Doug Brunk

LA JOLLA, CALIF. — Infectious disease experts are concerned about the circulation of two new GII.4 norovirus strains that emerged in 2006 in the United States.

Previously referred to as calicivirus, norovirus is transmitted through food, water, environmental surfaces, and person to person, Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Outbreaks of the new strains have been reported in close contact facilities such as child care centers, nursing homes, cruise ships, and family settings (MMWR 2007;56:842–6).

Diarrheal disease associated with norovirus “is very severe but it's short lived; it only lasts 24–48 hours but it may seem like 24–48 days for patients,” said Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

“The assays for this specific organism are not widely available, so most laboratories cannot detect norovirus. There is no specific therapy and no vaccine for norovirus. I think we're going to see a lot more activity because the new strains appear to be more virulent,” he said.

A study of foodborne outbreaks reported to the CDC between 1998 and 2002 revealed that the etiology could not be determined in 67% of outbreaks. When a pathogen was determined, a bacterial pathogen was identified as the culprit in 55% of outbreaks, followed by viral pathogens (33%), chemical agents such as mushroom toxins and fish toxins (10%), parasites (1%), and multiple etiologies (1%) (MMWR Surveill. Summ. 2006;55[10]:1–42).

“Some people believe that if all of the outbreaks reported had norovirus testing, the viral causes would be number one,” Dr. Pickering said.

Most outbreaks of diarrheal disease in child care centers are due to parasites and viruses. Common pathogens are the spore-forming protozoa Cryptosporidium parvum and rotaviruses.

“In child care centers, person-to-person transmission of Cryptosporidium parvum and rotavirus is common, due to the low inoculum dose [needed],” he said.

Another common diarrheal illness in children is giardiasis, which is caused by the microscopic parasite Giardia lamblia that affects the duodenum and small intestine. The highest incidence is in children aged 1–4 years. “Most of this occurs in June, July, August, and September, and then it starts to fall off a bit,” said Dr. Pickering, who is also professor of pediatrics at Emory University, Atlanta.

Antimicrobial therapy options for giardiasis include albendazole, furazolidone, metronidazole, nitazoxanide, paromomycin, quinacrine, and tinidazole. Dr. Pickering said that his drug of choice for children older than 3 years of age is tinidazole because it requires only a single dose. Furazolidone and nitazoxanide are ideal for younger children, he said, because they come in liquid form.

Diarrheal illness also can be caused by salmonella. The most common strain is the nontyphoidal form, which can cause asymptomatic carriage, gastroenteritis, and systemic illness. A meta-analysis of antimicrobial therapy for uncomplicated nontyphoidal salmonella gastroenteritis found no decrease in length of illness, increased risk for relapse, increased risk for positive culture after 3 weeks, and increased risk for adverse drug reaction (Cochrane Database Syst. Rev. 2000;93:CD001167).

“However, in infants less than 3 months of age who have salmonella gastroenteritis, most of us would recommend [antimicrobial] therapy because approximately 5% of these infants will develop bacteremia,” Dr. Pickering said.

Clostridium difficile also can cause diarrheal illness in children. Transmission occurs mainly in health care settings, and the hallmark presentations are fever, severe abdominal pain, leukocytosis, and fecal polymorphonuclear leukocytes in the stool.

Oral metronidazole is the drug of choice for children with this type of diarrhea, but vancomycin also can be used. The relapse rate in patients who are treated with either drug is 10%–20%. “Relapse is not due to development of resistance,” Dr. Pickering said. “The same drug can be used for the second course.” Dr. Pickering had no relevant conflicts to disclose.

LA JOLLA, CALIF. — Infectious disease experts are concerned about the circulation of two new GII.4 norovirus strains that emerged in 2006 in the United States.

Previously referred to as calicivirus, norovirus is transmitted through food, water, environmental surfaces, and person to person, Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Outbreaks of the new strains have been reported in close contact facilities such as child care centers, nursing homes, cruise ships, and family settings (MMWR 2007;56:842–6).

