Doug Brunk

SAN DIEGO — Any physician who cares for newborns should consider neonatal herpes simplex virus infection a must-make diagnosis, Dr. Richard F. Jacobs said.

"This is one of my top 10 'please don't let me miss this' diagnoses," said Dr. Jacobs, a longtime member of the National Institutes of Health's Collaborative Antiviral Study Group. "You can't miss this diagnosis because HSV untreated has a natural history that is truly horrible."

An estimated 15%-20% of women of childbearing age have latent HSV infection that would be a potential factor in pregnancy. The risk of transmission to offspring is believed to be about 50% in mothers who have a primary infection and skin lesions present and 3%-4% in mothers with a recurrent infection and skin lesions present. Actual neonatal disease is about 1 per 7,500 live births.

"Visible lesions would be an automatic indication to go to C-section unless there have been prolonged ruptured membranes," Dr. Jacobs said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "With prolonged ruptured membranes, you don't get any benefit from C-section."

Neonatal HSV presents as one of three clinical types: skin, eye, or mucous membranes (SEM); central nervous system (CNS); or disseminated. Neonates with SEM HSV present at a mean 11 days old and have discrete skin vesicles in 80% of cases. "That means that you have to look carefully for the other 20% during your clinical exam," said Dr. Jacobs, who is also chair of pediatrics at the University of Arkansas, Little Rock. "Look in any mucous membrane, anywhere on the skin. You can find them in the conjunctiva or in the mouth." A CSF polymerase chain reaction (PCR) that is negative is required to make the diagnosis of the SEM form of HSV.

If the SEM form of the disease goes untreated, 70% of cases will progress to CNS or disseminated disease. The recommended course of treatment is 20 mg/kg per dose of acyclovir every 8 hours for 2 weeks. "People with cold sores can transmit to the skin of newborns, but all of these babies will be normal if you treat them," Dr. Jacobs said. "Survival is 100% if they're treated."

Neonates with the CNS form typically present with encephalitis virus at a mean 16 days old, likely caused by retrograde axonal transmission of HSV. An infant may get HSV in the nose or eyes that spreads transneuronally to the brain, but the CNS form of neonatal HSV doesn't present like sepsis, he explained.

Other telltale signs include fever and lethargy for 1-2 days followed by the sudden onset of nearly intractable seizures. Initially the infection is localized to the temporal lobes, but it spreads to the brainstem. If the infection goes untreated, the mortality is greater than 50%. With acyclovir treatment the mortality is 15%.

Neonates with the disseminated form of HSV disease present at a mean 11 days old with symptoms that mimic sepsis. Encephalitis is present in 60%-70% of cases; pneumonitis and hepatitis/coagulopathy also are common. The process involves a blood-borne seeding of the CNS, with multiple areas of cortical hemorrhagic necrosis. If the disseminated form of the disease goes untreated, the mortality exceeds 80%. With acyclovir treatment the mortality is greater than 50%, Dr. Jacobs said.

Only about one-half of neonates with the CNS or disseminated forms of disease have cutaneous lesions. "If you do see a cutaneous skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise," Dr. Jacobs said. "I don't care if that fluid is clear, cloudy, or green."

Dr. Jacobs reported that he had no conflicts to disclose.

If you see a 'skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise.' DR. JACOBS

SAN DIEGO — Any physician who cares for newborns should consider neonatal herpes simplex virus infection a must-make diagnosis, Dr. Richard F. Jacobs said.

"This is one of my top 10 'please don't let me miss this' diagnoses," said Dr. Jacobs, a longtime member of the National Institutes of Health's Collaborative Antiviral Study Group. "You can't miss this diagnosis because HSV untreated has a natural history that is truly horrible."

An estimated 15%-20% of women of childbearing age have latent HSV infection that would be a potential factor in pregnancy. The risk of transmission to offspring is believed to be about 50% in mothers who have a primary infection and skin lesions present and 3%-4% in mothers with a recurrent infection and skin lesions present. Actual neonatal disease is about 1 per 7,500 live births.

"Visible lesions would be an automatic indication to go to C-section unless there have been prolonged ruptured membranes," Dr. Jacobs said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "With prolonged ruptured membranes, you don't get any benefit from C-section."

Neonatal HSV presents as one of three clinical types: skin, eye, or mucous membranes (SEM); central nervous system (CNS); or disseminated. Neonates with SEM HSV present at a mean 11 days old and have discrete skin vesicles in 80% of cases. "That means that you have to look carefully for the other 20% during your clinical exam," said Dr. Jacobs, who is also chair of pediatrics at the University of Arkansas, Little Rock. "Look in any mucous membrane, anywhere on the skin. You can find them in the conjunctiva or in the mouth." A CSF polymerase chain reaction (PCR) that is negative is required to make the diagnosis of the SEM form of HSV.

If the SEM form of the disease goes untreated, 70% of cases will progress to CNS or disseminated disease. The recommended course of treatment is 20 mg/kg per dose of acyclovir every 8 hours for 2 weeks. "People with cold sores can transmit to the skin of newborns, but all of these babies will be normal if you treat them," Dr. Jacobs said. "Survival is 100% if they're treated."

Neonates with the CNS form typically present with encephalitis virus at a mean 16 days old, likely caused by retrograde axonal transmission of HSV. An infant may get HSV in the nose or eyes that spreads transneuronally to the brain, but the CNS form of neonatal HSV doesn't present like sepsis, he explained.

Other telltale signs include fever and lethargy for 1-2 days followed by the sudden onset of nearly intractable seizures. Initially the infection is localized to the temporal lobes, but it spreads to the brainstem. If the infection goes untreated, the mortality is greater than 50%. With acyclovir treatment the mortality is 15%.

Neonates with the disseminated form of HSV disease present at a mean 11 days old with symptoms that mimic sepsis. Encephalitis is present in 60%-70% of cases; pneumonitis and hepatitis/coagulopathy also are common. The process involves a blood-borne seeding of the CNS, with multiple areas of cortical hemorrhagic necrosis. If the disseminated form of the disease goes untreated, the mortality exceeds 80%. With acyclovir treatment the mortality is greater than 50%, Dr. Jacobs said.

Only about one-half of neonates with the CNS or disseminated forms of disease have cutaneous lesions. "If you do see a cutaneous skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise," Dr. Jacobs said. "I don't care if that fluid is clear, cloudy, or green."

Dr. Jacobs reported that he had no conflicts to disclose.

If you see a 'skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise.' DR. JACOBS

SAN DIEGO — Any physician who cares for newborns should consider neonatal herpes simplex virus infection a must-make diagnosis, Dr. Richard F. Jacobs said.

"This is one of my top 10 'please don't let me miss this' diagnoses," said Dr. Jacobs, a longtime member of the National Institutes of Health's Collaborative Antiviral Study Group. "You can't miss this diagnosis because HSV untreated has a natural history that is truly horrible."

An estimated 15%-20% of women of childbearing age have latent HSV infection that would be a potential factor in pregnancy. The risk of transmission to offspring is believed to be about 50% in mothers who have a primary infection and skin lesions present and 3%-4% in mothers with a recurrent infection and skin lesions present. Actual neonatal disease is about 1 per 7,500 live births.

"Visible lesions would be an automatic indication to go to C-section unless there have been prolonged ruptured membranes," Dr. Jacobs said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "With prolonged ruptured membranes, you don't get any benefit from C-section."

Neonatal HSV presents as one of three clinical types: skin, eye, or mucous membranes (SEM); central nervous system (CNS); or disseminated. Neonates with SEM HSV present at a mean 11 days old and have discrete skin vesicles in 80% of cases. "That means that you have to look carefully for the other 20% during your clinical exam," said Dr. Jacobs, who is also chair of pediatrics at the University of Arkansas, Little Rock. "Look in any mucous membrane, anywhere on the skin. You can find them in the conjunctiva or in the mouth." A CSF polymerase chain reaction (PCR) that is negative is required to make the diagnosis of the SEM form of HSV.

If the SEM form of the disease goes untreated, 70% of cases will progress to CNS or disseminated disease. The recommended course of treatment is 20 mg/kg per dose of acyclovir every 8 hours for 2 weeks. "People with cold sores can transmit to the skin of newborns, but all of these babies will be normal if you treat them," Dr. Jacobs said. "Survival is 100% if they're treated."

Neonates with the CNS form typically present with encephalitis virus at a mean 16 days old, likely caused by retrograde axonal transmission of HSV. An infant may get HSV in the nose or eyes that spreads transneuronally to the brain, but the CNS form of neonatal HSV doesn't present like sepsis, he explained.

