. The syndrome typically arises in a person's fifth decade. “What is striking in the [two] patients I've seen … is the significant pain, similar to a burn,” said Dr. Vandersteen, a dermatologist at MeritCare Medical Group in Fargo, N.D.

Necrolytic migratory erythema (NME) is the hallmark sign and the overall incidence of NME is 57% and up to 77% at initial presentation. It typically appears periorally or perinasally, as well as on the lower abdomen, perineum, genitals, and lower extremities. Generally, the erythematous patch follows a 7- to 14-day cycle during which it blisters centrally, erodes and crusts over, and heals with hyperpigmentation.

Glucagonoma is also known as the 4D syndrome, for dermatitis, diabetes, depression, and deep venous thrombosis. In addition to NME and diabetes mellitus, the most common presenting symptoms are weight loss, cheilosis, stomatitis, diarrhea, weakness, and mental changes. Laboratory signs include hypoaminoacidemia and hypoproteinemia, said Dr. Vandersteen, who is also a clinical professor of medicine at the University of North Dakota, Grand Forks.

The differential diagnosis includes acrodermatitis enteropathica, essential fatty acid deficiency, annular chronic lupus erythematosus, adverse drug reactions, contact dermatitis, and various vitamin deficiencies.

Imaging is helpful for diagnosis, particularly endoscopic ultrasonography and abdominal CT scans, “but remember, ours was negative,” Dr. Vandersteen said. Other imaging modalities are less useful, such as angiography, transabdominal ultrasound, or somatostatin receptor scintigraphy.

Treatment was a partial pancreatectomy. Postoperatively, the patient developed another deep venous thrombosis. Her glucagon level decreased significantly to 126 pg/mL at 4 days. Her NME gradually resolved over the following month.

Seven years after initial presentation the patient had pancreatic surgery. Mean survival is 3-7 years, but some live up to 20 years. Another 7 years later, she was hospitalized and a large mass was detected. Dr. Vandersteen said, “They decided to do nothing; she went home and succumbed 2 days later.”

KEY BISCAYNE, FLA. — A full-body examination is a quick and useful tool to screen patients and uncover benign and cancerous lesions that would otherwise remain undetected, according to a study presented at the annual meeting of the Noah Worcester Dermatological Society.

Kenneth B. Bielinski, M.D., offered a full-body exam to all new patients and those not previously given the option. Of the 1,148 patients offered a full-body exam during the 4-month study, 634 (55%) declined.

“I was surprised by the high number who said no. Over half the clients—more than I would have thought—said they did not want it or thought they did not need it,” said Dr. Bielinski, a private practice dermatologist in Oak Lawn, Ill.

Of the 514 consenting patients, 399 full-body exams (78%) were negative for clinically significant findings. Of the patients with positive findings, 33 had pathology-proven skin cancers; these included 23 basal cell carcinomas, 4 squamous cell carcinomas, 1 sebaceous carcinoma, and 5 melanomas.

The full-body exam uncovered 12 of the basal cell carcinomas, 3 of the squamous cell carcinomas, and 2 of the melanomas. These lesions would have otherwise remained undetected. “These were in areas we would not normally check,” Dr. Bielinski said. “I was not exactly surprised by the number of skin cancers, but it shows what is being missed.”

Among the consenting patients, 46 had actinic keratoses, 12 of which were detected by the full-body exam. There were 36 people with pathology-proven dysplastic nevi, including 32 found via the full-body exam.

Many physicians do not offer a full-body examination because of a lack of time,. “I thought it was easy to do if a patient is prepped ahead of time.” In his practice, patients are given a gown to change into and are ready for the exam when Dr. Bielinski or a physician assistant enters the room.

Although patients may opt to sign a waiver declining the full-body examination, the exams are required for all of Dr. Bielinski's high-risk patients.

More than 1 million new cases of skin cancer are diagnosed annually. Also, there is a high cure rate for basal cell carcinomas and squamous cell carcinomas if detected early. There are an estimated 91,000 new cases of melanoma each year; melanoma mortality is high, accounting for 7,600 of the 9,800 skin cancer deaths annually.