Diarrheal disease associated with norovirus “is very severe but it's short lived; it only lasts 24–48 hours but it may seem like 24–48 days for patients,” said Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

“The assays for this specific organism are not widely available, so most laboratories cannot detect norovirus. There is no specific therapy and no vaccine for norovirus. I think we're going to see a lot more activity because the new strains appear to be more virulent,” he said.

A study of foodborne outbreaks reported to the CDC between 1998 and 2002 revealed that the etiology could not be determined in 67% of outbreaks. When a pathogen was determined, a bacterial pathogen was identified as the culprit in 55% of outbreaks, followed by viral pathogens (33%), chemical agents such as mushroom toxins and fish toxins (10%), parasites (1%), and multiple etiologies (1%) (MMWR Surveill. Summ. 2006;55[10]:1–42).

“Some people believe that if all of the outbreaks reported had norovirus testing, the viral causes would be number one,” Dr. Pickering said.

Most outbreaks of diarrheal disease in child care centers are due to parasites and viruses. Common pathogens are the spore-forming protozoa Cryptosporidium parvum and rotaviruses.

“In child care centers, person-to-person transmission of Cryptosporidium parvum and rotavirus is common, due to the low inoculum dose [needed],” he said.

Another common diarrheal illness in children is giardiasis, which is caused by the microscopic parasite Giardia lamblia that affects the duodenum and small intestine. The highest incidence is in children aged 1–4 years. “Most of this occurs in June, July, August, and September, and then it starts to fall off a bit,” said Dr. Pickering, who is also professor of pediatrics at Emory University, Atlanta.

Antimicrobial therapy options for giardiasis include albendazole, furazolidone, metronidazole, nitazoxanide, paromomycin, quinacrine, and tinidazole. Dr. Pickering said that his drug of choice for children older than 3 years of age is tinidazole because it requires only a single dose. Furazolidone and nitazoxanide are ideal for younger children, he said, because they come in liquid form.

Diarrheal illness also can be caused by salmonella. The most common strain is the nontyphoidal form, which can cause asymptomatic carriage, gastroenteritis, and systemic illness. A meta-analysis of antimicrobial therapy for uncomplicated nontyphoidal salmonella gastroenteritis found no decrease in length of illness, increased risk for relapse, increased risk for positive culture after 3 weeks, and increased risk for adverse drug reaction (Cochrane Database Syst. Rev. 2000;93:CD001167).

“However, in infants less than 3 months of age who have salmonella gastroenteritis, most of us would recommend [antimicrobial] therapy because approximately 5% of these infants will develop bacteremia,” Dr. Pickering said.

Clostridium difficile also can cause diarrheal illness in children. Transmission occurs mainly in health care settings, and the hallmark presentations are fever, severe abdominal pain, leukocytosis, and fecal polymorphonuclear leukocytes in the stool.

Oral metronidazole is the drug of choice for children with this type of diarrhea, but vancomycin also can be used. The relapse rate in patients who are treated with either drug is 10%–20%. “Relapse is not due to development of resistance,” Dr. Pickering said. “The same drug can be used for the second course.” Dr. Pickering had no relevant conflicts to disclose.

LA JOLLA, CALIF. — Infectious disease experts are concerned about the circulation of two new GII.4 norovirus strains that emerged in 2006 in the United States.

Previously referred to as calicivirus, norovirus is transmitted through food, water, environmental surfaces, and person to person, Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Outbreaks of the new strains have been reported in close contact facilities such as child care centers, nursing homes, cruise ships, and family settings (MMWR 2007;56:842–6).

Diarrheal disease associated with norovirus “is very severe but it's short lived; it only lasts 24–48 hours but it may seem like 24–48 days for patients,” said Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

“The assays for this specific organism are not widely available, so most laboratories cannot detect norovirus. There is no specific therapy and no vaccine for norovirus. I think we're going to see a lot more activity because the new strains appear to be more virulent,” he said.

A study of foodborne outbreaks reported to the CDC between 1998 and 2002 revealed that the etiology could not be determined in 67% of outbreaks. When a pathogen was determined, a bacterial pathogen was identified as the culprit in 55% of outbreaks, followed by viral pathogens (33%), chemical agents such as mushroom toxins and fish toxins (10%), parasites (1%), and multiple etiologies (1%) (MMWR Surveill. Summ. 2006;55[10]:1–42).