Other telltale signs include fever and lethargy for 1-2 days followed by the sudden onset of nearly intractable seizures. Initially the infection is localized to the temporal lobes, but it spreads to the brainstem. If the infection goes untreated, the mortality is greater than 50%. With acyclovir treatment the mortality is 15%.

Neonates with the disseminated form of HSV disease present at a mean 11 days old with symptoms that mimic sepsis. Encephalitis is present in 60%-70% of cases; pneumonitis and hepatitis/coagulopathy also are common. The process involves a blood-borne seeding of the CNS, with multiple areas of cortical hemorrhagic necrosis. If the disseminated form of the disease goes untreated, the mortality exceeds 80%. With acyclovir treatment the mortality is greater than 50%, Dr. Jacobs said.

Only about one-half of neonates with the CNS or disseminated forms of disease have cutaneous lesions. "If you do see a cutaneous skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise," Dr. Jacobs said. "I don't care if that fluid is clear, cloudy, or green."

Dr. Jacobs reported that he had no conflicts to disclose.

If you see a 'skin lesion with an ulcerative base that is necrotic, that is HSV in a baby until proven otherwise.' DR. JACOBS

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

"We want to know how long it's been there and what the associated symptoms are," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?"

Such questions can help determine what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that "begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix," Dr. Pransky said. "You can milk out the secretions. If you get that kind of discharge, we generally recommend surgical excision, and ultimately recurrent acute infection occurs. If there's no discharge we'll leave it alone."

Incising and draining preauricular anomalies make the ultimate surgical excision more difficult, he added. "These need to be treated conservatively with antibiotics and warm compresses … until the ultimate surgical excision can be carried out."

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. "These are a lot more challenging to manage surgically," Dr. Pransky said. "Fortunately they are rare."

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. "If you milk it you'll see strandy secretions, which are probably mucus," he said. "I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract."

Second branchial cysts are "soft and fluctuate and frequently present as a soft swelling, not as an infectious problem," he said. Other assorted second branchial anomalies include skin tags, punctums, or cartilaginous remnants.

Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. "When you aspirate the lesion, you're going to get a mixed polymicrobial infection," Dr. Pransky said. "That's because you're getting organisms from the hypopharynx."

These anomalies may also present as acute thyroiditis. "That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck," he said. "When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly."

Midline neck masses are also common. The three most common diagnoses are thyroglossal duct cyst, dermoid cyst, and lymphadenitis. Location and the clinical picture at presentation of the swelling are helpful in determining the correct diagnosis.

Lymphadenitis tends to be submental and associated with infection of either the chin region (often from acne) or teeth.

Dermoids can occur anywhere from the submental region to the suprasternal notch and are usually small, quite mobile, and located in the subcutaneous tissue.

Thyroglossal duct cysts are very common and generally are located at the level of or just below the hyoid. These are anatomically beneath the strap muscles of the neck and therefore are less mobile, often present after an upper respiratory infection, and tend to be larger than dermoids.

Another congenital neck mass Dr. Pransky discussed is pilomatixoma, which is a tumor of the hair cell shaft that grows slowly, is painless, and appears in different regions on the neck and face. These tumors feel firm and gritty, are bluish in color, and contain deposits of calcium.

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole that can extend up to the tonsillar fossae and have "strandy secretions, which are probably mucus." Courtesy Dr. Seth M. Pransky

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

"We want to know how long it's been there and what the associated symptoms are," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?"

Such questions can help determine what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that "begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix," Dr. Pransky said. "You can milk out the secretions. If you get that kind of discharge, we generally recommend surgical excision, and ultimately recurrent acute infection occurs. If there's no discharge we'll leave it alone."

Incising and draining preauricular anomalies make the ultimate surgical excision more difficult, he added. "These need to be treated conservatively with antibiotics and warm compresses … until the ultimate surgical excision can be carried out."

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. "These are a lot more challenging to manage surgically," Dr. Pransky said. "Fortunately they are rare."

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. "If you milk it you'll see strandy secretions, which are probably mucus," he said. "I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract."

Second branchial cysts are "soft and fluctuate and frequently present as a soft swelling, not as an infectious problem," he said. Other assorted second branchial anomalies include skin tags, punctums, or cartilaginous remnants.

Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. "When you aspirate the lesion, you're going to get a mixed polymicrobial infection," Dr. Pransky said. "That's because you're getting organisms from the hypopharynx."

These anomalies may also present as acute thyroiditis. "That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck," he said. "When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly."

Midline neck masses are also common. The three most common diagnoses are thyroglossal duct cyst, dermoid cyst, and lymphadenitis. Location and the clinical picture at presentation of the swelling are helpful in determining the correct diagnosis.

Lymphadenitis tends to be submental and associated with infection of either the chin region (often from acne) or teeth.

Dermoids can occur anywhere from the submental region to the suprasternal notch and are usually small, quite mobile, and located in the subcutaneous tissue.

Thyroglossal duct cysts are very common and generally are located at the level of or just below the hyoid. These are anatomically beneath the strap muscles of the neck and therefore are less mobile, often present after an upper respiratory infection, and tend to be larger than dermoids.

Another congenital neck mass Dr. Pransky discussed is pilomatixoma, which is a tumor of the hair cell shaft that grows slowly, is painless, and appears in different regions on the neck and face. These tumors feel firm and gritty, are bluish in color, and contain deposits of calcium.

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole that can extend up to the tonsillar fossae and have "strandy secretions, which are probably mucus." Courtesy Dr. Seth M. Pransky

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

"We want to know how long it's been there and what the associated symptoms are," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?"

Such questions can help determine what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that "begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix," Dr. Pransky said. "You can milk out the secretions. If you get that kind of discharge, we generally recommend surgical excision, and ultimately recurrent acute infection occurs. If there's no discharge we'll leave it alone."

Incising and draining preauricular anomalies make the ultimate surgical excision more difficult, he added. "These need to be treated conservatively with antibiotics and warm compresses … until the ultimate surgical excision can be carried out."

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. "These are a lot more challenging to manage surgically," Dr. Pransky said. "Fortunately they are rare."

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. "If you milk it you'll see strandy secretions, which are probably mucus," he said. "I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract."

Second branchial cysts are "soft and fluctuate and frequently present as a soft swelling, not as an infectious problem," he said. Other assorted second branchial anomalies include skin tags, punctums, or cartilaginous remnants.

Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. "When you aspirate the lesion, you're going to get a mixed polymicrobial infection," Dr. Pransky said. "That's because you're getting organisms from the hypopharynx."

These anomalies may also present as acute thyroiditis. "That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck," he said. "When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly."

Midline neck masses are also common. The three most common diagnoses are thyroglossal duct cyst, dermoid cyst, and lymphadenitis. Location and the clinical picture at presentation of the swelling are helpful in determining the correct diagnosis.

Lymphadenitis tends to be submental and associated with infection of either the chin region (often from acne) or teeth.

Dermoids can occur anywhere from the submental region to the suprasternal notch and are usually small, quite mobile, and located in the subcutaneous tissue.

Thyroglossal duct cysts are very common and generally are located at the level of or just below the hyoid. These are anatomically beneath the strap muscles of the neck and therefore are less mobile, often present after an upper respiratory infection, and tend to be larger than dermoids.

Another congenital neck mass Dr. Pransky discussed is pilomatixoma, which is a tumor of the hair cell shaft that grows slowly, is painless, and appears in different regions on the neck and face. These tumors feel firm and gritty, are bluish in color, and contain deposits of calcium.

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole that can extend up to the tonsillar fossae and have "strandy secretions, which are probably mucus." Courtesy Dr. Seth M. Pransky

LAS VEGAS — The way Dr. Vic A. Narurkar sees it, multimodal therapy is integral to most noninvasive dermatologic treatments.

"We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They complement each other, but we need to do controlled studies to see if there is true synergy, for example, between injectables and fractional resurfacing."

He discussed the role of multimodal therapy for treating several conditions:

▸ Acne and acne scarring. Prevention options include topical and systemic agents and devices for acute treatment. "We then can correct acne scars with Fraxel laser and injectable fillers such as Juvéderm," said Dr. Narurkar, a dermatologist who practices in San Francisco. Posttreatment acne still needs to be controlled with topical agents.

Isolaz, a device from Aesthera Corp., uses pneumatics to cleanse pores mechanically; it is cleared by the Food and Drug Administration to treat pustular and comedonal acne as well as mild to moderate acne vulgaris. "I call this dermatologic fantasy, because it's this extrusion of pores that we all strive for," said Dr. Narurkar, who is also associate professor of clinical dermatology at the University of California, Davis.