KEY BISCAYNE, FLA. — A full-body examination is a quick and useful tool to screen patients and uncover benign and cancerous lesions that would otherwise remain undetected, according to a study presented at the annual meeting of the Noah Worcester Dermatological Society.

Kenneth B. Bielinski, M.D., offered a full-body exam to all new patients and those not previously given the option. Of the 1,148 patients offered a full-body exam during the 4-month study, 634 (55%) declined.

“I was surprised by the high number who said no. Over half the clients—more than I would have thought—said they did not want it or thought they did not need it,” said Dr. Bielinski, a private practice dermatologist in Oak Lawn, Ill.

Of the 514 consenting patients, 399 full-body exams (78%) were negative for clinically significant findings. Of the patients with positive findings, 33 had pathology-proven skin cancers; these included 23 basal cell carcinomas, 4 squamous cell carcinomas, 1 sebaceous carcinoma, and 5 melanomas.

The full-body exam uncovered 12 of the basal cell carcinomas, 3 of the squamous cell carcinomas, and 2 of the melanomas. These lesions would have otherwise remained undetected. “These were in areas we would not normally check,” Dr. Bielinski said. “I was not exactly surprised by the number of skin cancers, but it shows what is being missed.”

Among the consenting patients, 46 had actinic keratoses, 12 of which were detected by the full-body exam. There were 36 people with pathology-proven dysplastic nevi, including 32 found via the full-body exam.

Many physicians do not offer a full-body examination because of a lack of time,. “I thought it was easy to do if a patient is prepped ahead of time.” In his practice, patients are given a gown to change into and are ready for the exam when Dr. Bielinski or a physician assistant enters the room.

Although patients may opt to sign a waiver declining the full-body examination, the exams are required for all of Dr. Bielinski's high-risk patients.

More than 1 million new cases of skin cancer are diagnosed annually. Also, there is a high cure rate for basal cell carcinomas and squamous cell carcinomas if detected early. There are an estimated 91,000 new cases of melanoma each year; melanoma mortality is high, accounting for 7,600 of the 9,800 skin cancer deaths annually.

KEY BISCAYNE, FLA. — A full-body examination is a quick and useful tool to screen patients and uncover benign and cancerous lesions that would otherwise remain undetected, according to a study presented at the annual meeting of the Noah Worcester Dermatological Society.

Kenneth B. Bielinski, M.D., offered a full-body exam to all new patients and those not previously given the option. Of the 1,148 patients offered a full-body exam during the 4-month study, 634 (55%) declined.

“I was surprised by the high number who said no. Over half the clients—more than I would have thought—said they did not want it or thought they did not need it,” said Dr. Bielinski, a private practice dermatologist in Oak Lawn, Ill.

Of the 514 consenting patients, 399 full-body exams (78%) were negative for clinically significant findings. Of the patients with positive findings, 33 had pathology-proven skin cancers; these included 23 basal cell carcinomas, 4 squamous cell carcinomas, 1 sebaceous carcinoma, and 5 melanomas.

The full-body exam uncovered 12 of the basal cell carcinomas, 3 of the squamous cell carcinomas, and 2 of the melanomas. These lesions would have otherwise remained undetected. “These were in areas we would not normally check,” Dr. Bielinski said. “I was not exactly surprised by the number of skin cancers, but it shows what is being missed.”

Among the consenting patients, 46 had actinic keratoses, 12 of which were detected by the full-body exam. There were 36 people with pathology-proven dysplastic nevi, including 32 found via the full-body exam.

Many physicians do not offer a full-body examination because of a lack of time,. “I thought it was easy to do if a patient is prepped ahead of time.” In his practice, patients are given a gown to change into and are ready for the exam when Dr. Bielinski or a physician assistant enters the room.

Although patients may opt to sign a waiver declining the full-body examination, the exams are required for all of Dr. Bielinski's high-risk patients.

More than 1 million new cases of skin cancer are diagnosed annually. Also, there is a high cure rate for basal cell carcinomas and squamous cell carcinomas if detected early. There are an estimated 91,000 new cases of melanoma each year; melanoma mortality is high, accounting for 7,600 of the 9,800 skin cancer deaths annually.