“Some people believe that if all of the outbreaks reported had norovirus testing, the viral causes would be number one,” Dr. Pickering said.

Most outbreaks of diarrheal disease in child care centers are due to parasites and viruses. Common pathogens are the spore-forming protozoa Cryptosporidium parvum and rotaviruses.

“In child care centers, person-to-person transmission of Cryptosporidium parvum and rotavirus is common, due to the low inoculum dose [needed],” he said.

Another common diarrheal illness in children is giardiasis, which is caused by the microscopic parasite Giardia lamblia that affects the duodenum and small intestine. The highest incidence is in children aged 1–4 years. “Most of this occurs in June, July, August, and September, and then it starts to fall off a bit,” said Dr. Pickering, who is also professor of pediatrics at Emory University, Atlanta.

Antimicrobial therapy options for giardiasis include albendazole, furazolidone, metronidazole, nitazoxanide, paromomycin, quinacrine, and tinidazole. Dr. Pickering said that his drug of choice for children older than 3 years of age is tinidazole because it requires only a single dose. Furazolidone and nitazoxanide are ideal for younger children, he said, because they come in liquid form.

Diarrheal illness also can be caused by salmonella. The most common strain is the nontyphoidal form, which can cause asymptomatic carriage, gastroenteritis, and systemic illness. A meta-analysis of antimicrobial therapy for uncomplicated nontyphoidal salmonella gastroenteritis found no decrease in length of illness, increased risk for relapse, increased risk for positive culture after 3 weeks, and increased risk for adverse drug reaction (Cochrane Database Syst. Rev. 2000;93:CD001167).

“However, in infants less than 3 months of age who have salmonella gastroenteritis, most of us would recommend [antimicrobial] therapy because approximately 5% of these infants will develop bacteremia,” Dr. Pickering said.

Clostridium difficile also can cause diarrheal illness in children. Transmission occurs mainly in health care settings, and the hallmark presentations are fever, severe abdominal pain, leukocytosis, and fecal polymorphonuclear leukocytes in the stool.

Oral metronidazole is the drug of choice for children with this type of diarrhea, but vancomycin also can be used. The relapse rate in patients who are treated with either drug is 10%–20%. “Relapse is not due to development of resistance,” Dr. Pickering said. “The same drug can be used for the second course.” Dr. Pickering had no relevant conflicts to disclose.

SALT LAKE CITY – Most Americans find it difficult to accept late-life sexuality, according to Dr. Andrew S. Rosenzweig.

“Our culture still has this pervasive negative attitude about late-life sexuality in terms of discreet silence, distaste, and tunnel vision,” said Dr. Rosenzweig, an assistant clinical professor of psychiatry at Brown University, Providence, R.I.

Nevertheless, sexual desires among residents are normal and should be accepted, he said at the annual symposium of the American Medical Directors Association.

Not only family members of residents, but health professionals also have biases and can be judgmental on the topic, said Rosenzweig, medical director of MedOptions, a company based in Old Saybrook, Conn., that provides behavioral and primary care consulting services to nursing homes and assisted living facilities.

For instance, one Israeli study observed that nursing staff caring for Alzheimer's residents at a nursing home categorized residents' sexual behaviors in three ways: love and care, romance, and eroticism (Nursing Forum 2006;41:158–66).

The nursing staff showed acceptance and support of love and care, mixed reactions to romance, and strong reactions of anger and resentment to erotic behavior. That some staff found romance between residents troublesome and that most were appalled by erotic behavior reflects narrow biases, Dr. Rosenzweig said. “So clearly there's a lot of staff confusion and ignorance, and lack of training about late-life sexuality. … We should not underestimate the need for affection, for touch, for a connection with someone else.”

The goal for nursing facility professionals should be to create an environment that will help residents fulfill their sexual needs and desires while maintaining dignity and protecting rights of competent and incompetent residents. Some of the competing principles and values include the right to privacy, the right to experience a loving relationship, and the right to make one's own decision. Beyond that, however, staff members need to refrain from being judgmental. “It's very easy to project one's own religious, cultural, and personal beliefs on another,” Dr. Rosenzweig said.