"You get mechanical cleansing by the application of gentle suction. What's interesting about this technology is that you can see immediate impact, similar to cortisone injections. If you combine it with topical retinoids and topical antibiotics, you get an even better result."

▸ Rosacea. Prevention and management options include topical agents such as azelaic acid, metronidazole or sulfur, and oral antibiotics. Treatment of diffuse and isolated telangiectasias "is most effective with the use of vascular lasers—pulsed dye or pulsed KTP [potassium-titanyl-phosphate]—or with the second- and third-generation intense pulsed light sources," he said.

▸ Melasma. Dr. Narurkar called this condition "the sin of dermatology," noting that melasma is difficult to treat and manage. "We pretreat with hydroquinones or retinoids," he said. "The only laser I'll use for therapy-resistant melasma is nonablative fractional resurfacing with the Fraxel Re:Store Laser. I haven't had success with any other laser and you can still get recurrence if it is not managed topically."

For posttreatment, he suggests hydroquinones and retinoids and daily use of a broad spectrum sunscreen. "If patients can avoid birth control pills and other estrogen agents, that's even better," he said.

▸ Skin rejuvenation. For optimal results he recommends "the four Rs": retain and replenish with skin care and sunscreen, resurface with devices, relax with botulinum toxins, and refill with dermal fillers.

Acute treatment of mild to moderate photoaging can be achieved via photofacials with pulsed light sources, vascular and pigmented lesion lasers, and mild nonablative fractional resurfacing.

Treatment of moderate to severe photoaging can be achieved with photodynamic therapy and aggressive nonablative and ablative fractional resurfacing. "For advanced photoaging, you can enhance IPL [intense-pulsed light] and PDL [pulsed dye laser] treatments with Levulan," he said. "You need fewer treatments, there are more immediate results, but there is significantly more down time."

Dr. Narurkar disclosed that he is a consultant to and has performed clinical trials for Aesthera Corp., Allergan Inc., BioForm Medical Inc., Palomar Medical Technologies Inc., and Reliant Technologies Inc.

'We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined.' DR. NARURKAR

LAS VEGAS — The way Dr. Vic A. Narurkar sees it, multimodal therapy is integral to most noninvasive dermatologic treatments.

"We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They complement each other, but we need to do controlled studies to see if there is true synergy, for example, between injectables and fractional resurfacing."

He discussed the role of multimodal therapy for treating several conditions:

▸ Acne and acne scarring. Prevention options include topical and systemic agents and devices for acute treatment. "We then can correct acne scars with Fraxel laser and injectable fillers such as Juvéderm," said Dr. Narurkar, a dermatologist who practices in San Francisco. Posttreatment acne still needs to be controlled with topical agents.

Isolaz, a device from Aesthera Corp., uses pneumatics to cleanse pores mechanically; it is cleared by the Food and Drug Administration to treat pustular and comedonal acne as well as mild to moderate acne vulgaris. "I call this dermatologic fantasy, because it's this extrusion of pores that we all strive for," said Dr. Narurkar, who is also associate professor of clinical dermatology at the University of California, Davis.

"You get mechanical cleansing by the application of gentle suction. What's interesting about this technology is that you can see immediate impact, similar to cortisone injections. If you combine it with topical retinoids and topical antibiotics, you get an even better result."

▸ Rosacea. Prevention and management options include topical agents such as azelaic acid, metronidazole or sulfur, and oral antibiotics. Treatment of diffuse and isolated telangiectasias "is most effective with the use of vascular lasers—pulsed dye or pulsed KTP [potassium-titanyl-phosphate]—or with the second- and third-generation intense pulsed light sources," he said.

▸ Melasma. Dr. Narurkar called this condition "the sin of dermatology," noting that melasma is difficult to treat and manage. "We pretreat with hydroquinones or retinoids," he said. "The only laser I'll use for therapy-resistant melasma is nonablative fractional resurfacing with the Fraxel Re:Store Laser. I haven't had success with any other laser and you can still get recurrence if it is not managed topically."

For posttreatment, he suggests hydroquinones and retinoids and daily use of a broad spectrum sunscreen. "If patients can avoid birth control pills and other estrogen agents, that's even better," he said.

▸ Skin rejuvenation. For optimal results he recommends "the four Rs": retain and replenish with skin care and sunscreen, resurface with devices, relax with botulinum toxins, and refill with dermal fillers.

Acute treatment of mild to moderate photoaging can be achieved via photofacials with pulsed light sources, vascular and pigmented lesion lasers, and mild nonablative fractional resurfacing.

Treatment of moderate to severe photoaging can be achieved with photodynamic therapy and aggressive nonablative and ablative fractional resurfacing. "For advanced photoaging, you can enhance IPL [intense-pulsed light] and PDL [pulsed dye laser] treatments with Levulan," he said. "You need fewer treatments, there are more immediate results, but there is significantly more down time."

Dr. Narurkar disclosed that he is a consultant to and has performed clinical trials for Aesthera Corp., Allergan Inc., BioForm Medical Inc., Palomar Medical Technologies Inc., and Reliant Technologies Inc.

'We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined.' DR. NARURKAR

LAS VEGAS — The way Dr. Vic A. Narurkar sees it, multimodal therapy is integral to most noninvasive dermatologic treatments.

"We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined," he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They complement each other, but we need to do controlled studies to see if there is true synergy, for example, between injectables and fractional resurfacing."

He discussed the role of multimodal therapy for treating several conditions:

▸ Acne and acne scarring. Prevention options include topical and systemic agents and devices for acute treatment. "We then can correct acne scars with Fraxel laser and injectable fillers such as Juvéderm," said Dr. Narurkar, a dermatologist who practices in San Francisco. Posttreatment acne still needs to be controlled with topical agents.

Isolaz, a device from Aesthera Corp., uses pneumatics to cleanse pores mechanically; it is cleared by the Food and Drug Administration to treat pustular and comedonal acne as well as mild to moderate acne vulgaris. "I call this dermatologic fantasy, because it's this extrusion of pores that we all strive for," said Dr. Narurkar, who is also associate professor of clinical dermatology at the University of California, Davis.

"You get mechanical cleansing by the application of gentle suction. What's interesting about this technology is that you can see immediate impact, similar to cortisone injections. If you combine it with topical retinoids and topical antibiotics, you get an even better result."

▸ Rosacea. Prevention and management options include topical agents such as azelaic acid, metronidazole or sulfur, and oral antibiotics. Treatment of diffuse and isolated telangiectasias "is most effective with the use of vascular lasers—pulsed dye or pulsed KTP [potassium-titanyl-phosphate]—or with the second- and third-generation intense pulsed light sources," he said.

▸ Melasma. Dr. Narurkar called this condition "the sin of dermatology," noting that melasma is difficult to treat and manage. "We pretreat with hydroquinones or retinoids," he said. "The only laser I'll use for therapy-resistant melasma is nonablative fractional resurfacing with the Fraxel Re:Store Laser. I haven't had success with any other laser and you can still get recurrence if it is not managed topically."

For posttreatment, he suggests hydroquinones and retinoids and daily use of a broad spectrum sunscreen. "If patients can avoid birth control pills and other estrogen agents, that's even better," he said.

▸ Skin rejuvenation. For optimal results he recommends "the four Rs": retain and replenish with skin care and sunscreen, resurface with devices, relax with botulinum toxins, and refill with dermal fillers.

Acute treatment of mild to moderate photoaging can be achieved via photofacials with pulsed light sources, vascular and pigmented lesion lasers, and mild nonablative fractional resurfacing.

Treatment of moderate to severe photoaging can be achieved with photodynamic therapy and aggressive nonablative and ablative fractional resurfacing. "For advanced photoaging, you can enhance IPL [intense-pulsed light] and PDL [pulsed dye laser] treatments with Levulan," he said. "You need fewer treatments, there are more immediate results, but there is significantly more down time."

Dr. Narurkar disclosed that he is a consultant to and has performed clinical trials for Aesthera Corp., Allergan Inc., BioForm Medical Inc., Palomar Medical Technologies Inc., and Reliant Technologies Inc.

'We can't think of lasers, devices, toxins, fillers, and skin care in isolation; they have to be combined.' DR. NARURKAR

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

“We want to know how long it's been there and what the associated symptoms are,” he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?”

Such questions can guide you in determining what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that “begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix,” Dr. Pransky said. Surgical excision is advised if there is a discharge. “If there's no discharge we'll leave it alone.”

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. “These are a lot more challenging to manage surgically,” he said. “Fortunately they are rare.”

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. “If you milk it you'll see strandy secretions, which are probably mucus,” he said. “I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract.”

Second branchial cysts “frequently present as a soft swelling, not as an infectious problem,” he said. Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. “When you aspirate the lesion, you're going to get a mixed polymicrobial infection,” Dr. Pransky said. “That's because you're getting organisms from the hypopharynx.”

These anomalies may also present as acute thyroiditis. “That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck,” he said. “When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly.”

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. Courtesy Dr. Seth M. Pransky

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

“We want to know how long it's been there and what the associated symptoms are,” he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?”

Such questions can guide you in determining what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that “begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix,” Dr. Pransky said. Surgical excision is advised if there is a discharge. “If there's no discharge we'll leave it alone.”

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. “These are a lot more challenging to manage surgically,” he said. “Fortunately they are rare.”

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. “If you milk it you'll see strandy secretions, which are probably mucus,” he said. “I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract.”

Second branchial cysts “frequently present as a soft swelling, not as an infectious problem,” he said. Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. “When you aspirate the lesion, you're going to get a mixed polymicrobial infection,” Dr. Pransky said. “That's because you're getting organisms from the hypopharynx.”

These anomalies may also present as acute thyroiditis. “That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck,” he said. “When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly.”

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. Courtesy Dr. Seth M. Pransky

SAN DIEGO — Be thorough in your history taking when infants or children present with a neck mass, Dr. Seth M. Pransky advised.

“We want to know how long it's been there and what the associated symptoms are,” he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “Was there an antecedent respiratory infection or antecedent trauma? Has it become bigger or smaller, or has it remained the same size? What have the child's exposures been in terms of ill contacts, animals, and food?”

Such questions can guide you in determining what the correct diagnosis might be, said Dr. Pransky, director of pediatric otolaryngology at Children's Specialists Medical Group, San Diego.

An estimated 55% of pediatric neck masses are congenital, followed by acquired forms that include infectious, neoplastic, and inflammatory processes.

Branchial cleft anomalies are some of the most common types of congenital neck masses. These typically present as sinus tracts or fistulas detected at birth, with an opening in the skin with subsequent discharge that can be mucoid or mucopurulent. They may also present as cysts that enlarge gradually and present in the second or third decade of life.

A common type of branchial cleft anomaly is a preauricular anomaly that “begins as a pit in the preauricular region and often extends via a sinus tract down to a cystic dilatation almost always at the root of the helix,” Dr. Pransky said. Surgical excision is advised if there is a discharge. “If there's no discharge we'll leave it alone.”

First branchial arch anomalies can extend deeply into the neck. They present either as parallel to the external auditory canal or in the upper neck, below the angle of the mandible. “These are a lot more challenging to manage surgically,” he said. “Fortunately they are rare.”

Second branchial anomalies occur in the mid to lower portion of the neck along the anterior sternocleidomastoid muscle. Fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. “If you milk it you'll see strandy secretions, which are probably mucus,” he said. “I'm not comfortable with just taking out the neck portion of these lesions. I also take out the tonsil in conjunction with the entire fistulous tract.”

Second branchial cysts “frequently present as a soft swelling, not as an infectious problem,” he said. Third/fourth branchial cleft anomalies are rare and may present as an infectious swelling low in the floor of the neck laterally or in the anterior neck adjacent to the thyroid gland. “When you aspirate the lesion, you're going to get a mixed polymicrobial infection,” Dr. Pransky said. “That's because you're getting organisms from the hypopharynx.”

These anomalies may also present as acute thyroiditis. “That tract goes from the pyriform fossa in the hypopharynx through the thyroid gland into the neck,” he said. “When a 5- or 6-year-old presents with a thyroiditis, my first thought is that they have a branchial three or branchial four anomaly.”

Dr. Pransky disclosed no conflicts of interest.

Second branchial fistulas present as a tiny hole in the neck and can extend up to the tonsillar fossae. Courtesy Dr. Seth M. Pransky

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich.

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2–3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration. “You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. “I don't like this modern stuff,” he said. “All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He said his wife, Norma Gail, is a “good critic” of his work. “She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

“Find something to help you relax. If you cannot paint, go play golf,” Dr. Robert R. Canas said. Courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich.

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2–3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration. “You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. “I don't like this modern stuff,” he said. “All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He said his wife, Norma Gail, is a “good critic” of his work. “She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

“Find something to help you relax. If you cannot paint, go play golf,” Dr. Robert R. Canas said. Courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich.

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2–3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration. “You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. “I don't like this modern stuff,” he said. “All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He said his wife, Norma Gail, is a “good critic” of his work. “She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

“Find something to help you relax. If you cannot paint, go play golf,” Dr. Robert R. Canas said. Courtesy Dr. Robert R. Canas

LAS VEGAS — Paracervical block decreases the pain associated with cervical manipulation, but has little effect on the pain associated with hysteroscopic placement of the Essure device for sterilization or on the technical success of the placement, a single-center randomized trial showed.

“The management of the pain should be individualized between the patient and the physician, and attention to technique and patient reassurance are key to successful in-office placement of Essure devices,” Dr. Scott Chudnoff said at the annual meeting of the AAGL.

Although several researchers have performed assessments of pain during hysteroscopy, as well as during the Essure procedure, “most of these studies have significant methodological flaws, or they focused on diagnostic hysteroscopy,” noted Dr. Chudnoff of the department of obstetrics and gynecology and women's health at Albert Einstein College of Medicine, New York. “None focusing on Essure were randomized, placebo-controlled studies.”

To determine if paracervical block at the time of hysteroscopic placement of the Essure device provides clinical pain relief, he and his associates randomized 40 women to receive 10 cc of 1% lidocaine, and another 40 to receive 10 cc of normal saline, as a paracervical injection prior to the start of the procedure. The 10-cc dose of lidocaine “is the amount we used in a pilot study and is the recommended dose to be used based on the clinical indications for lidocaine in a paracervical block,” Dr. Chudnoff said in a later interview.

Patients were asked to complete the 8-point Visual Analog Scale to assess pain during ketorolac (Toradol) injection and at the conclusion of the placement of the Essure device.

Patients also used the VAS to report the average level and the highest level of pain during the procedure.

Dr. Chudnoff reported that there were three unsuccessful placements in each group.

The average pain score for hysteroscope placement into the cervix was 4.5 in the saline group, compared with 2.6 in the lidocaine group, a difference that was statistically significant. Similar findings were noted for transversing the external orifice of the cervix uteri (3.8 for the saline group vs. 1.5 for the lidocaine group) and for transversing the internal orifice of the cervix uteri (4.1 vs. 1.8).

However, there were no significant differences between the saline group and the lidocaine group in the average pain scores for placement of the Essure device (3.7 vs. 3.2).

For the procedures, which were performed between March 2007 and March 2008, all patients also received 60 mg IM ketorolac in the buttocks before the procedure to reduce tubal spasm. The researchers placed the speculum into the vagina, prepped the area, injected 1 cc of lidocaine into the anterior lip of the cervix, and placed a single-tooth tenaculum on the anterior lip.

Patients received 5 cc of 1% lidocaine or saline injected at the 4 o'clock location on the cervix and 5 cc of 1% lidocaine or saline injected at the 7 o'clock location. The researchers allowed for a 3- to 5-minute rest period to permit the block to set before the introduction of the hysteroscope and subsequent placement of the Essure device.

All subjects and investigators were blinded to the treatment groups, and no errors in randomization occurred. The average age of the patients was 35 years, and 62% were Hispanic.

Dr. Chudnoff disclosed that one of his associates, Dr. Mark Levie, serves on the medical advisory board and is on the speakers bureau for Conceptus Inc., which developed the Essure procedure.

LAS VEGAS — Paracervical block decreases the pain associated with cervical manipulation, but has little effect on the pain associated with hysteroscopic placement of the Essure device for sterilization or on the technical success of the placement, a single-center randomized trial showed.

“The management of the pain should be individualized between the patient and the physician, and attention to technique and patient reassurance are key to successful in-office placement of Essure devices,” Dr. Scott Chudnoff said at the annual meeting of the AAGL.

Although several researchers have performed assessments of pain during hysteroscopy, as well as during the Essure procedure, “most of these studies have significant methodological flaws, or they focused on diagnostic hysteroscopy,” noted Dr. Chudnoff of the department of obstetrics and gynecology and women's health at Albert Einstein College of Medicine, New York. “None focusing on Essure were randomized, placebo-controlled studies.”

To determine if paracervical block at the time of hysteroscopic placement of the Essure device provides clinical pain relief, he and his associates randomized 40 women to receive 10 cc of 1% lidocaine, and another 40 to receive 10 cc of normal saline, as a paracervical injection prior to the start of the procedure. The 10-cc dose of lidocaine “is the amount we used in a pilot study and is the recommended dose to be used based on the clinical indications for lidocaine in a paracervical block,” Dr. Chudnoff said in a later interview.