Sexually inappropriate behavior may include genital exposure, masturbating in public, propositions to others for sexual intercourse, fondling another resident's genitals or breasts, requesting unnecessary genital care from staff, touching a caregiver in a sexually suggestive manner, and openly reading pornographic material. Sexually provocative but less problematic behaviors in nursing home and assisted living settings may include flirting, excessive flattery, commenting on a caregiver's behavior or appearance, and asking staff members personal questions.

The prevalence of sexual-behavior reports among dementia patients in nursing homes ranges from 3%–15% of reports of inappropriate behaviors, “but there have been very few studies,” Dr. Rosenzweig said. However, some evidence has linked those behaviors to frontal and temporal lobe pathology, especially disinhibited types of behaviors, he said. Acute onset of sexually inappropriate behaviors may follow stroke, vascular insult, and head injury. Differential diagnosis includes delirium, mania, seizure disorder, dopaminergic drugs, social isolation, and boredom.

Dr. Rosenzweig urged those attending the meeting to consider the barriers that nursing facilities residents face in making intimate human connections.

“Imagine your typical nursing home or assisted living facility, where the amount of privacy is zero and opportunities for expressing sexual desires are zero,” he said. “The literature on geriatric sexuality is showing that even with all these obstacles, there is a high amount of sexual desire in our residents, regardless of medical or psychosocial comorbidities.”

He cautioned, however, that physicians and staff can underestimate intimacy needs in residents that do not involve sex. “Many people view late-life sexuality as all about genital sex as opposed to intimacy and affection. Older people adapt and reprioritize sex, expressing sexuality in more diffuse ways.”

To determine whether a sexual behavior is inappropriate, Dr. Rosenzweig recommends that staff describe and document the behavior accurately, consider the reactions of other residents, identify why the behavior is occurring, and evaluate the competency and consent of all parties. “Many times, nursing home staff doesn't have a problem if the two residents engaging in a relationship are in a similar stage of dementia, but if one of the two is less cognitively impaired that creates a lot of ethical issues,” he said.

He also recommends evaluating one resident's awareness of potential risks from another's romantic advances and reporting the situation to their families. Nursing home staff often “view these relationships as taboo and they don't even let the family know until it's gotten to an advanced stage. The better approach is to let the family in on it earlier. But that brings up another ethical issue: Do you let the family make a decision or interfere in the love life or sex life of an elderly couple in your facility?”

Another complexity in evaluating sexual relationships between residents is the issue of their understanding of the involvement. A demented resident may be unaware of the situation altogether. “Sometimes they don't know the name of the person they're having the relationship with, which is fascinating,” Dr. Rosenzweig said. “Yet it's just as meaningful and emotionally rewarding to them.”

Nonpharmacologic interventions for dealing with sexually inappropriate behaviors include a nursing facility's medical director advising staff to maintain professional boundaries with residents, a concept that can be hard for some nurses to buy in to, Rosenzweig said. The certified nurse assistants see themselves as the resident's friend and confidant as opposed to having that professional boundary,” he said.

Other strategies include coworkers consulting with one another to establish a consistent approach to dealing with the behavior; fostering social stimulation and recreational activities, modifying the clothing of a resident acting inappropriately, such as dressing a man in a one- piece jump suit with back snaps and clasps, or discouraging revealing clothing for staff members, avoiding explicit television shows, encouraging appropriate behavior through rewards and attention, and isolating an offending resident from potential targets of inappropriate behavior.

Pharmacologic interventions for sexually inappropriate behaviors are poorly studied and ethically controversial, Dr. Rosenzweig said. Medications that have been studied but are without clear indications in this area include hormonal agents, serotonergic agents, antipsychotics, and mood stabilizers. Despite several recent successes with oral estrogen, any drug should generally be “an intervention of last resort,” he said.

“You have to be thoughtful and you have to use common sense and trial and error approaches,” he concluded.