Patients were asked to complete the 8-point Visual Analog Scale to assess pain during ketorolac (Toradol) injection and at the conclusion of the placement of the Essure device.

Patients also used the VAS to report the average level and the highest level of pain during the procedure.

Dr. Chudnoff reported that there were three unsuccessful placements in each group.

The average pain score for hysteroscope placement into the cervix was 4.5 in the saline group, compared with 2.6 in the lidocaine group, a difference that was statistically significant. Similar findings were noted for transversing the external orifice of the cervix uteri (3.8 for the saline group vs. 1.5 for the lidocaine group) and for transversing the internal orifice of the cervix uteri (4.1 vs. 1.8).

However, there were no significant differences between the saline group and the lidocaine group in the average pain scores for placement of the Essure device (3.7 vs. 3.2).

For the procedures, which were performed between March 2007 and March 2008, all patients also received 60 mg IM ketorolac in the buttocks before the procedure to reduce tubal spasm. The researchers placed the speculum into the vagina, prepped the area, injected 1 cc of lidocaine into the anterior lip of the cervix, and placed a single-tooth tenaculum on the anterior lip.

Patients received 5 cc of 1% lidocaine or saline injected at the 4 o'clock location on the cervix and 5 cc of 1% lidocaine or saline injected at the 7 o'clock location. The researchers allowed for a 3- to 5-minute rest period to permit the block to set before the introduction of the hysteroscope and subsequent placement of the Essure device.

All subjects and investigators were blinded to the treatment groups, and no errors in randomization occurred. The average age of the patients was 35 years, and 62% were Hispanic.

Dr. Chudnoff disclosed that one of his associates, Dr. Mark Levie, serves on the medical advisory board and is on the speakers bureau for Conceptus Inc., which developed the Essure procedure.

LAS VEGAS — Paracervical block decreases the pain associated with cervical manipulation, but has little effect on the pain associated with hysteroscopic placement of the Essure device for sterilization or on the technical success of the placement, a single-center randomized trial showed.

“The management of the pain should be individualized between the patient and the physician, and attention to technique and patient reassurance are key to successful in-office placement of Essure devices,” Dr. Scott Chudnoff said at the annual meeting of the AAGL.

Although several researchers have performed assessments of pain during hysteroscopy, as well as during the Essure procedure, “most of these studies have significant methodological flaws, or they focused on diagnostic hysteroscopy,” noted Dr. Chudnoff of the department of obstetrics and gynecology and women's health at Albert Einstein College of Medicine, New York. “None focusing on Essure were randomized, placebo-controlled studies.”

To determine if paracervical block at the time of hysteroscopic placement of the Essure device provides clinical pain relief, he and his associates randomized 40 women to receive 10 cc of 1% lidocaine, and another 40 to receive 10 cc of normal saline, as a paracervical injection prior to the start of the procedure. The 10-cc dose of lidocaine “is the amount we used in a pilot study and is the recommended dose to be used based on the clinical indications for lidocaine in a paracervical block,” Dr. Chudnoff said in a later interview.

Patients were asked to complete the 8-point Visual Analog Scale to assess pain during ketorolac (Toradol) injection and at the conclusion of the placement of the Essure device.

Patients also used the VAS to report the average level and the highest level of pain during the procedure.

Dr. Chudnoff reported that there were three unsuccessful placements in each group.

The average pain score for hysteroscope placement into the cervix was 4.5 in the saline group, compared with 2.6 in the lidocaine group, a difference that was statistically significant. Similar findings were noted for transversing the external orifice of the cervix uteri (3.8 for the saline group vs. 1.5 for the lidocaine group) and for transversing the internal orifice of the cervix uteri (4.1 vs. 1.8).

However, there were no significant differences between the saline group and the lidocaine group in the average pain scores for placement of the Essure device (3.7 vs. 3.2).

For the procedures, which were performed between March 2007 and March 2008, all patients also received 60 mg IM ketorolac in the buttocks before the procedure to reduce tubal spasm. The researchers placed the speculum into the vagina, prepped the area, injected 1 cc of lidocaine into the anterior lip of the cervix, and placed a single-tooth tenaculum on the anterior lip.

Patients received 5 cc of 1% lidocaine or saline injected at the 4 o'clock location on the cervix and 5 cc of 1% lidocaine or saline injected at the 7 o'clock location. The researchers allowed for a 3- to 5-minute rest period to permit the block to set before the introduction of the hysteroscope and subsequent placement of the Essure device.

All subjects and investigators were blinded to the treatment groups, and no errors in randomization occurred. The average age of the patients was 35 years, and 62% were Hispanic.

Dr. Chudnoff disclosed that one of his associates, Dr. Mark Levie, serves on the medical advisory board and is on the speakers bureau for Conceptus Inc., which developed the Essure procedure.

LAS VEGAS — Patient compliance with the recommendation for a hysterosalpingogram after Essure hysteroscopic sterilization can be high in the private practice setting, according to Dr. Larry R. Glazerman, who tracked compliance in a chart review of his practice.

“Since the introduction of Essure in 2003, physician uptake has been substantially less than expected, despite the obvious advantages in terms of no incisions, no general anesthesia, and no hospital stay,” Dr. Glazerman said at the annual meeting of the AAGL. “One of the expressed concerns is that the [Food and Drug Administration] requires a 3-month confirmatory hysterosalpingogram [HSG] after the procedure, before the patient is allowed to rely on the device for contraception. In my personal discussions with physicians, I hear all the time that 'my patients don't want to come back for the HSG. They'd rather know right away that they are sterile.'”

Dr. Glazerman disclosed that he is a preceptor, speaker, and consultant for Conceptus Inc., which developed the Essure procedure. He is also a preceptor for Karl Storz Endoscopy-America Inc.

To determine the rate of compliance with the FDA recommendation for the hysterosalpingogram, Dr. Glazerman studied the medical charts of 130 consecutive patients who underwent Essure hysteroscopic sterilization in his former private ob.gyn. practice in Allentown, Pa., from December 2003 through May 2008.

Of those patients, 128 were at least 3 months post procedure and 2 were not, said Dr. Glazerman, who is now director of minimally invasive surgery in the department of obstetrics and gynecology at the University of South Florida, Tampa. Of the 128 patients, 116 (91%) underwent hysterosalpingography, and 100 (86%) of those 116 showed bilateral tubal occlusion on their first hysterosalpingogram. Of the 16 patients who failed their initial HSG, 13 had documented tubal occlusion on their second HSG; 2 had a previous unilateral salpingectomy; and 1 had unilateral placement, and subsequently conceived.

Based on the findings, Dr. Glazerman concluded that concern about noncompliance with HSG “should not deter physicians from offering hysteroscopic sterilization. The way I present the Essure procedure to patients is like this: 'If they have a laparoscopic tubal failure (a rate of 0.5%-1%), the only way they know if it fails is if they get pregnant. On the other hand, if they have a hysterosalpingogram after the Essure that shows bilateral occlusion, there's a pregnancy rate of less than 1 in 200,000 cases. My patients seem to like that. In addition, they like the fact that there's no hospital stay, no incision, and no general anesthesia.”

Concern about noncompliance with HSG should not deter physicians from offering the Essure procedure. DR. GLAZERMAN

LAS VEGAS — Patient compliance with the recommendation for a hysterosalpingogram after Essure hysteroscopic sterilization can be high in the private practice setting, according to Dr. Larry R. Glazerman, who tracked compliance in a chart review of his practice.

“Since the introduction of Essure in 2003, physician uptake has been substantially less than expected, despite the obvious advantages in terms of no incisions, no general anesthesia, and no hospital stay,” Dr. Glazerman said at the annual meeting of the AAGL. “One of the expressed concerns is that the [Food and Drug Administration] requires a 3-month confirmatory hysterosalpingogram [HSG] after the procedure, before the patient is allowed to rely on the device for contraception. In my personal discussions with physicians, I hear all the time that 'my patients don't want to come back for the HSG. They'd rather know right away that they are sterile.'”

Dr. Glazerman disclosed that he is a preceptor, speaker, and consultant for Conceptus Inc., which developed the Essure procedure. He is also a preceptor for Karl Storz Endoscopy-America Inc.

To determine the rate of compliance with the FDA recommendation for the hysterosalpingogram, Dr. Glazerman studied the medical charts of 130 consecutive patients who underwent Essure hysteroscopic sterilization in his former private ob.gyn. practice in Allentown, Pa., from December 2003 through May 2008.

Of those patients, 128 were at least 3 months post procedure and 2 were not, said Dr. Glazerman, who is now director of minimally invasive surgery in the department of obstetrics and gynecology at the University of South Florida, Tampa. Of the 128 patients, 116 (91%) underwent hysterosalpingography, and 100 (86%) of those 116 showed bilateral tubal occlusion on their first hysterosalpingogram. Of the 16 patients who failed their initial HSG, 13 had documented tubal occlusion on their second HSG; 2 had a previous unilateral salpingectomy; and 1 had unilateral placement, and subsequently conceived.

Based on the findings, Dr. Glazerman concluded that concern about noncompliance with HSG “should not deter physicians from offering hysteroscopic sterilization. The way I present the Essure procedure to patients is like this: 'If they have a laparoscopic tubal failure (a rate of 0.5%-1%), the only way they know if it fails is if they get pregnant. On the other hand, if they have a hysterosalpingogram after the Essure that shows bilateral occlusion, there's a pregnancy rate of less than 1 in 200,000 cases. My patients seem to like that. In addition, they like the fact that there's no hospital stay, no incision, and no general anesthesia.”

Concern about noncompliance with HSG should not deter physicians from offering the Essure procedure. DR. GLAZERMAN

LAS VEGAS — Patient compliance with the recommendation for a hysterosalpingogram after Essure hysteroscopic sterilization can be high in the private practice setting, according to Dr. Larry R. Glazerman, who tracked compliance in a chart review of his practice.

“Since the introduction of Essure in 2003, physician uptake has been substantially less than expected, despite the obvious advantages in terms of no incisions, no general anesthesia, and no hospital stay,” Dr. Glazerman said at the annual meeting of the AAGL. “One of the expressed concerns is that the [Food and Drug Administration] requires a 3-month confirmatory hysterosalpingogram [HSG] after the procedure, before the patient is allowed to rely on the device for contraception. In my personal discussions with physicians, I hear all the time that 'my patients don't want to come back for the HSG. They'd rather know right away that they are sterile.'”

Dr. Glazerman disclosed that he is a preceptor, speaker, and consultant for Conceptus Inc., which developed the Essure procedure. He is also a preceptor for Karl Storz Endoscopy-America Inc.

To determine the rate of compliance with the FDA recommendation for the hysterosalpingogram, Dr. Glazerman studied the medical charts of 130 consecutive patients who underwent Essure hysteroscopic sterilization in his former private ob.gyn. practice in Allentown, Pa., from December 2003 through May 2008.

Of those patients, 128 were at least 3 months post procedure and 2 were not, said Dr. Glazerman, who is now director of minimally invasive surgery in the department of obstetrics and gynecology at the University of South Florida, Tampa. Of the 128 patients, 116 (91%) underwent hysterosalpingography, and 100 (86%) of those 116 showed bilateral tubal occlusion on their first hysterosalpingogram. Of the 16 patients who failed their initial HSG, 13 had documented tubal occlusion on their second HSG; 2 had a previous unilateral salpingectomy; and 1 had unilateral placement, and subsequently conceived.

Based on the findings, Dr. Glazerman concluded that concern about noncompliance with HSG “should not deter physicians from offering hysteroscopic sterilization. The way I present the Essure procedure to patients is like this: 'If they have a laparoscopic tubal failure (a rate of 0.5%-1%), the only way they know if it fails is if they get pregnant. On the other hand, if they have a hysterosalpingogram after the Essure that shows bilateral occlusion, there's a pregnancy rate of less than 1 in 200,000 cases. My patients seem to like that. In addition, they like the fact that there's no hospital stay, no incision, and no general anesthesia.”

Concern about noncompliance with HSG should not deter physicians from offering the Essure procedure. DR. GLAZERMAN

LAS VEGAS — A systematic review of the medical literature yielded mixed results concerning the effects of bilateral oophorectomy on the risk of coronary heart disease.

“There's been a concern that bilateral oophorectomy may increase the risk of coronary heart disease because estrogen deprivation might accelerate the rate of atherosclerosis,” Dr. Vanessa Jacoby said at the annual meeting of the AAGL.

Dr. Jacoby and her associates sought to identify all of the available related literature on PubMed and Embase between 1966 and 2007, all related abstracts that were presented at the annual clinical meeting of the American College of Obstetricians and Gynecologists between 1996 and 2006, and reference lists from the retrieved articles. Studies were included if they compared women who had bilateral oophorectomy with a hysterectomy to women who had a hysterectomy and ovarian conservation, naturally menopausal women, premenopausal women, or premenopausal women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status. The primary outcome was fatal or nonfatal coronary heart disease.

Nearly 2,000 abstracts were reviewed, said Dr. Jacoby of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. From these, 16 observational studies were reviewed in full and 7 were used in the final analysis. No randomized trials were located.

Two studies involving women with a hysterectomy and ovarian conservation showed no significant increased risk of coronary heart disease following bilateral oophorectomy.

One of three studies involving naturally menopausal women did show a slight increased risk of CHD, with a hazard ratio of 1.16 (Circulation 2005;111:1462–70). “But in a subsequent analysis that accounted for the effect of all demographic and cardiovascular risk factors like hypertension, diabetes, and smoking, there was no statistically significant increased risk of coronary heart disease,” Dr. Jacoby said.

One of two studies involving premenopausal women, the Nurse's Health Study, reported an increased risk of CHD, with a relative risk of 2.2 (N. Engl. J. Med. 1987;316:1105–10). “That was only in women who never took estrogen following bilateral oophorectomy, and only in an analysis that accounted for age and smoking,” she said. “But in a subsequent analysis that accounted for other cardiovascular risk factors such as obesity, hypertension, and diabetes, there was no increased risk.”

The other study involving premenopausal women found a significantly increased risk of CHD in women aged 40–44 years who had undergone hysterectomy and bilateral oophorectomy, but not in women aged 45 years and older (Ann. Intern. Med. 1978;89:157–61). One of two studies involving women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status showed a significantly increased risk of CHD, but only in women younger than age 60 years (Acta. Obstet. Gynecol. Scand. 1981;106 [Suppl.]:11–5).

A limitation of the analysis, she said, is that the observational studies used “are inherently limited by the potential effect of confounding on the outcome. To that end, our goal is to implement a randomized trial of bilateral oophorectomy so we can have the highest-quality evidence to guide our clinical practice for this very common clinical question.”

LAS VEGAS — A systematic review of the medical literature yielded mixed results concerning the effects of bilateral oophorectomy on the risk of coronary heart disease.

“There's been a concern that bilateral oophorectomy may increase the risk of coronary heart disease because estrogen deprivation might accelerate the rate of atherosclerosis,” Dr. Vanessa Jacoby said at the annual meeting of the AAGL.

Dr. Jacoby and her associates sought to identify all of the available related literature on PubMed and Embase between 1966 and 2007, all related abstracts that were presented at the annual clinical meeting of the American College of Obstetricians and Gynecologists between 1996 and 2006, and reference lists from the retrieved articles. Studies were included if they compared women who had bilateral oophorectomy with a hysterectomy to women who had a hysterectomy and ovarian conservation, naturally menopausal women, premenopausal women, or premenopausal women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status. The primary outcome was fatal or nonfatal coronary heart disease.

Nearly 2,000 abstracts were reviewed, said Dr. Jacoby of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. From these, 16 observational studies were reviewed in full and 7 were used in the final analysis. No randomized trials were located.

Two studies involving women with a hysterectomy and ovarian conservation showed no significant increased risk of coronary heart disease following bilateral oophorectomy.

One of three studies involving naturally menopausal women did show a slight increased risk of CHD, with a hazard ratio of 1.16 (Circulation 2005;111:1462–70). “But in a subsequent analysis that accounted for the effect of all demographic and cardiovascular risk factors like hypertension, diabetes, and smoking, there was no statistically significant increased risk of coronary heart disease,” Dr. Jacoby said.

One of two studies involving premenopausal women, the Nurse's Health Study, reported an increased risk of CHD, with a relative risk of 2.2 (N. Engl. J. Med. 1987;316:1105–10). “That was only in women who never took estrogen following bilateral oophorectomy, and only in an analysis that accounted for age and smoking,” she said. “But in a subsequent analysis that accounted for other cardiovascular risk factors such as obesity, hypertension, and diabetes, there was no increased risk.”

The other study involving premenopausal women found a significantly increased risk of CHD in women aged 40–44 years who had undergone hysterectomy and bilateral oophorectomy, but not in women aged 45 years and older (Ann. Intern. Med. 1978;89:157–61). One of two studies involving women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status showed a significantly increased risk of CHD, but only in women younger than age 60 years (Acta. Obstet. Gynecol. Scand. 1981;106 [Suppl.]:11–5).

A limitation of the analysis, she said, is that the observational studies used “are inherently limited by the potential effect of confounding on the outcome. To that end, our goal is to implement a randomized trial of bilateral oophorectomy so we can have the highest-quality evidence to guide our clinical practice for this very common clinical question.”

LAS VEGAS — A systematic review of the medical literature yielded mixed results concerning the effects of bilateral oophorectomy on the risk of coronary heart disease.

“There's been a concern that bilateral oophorectomy may increase the risk of coronary heart disease because estrogen deprivation might accelerate the rate of atherosclerosis,” Dr. Vanessa Jacoby said at the annual meeting of the AAGL.

Dr. Jacoby and her associates sought to identify all of the available related literature on PubMed and Embase between 1966 and 2007, all related abstracts that were presented at the annual clinical meeting of the American College of Obstetricians and Gynecologists between 1996 and 2006, and reference lists from the retrieved articles. Studies were included if they compared women who had bilateral oophorectomy with a hysterectomy to women who had a hysterectomy and ovarian conservation, naturally menopausal women, premenopausal women, or premenopausal women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status. The primary outcome was fatal or nonfatal coronary heart disease.

Nearly 2,000 abstracts were reviewed, said Dr. Jacoby of the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. From these, 16 observational studies were reviewed in full and 7 were used in the final analysis. No randomized trials were located.

Two studies involving women with a hysterectomy and ovarian conservation showed no significant increased risk of coronary heart disease following bilateral oophorectomy.

One of three studies involving naturally menopausal women did show a slight increased risk of CHD, with a hazard ratio of 1.16 (Circulation 2005;111:1462–70). “But in a subsequent analysis that accounted for the effect of all demographic and cardiovascular risk factors like hypertension, diabetes, and smoking, there was no statistically significant increased risk of coronary heart disease,” Dr. Jacoby said.

One of two studies involving premenopausal women, the Nurse's Health Study, reported an increased risk of CHD, with a relative risk of 2.2 (N. Engl. J. Med. 1987;316:1105–10). “That was only in women who never took estrogen following bilateral oophorectomy, and only in an analysis that accounted for age and smoking,” she said. “But in a subsequent analysis that accounted for other cardiovascular risk factors such as obesity, hypertension, and diabetes, there was no increased risk.”

The other study involving premenopausal women found a significantly increased risk of CHD in women aged 40–44 years who had undergone hysterectomy and bilateral oophorectomy, but not in women aged 45 years and older (Ann. Intern. Med. 1978;89:157–61). One of two studies involving women with no history of hysterectomy or bilateral oophorectomy but unreported or unknown menopausal status showed a significantly increased risk of CHD, but only in women younger than age 60 years (Acta. Obstet. Gynecol. Scand. 1981;106 [Suppl.]:11–5).

A limitation of the analysis, she said, is that the observational studies used “are inherently limited by the potential effect of confounding on the outcome. To that end, our goal is to implement a randomized trial of bilateral oophorectomy so we can have the highest-quality evidence to guide our clinical practice for this very common clinical question.”

LAS VEGAS — Using 400 mcg vaginal misoprostol 12–24 hours before hysteroscopy reduces the pain related to the procedure and the maximum peak force needed for dilatation of the cervix, results from a double-blind randomized trial demonstrated.

While the off-label use of vaginal misoprostol has been widely used to make the dilatation of the cervix easier, “most studies have measured the effects on the cervix by the largest Hegar dilator that could be inserted without resistance, which is a subjective measure,” Dr. Guy Waddell said in an interview after his poster presentation at the annual meeting of the AAGL. “The quality of these studies therefore is underrated. Moreover, the pain reported by the patient was rarely assessed,” said Dr. Waddell, a gynecologist at the University of Sherbrooke (Que.).

He and his associates used a cervical tonometer to objectively measure the force needed to dilate the cervix after priming with vaginal misoprostol, compared with placebo, in 101 women undergoing diagnostic hysteroscopy. The researchers also used the Visual Analog Scale to assess pain after dilatation to 6 mm.

Of the 101 women, 50 self-administered 400 mcg vaginal misoprostol while 51 self-administered vaginal placebo 12–24 hours before hysteroscopy. Their mean age was 51 years and their mean parity was 2.2. Complete data were missing on nine patients in the misoprostol group and two in the placebo group.

Dr. Waddell and his associates reported that the mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group, a difference that was statistically significant. The difference between groups retained significance after the researchers adjusted for baseline pain scores measured before randomization and any intervention (43.2 vs. 55.5, respectively). The force needed to dilate the cervix at 6 mm also was significantly less in the misoprostol group than in the placebo group (5.0 newtons vs. 7.5 newtons, respectively). There were no significant differences in the force needed to dilate the cervix at 3 mm (1.7 vs. 1.8 newtons), 4 mm (2.6 vs. 3.0 newtons), or 5 mm (4.3 vs. 4.0 newtons).

The number of side effects and complications were few, but pelvic cramping was reported significantly more often in the misoprostol group than in the placebo group.

“The demonstration that the cervix is more easily dilated with misoprostol at 6 mm suggests that, for any procedure needing the insertion of a device of more than 5 mm into the endometrial cavity, priming would be facilitating and could reduce the risk of complications,” the researchers wrote.

Dr. Waddell said he had no conflicts of interest to disclose.

Mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group. DR. WADDELL

LAS VEGAS — Using 400 mcg vaginal misoprostol 12–24 hours before hysteroscopy reduces the pain related to the procedure and the maximum peak force needed for dilatation of the cervix, results from a double-blind randomized trial demonstrated.

While the off-label use of vaginal misoprostol has been widely used to make the dilatation of the cervix easier, “most studies have measured the effects on the cervix by the largest Hegar dilator that could be inserted without resistance, which is a subjective measure,” Dr. Guy Waddell said in an interview after his poster presentation at the annual meeting of the AAGL. “The quality of these studies therefore is underrated. Moreover, the pain reported by the patient was rarely assessed,” said Dr. Waddell, a gynecologist at the University of Sherbrooke (Que.).

He and his associates used a cervical tonometer to objectively measure the force needed to dilate the cervix after priming with vaginal misoprostol, compared with placebo, in 101 women undergoing diagnostic hysteroscopy. The researchers also used the Visual Analog Scale to assess pain after dilatation to 6 mm.

Of the 101 women, 50 self-administered 400 mcg vaginal misoprostol while 51 self-administered vaginal placebo 12–24 hours before hysteroscopy. Their mean age was 51 years and their mean parity was 2.2. Complete data were missing on nine patients in the misoprostol group and two in the placebo group.

Dr. Waddell and his associates reported that the mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group, a difference that was statistically significant. The difference between groups retained significance after the researchers adjusted for baseline pain scores measured before randomization and any intervention (43.2 vs. 55.5, respectively). The force needed to dilate the cervix at 6 mm also was significantly less in the misoprostol group than in the placebo group (5.0 newtons vs. 7.5 newtons, respectively). There were no significant differences in the force needed to dilate the cervix at 3 mm (1.7 vs. 1.8 newtons), 4 mm (2.6 vs. 3.0 newtons), or 5 mm (4.3 vs. 4.0 newtons).

The number of side effects and complications were few, but pelvic cramping was reported significantly more often in the misoprostol group than in the placebo group.

“The demonstration that the cervix is more easily dilated with misoprostol at 6 mm suggests that, for any procedure needing the insertion of a device of more than 5 mm into the endometrial cavity, priming would be facilitating and could reduce the risk of complications,” the researchers wrote.

Dr. Waddell said he had no conflicts of interest to disclose.

Mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group. DR. WADDELL

LAS VEGAS — Using 400 mcg vaginal misoprostol 12–24 hours before hysteroscopy reduces the pain related to the procedure and the maximum peak force needed for dilatation of the cervix, results from a double-blind randomized trial demonstrated.

While the off-label use of vaginal misoprostol has been widely used to make the dilatation of the cervix easier, “most studies have measured the effects on the cervix by the largest Hegar dilator that could be inserted without resistance, which is a subjective measure,” Dr. Guy Waddell said in an interview after his poster presentation at the annual meeting of the AAGL. “The quality of these studies therefore is underrated. Moreover, the pain reported by the patient was rarely assessed,” said Dr. Waddell, a gynecologist at the University of Sherbrooke (Que.).

He and his associates used a cervical tonometer to objectively measure the force needed to dilate the cervix after priming with vaginal misoprostol, compared with placebo, in 101 women undergoing diagnostic hysteroscopy. The researchers also used the Visual Analog Scale to assess pain after dilatation to 6 mm.

Of the 101 women, 50 self-administered 400 mcg vaginal misoprostol while 51 self-administered vaginal placebo 12–24 hours before hysteroscopy. Their mean age was 51 years and their mean parity was 2.2. Complete data were missing on nine patients in the misoprostol group and two in the placebo group.

Dr. Waddell and his associates reported that the mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group, a difference that was statistically significant. The difference between groups retained significance after the researchers adjusted for baseline pain scores measured before randomization and any intervention (43.2 vs. 55.5, respectively). The force needed to dilate the cervix at 6 mm also was significantly less in the misoprostol group than in the placebo group (5.0 newtons vs. 7.5 newtons, respectively). There were no significant differences in the force needed to dilate the cervix at 3 mm (1.7 vs. 1.8 newtons), 4 mm (2.6 vs. 3.0 newtons), or 5 mm (4.3 vs. 4.0 newtons).

The number of side effects and complications were few, but pelvic cramping was reported significantly more often in the misoprostol group than in the placebo group.

“The demonstration that the cervix is more easily dilated with misoprostol at 6 mm suggests that, for any procedure needing the insertion of a device of more than 5 mm into the endometrial cavity, priming would be facilitating and could reduce the risk of complications,” the researchers wrote.

Dr. Waddell said he had no conflicts of interest to disclose.

Mean pain score after dilatation to 6 mm was 42.1 in the misoprostol group, compared with 57.2 in the placebo group. DR. WADDELL

LAS VEGAS — Laparoscopic supracervical hysterectomy for the nonprolapsed uterus was associated with significantly shorter hospital stays, compared with laparoscopic-assisted vaginal hysterectomy, but all other perioperative measures were similar between the two procedures, results from a retrospective analysis showed.

But no definitive conclusions can be made as to the preferred procedure for a patient with a nonprolapsed uterus. This is in contrast to some of the previously published reports that compared laparoscopic-assisted vaginal hysterectomy (LAVH) with laparoscopic supracervical hysterectomy (LSH), “all of which are retrospective, relatively small case series and have findings that do not seem to be consistent,” Dr. Ali Ghomi cautioned at the annual meeting of the AAGL. “There are no randomized clinical trials comparing LAVH to LSH, and most studies did not account for pelvic organ prolapse as a confounding factor in LAVH. So before we make any shift to one procedure or another, we need to examine the available evidence very carefully and not jump to conclusions.”

To compare the perioperative outcomes of the two procedures when performed for the nonprolapsed uterus, Dr. Ghomi and his associates from Harvard Medical School, Boston, and the State University of New York at Buffalo, where he is a member of the department of gynecology-obstetrics, evaluated 248 successive cases of LAVH and 173 successive cases of LSH between January 2001 and December 2007. The study is the largest of its kind to date.

Patient demographics were similar between the two groups, reported Dr. Ghomi, who had no conflicts to disclose. The mean age of patients was 43 years, and their mean body mass index was 28 kg/m₂.

There was no significant difference in the mean operating time between both groups (145 minutes for the LAVH vs. 143 minutes for the LSH group) or in the rate of perioperative complications (19% vs. 15%, respectively). Postoperative hemoglobin change and febrile morbidity were similar between the groups.

Hospital stay was significantly shorter for women in the LSH group, compared with their counterparts in the LAVH group (a mean of 1.2 days vs. 1.6 days, respectively). Potential confounders to this relationship such as perioperative complications, intraoperative conversion to laparotomy, postoperative fever, and hemoglobin change did not differ significantly between the two groups.

“Shorter hospital stay in LSH is an interesting observation that might suggest overall faster patient recovery,” Dr. Ghomi said in a later interview. “Shorter hospital stay in LSH might also offset the cost of disposable instruments utilized in LSH, when compared to LAVH. Large randomized clinical trials are needed to further investigate the superiority of either of these two minimally invasive surgical alternatives to abdominal hysterectomy.”

LAS VEGAS — Laparoscopic supracervical hysterectomy for the nonprolapsed uterus was associated with significantly shorter hospital stays, compared with laparoscopic-assisted vaginal hysterectomy, but all other perioperative measures were similar between the two procedures, results from a retrospective analysis showed.

But no definitive conclusions can be made as to the preferred procedure for a patient with a nonprolapsed uterus. This is in contrast to some of the previously published reports that compared laparoscopic-assisted vaginal hysterectomy (LAVH) with laparoscopic supracervical hysterectomy (LSH), “all of which are retrospective, relatively small case series and have findings that do not seem to be consistent,” Dr. Ali Ghomi cautioned at the annual meeting of the AAGL. “There are no randomized clinical trials comparing LAVH to LSH, and most studies did not account for pelvic organ prolapse as a confounding factor in LAVH. So before we make any shift to one procedure or another, we need to examine the available evidence very carefully and not jump to conclusions.”

To compare the perioperative outcomes of the two procedures when performed for the nonprolapsed uterus, Dr. Ghomi and his associates from Harvard Medical School, Boston, and the State University of New York at Buffalo, where he is a member of the department of gynecology-obstetrics, evaluated 248 successive cases of LAVH and 173 successive cases of LSH between January 2001 and December 2007. The study is the largest of its kind to date.

Patient demographics were similar between the two groups, reported Dr. Ghomi, who had no conflicts to disclose. The mean age of patients was 43 years, and their mean body mass index was 28 kg/m₂.

There was no significant difference in the mean operating time between both groups (145 minutes for the LAVH vs. 143 minutes for the LSH group) or in the rate of perioperative complications (19% vs. 15%, respectively). Postoperative hemoglobin change and febrile morbidity were similar between the groups.

Hospital stay was significantly shorter for women in the LSH group, compared with their counterparts in the LAVH group (a mean of 1.2 days vs. 1.6 days, respectively). Potential confounders to this relationship such as perioperative complications, intraoperative conversion to laparotomy, postoperative fever, and hemoglobin change did not differ significantly between the two groups.

“Shorter hospital stay in LSH is an interesting observation that might suggest overall faster patient recovery,” Dr. Ghomi said in a later interview. “Shorter hospital stay in LSH might also offset the cost of disposable instruments utilized in LSH, when compared to LAVH. Large randomized clinical trials are needed to further investigate the superiority of either of these two minimally invasive surgical alternatives to abdominal hysterectomy.”

LAS VEGAS — Laparoscopic supracervical hysterectomy for the nonprolapsed uterus was associated with significantly shorter hospital stays, compared with laparoscopic-assisted vaginal hysterectomy, but all other perioperative measures were similar between the two procedures, results from a retrospective analysis showed.

But no definitive conclusions can be made as to the preferred procedure for a patient with a nonprolapsed uterus. This is in contrast to some of the previously published reports that compared laparoscopic-assisted vaginal hysterectomy (LAVH) with laparoscopic supracervical hysterectomy (LSH), “all of which are retrospective, relatively small case series and have findings that do not seem to be consistent,” Dr. Ali Ghomi cautioned at the annual meeting of the AAGL. “There are no randomized clinical trials comparing LAVH to LSH, and most studies did not account for pelvic organ prolapse as a confounding factor in LAVH. So before we make any shift to one procedure or another, we need to examine the available evidence very carefully and not jump to conclusions.”

To compare the perioperative outcomes of the two procedures when performed for the nonprolapsed uterus, Dr. Ghomi and his associates from Harvard Medical School, Boston, and the State University of New York at Buffalo, where he is a member of the department of gynecology-obstetrics, evaluated 248 successive cases of LAVH and 173 successive cases of LSH between January 2001 and December 2007. The study is the largest of its kind to date.

Patient demographics were similar between the two groups, reported Dr. Ghomi, who had no conflicts to disclose. The mean age of patients was 43 years, and their mean body mass index was 28 kg/m₂.

There was no significant difference in the mean operating time between both groups (145 minutes for the LAVH vs. 143 minutes for the LSH group) or in the rate of perioperative complications (19% vs. 15%, respectively). Postoperative hemoglobin change and febrile morbidity were similar between the groups.

Hospital stay was significantly shorter for women in the LSH group, compared with their counterparts in the LAVH group (a mean of 1.2 days vs. 1.6 days, respectively). Potential confounders to this relationship such as perioperative complications, intraoperative conversion to laparotomy, postoperative fever, and hemoglobin change did not differ significantly between the two groups.

“Shorter hospital stay in LSH is an interesting observation that might suggest overall faster patient recovery,” Dr. Ghomi said in a later interview. “Shorter hospital stay in LSH might also offset the cost of disposable instruments utilized in LSH, when compared to LAVH. Large randomized clinical trials are needed to further investigate the superiority of either of these two minimally invasive surgical alternatives to abdominal hysterectomy.”