Dr. Rosenzweig disclosed that he is a member of the speakers' bureaus for Abbott Laboratories, Eli Lilly and Company, Bristol-Myers Squibb, Novartis Pharmaceuticals, and Astra-Zeneca.

'Do you let the family make a decision or interfere in the love life … of an elderly couple in your facility?' DR. ROSENZWEIG

SALT LAKE CITY – Most Americans find it difficult to accept late-life sexuality, according to Dr. Andrew S. Rosenzweig.

“Our culture still has this pervasive negative attitude about late-life sexuality in terms of discreet silence, distaste, and tunnel vision,” said Dr. Rosenzweig, an assistant clinical professor of psychiatry at Brown University, Providence, R.I.

Nevertheless, sexual desires among residents are normal and should be accepted, he said at the annual symposium of the American Medical Directors Association.

Not only family members of residents, but health professionals also have biases and can be judgmental on the topic, said Rosenzweig, medical director of MedOptions, a company based in Old Saybrook, Conn., that provides behavioral and primary care consulting services to nursing homes and assisted living facilities.

For instance, one Israeli study observed that nursing staff caring for Alzheimer's residents at a nursing home categorized residents' sexual behaviors in three ways: love and care, romance, and eroticism (Nursing Forum 2006;41:158–66).

The nursing staff showed acceptance and support of love and care, mixed reactions to romance, and strong reactions of anger and resentment to erotic behavior. That some staff found romance between residents troublesome and that most were appalled by erotic behavior reflects narrow biases, Dr. Rosenzweig said. “So clearly there's a lot of staff confusion and ignorance, and lack of training about late-life sexuality. … We should not underestimate the need for affection, for touch, for a connection with someone else.”

The goal for nursing facility professionals should be to create an environment that will help residents fulfill their sexual needs and desires while maintaining dignity and protecting rights of competent and incompetent residents. Some of the competing principles and values include the right to privacy, the right to experience a loving relationship, and the right to make one's own decision. Beyond that, however, staff members need to refrain from being judgmental. “It's very easy to project one's own religious, cultural, and personal beliefs on another,” Dr. Rosenzweig said.

Sexually inappropriate behavior may include genital exposure, masturbating in public, propositions to others for sexual intercourse, fondling another resident's genitals or breasts, requesting unnecessary genital care from staff, touching a caregiver in a sexually suggestive manner, and openly reading pornographic material. Sexually provocative but less problematic behaviors in nursing home and assisted living settings may include flirting, excessive flattery, commenting on a caregiver's behavior or appearance, and asking staff members personal questions.

The prevalence of sexual-behavior reports among dementia patients in nursing homes ranges from 3%–15% of reports of inappropriate behaviors, “but there have been very few studies,” Dr. Rosenzweig said. However, some evidence has linked those behaviors to frontal and temporal lobe pathology, especially disinhibited types of behaviors, he said. Acute onset of sexually inappropriate behaviors may follow stroke, vascular insult, and head injury. Differential diagnosis includes delirium, mania, seizure disorder, dopaminergic drugs, social isolation, and boredom.

Dr. Rosenzweig urged those attending the meeting to consider the barriers that nursing facilities residents face in making intimate human connections.

“Imagine your typical nursing home or assisted living facility, where the amount of privacy is zero and opportunities for expressing sexual desires are zero,” he said. “The literature on geriatric sexuality is showing that even with all these obstacles, there is a high amount of sexual desire in our residents, regardless of medical or psychosocial comorbidities.”

He cautioned, however, that physicians and staff can underestimate intimacy needs in residents that do not involve sex. “Many people view late-life sexuality as all about genital sex as opposed to intimacy and affection. Older people adapt and reprioritize sex, expressing sexuality in more diffuse ways.”

To determine whether a sexual behavior is inappropriate, Dr. Rosenzweig recommends that staff describe and document the behavior accurately, consider the reactions of other residents, identify why the behavior is occurring, and evaluate the competency and consent of all parties. “Many times, nursing home staff doesn't have a problem if the two residents engaging in a relationship are in a similar stage of dementia, but if one of the two is less cognitively impaired that creates a lot of ethical issues,” he said.

He also recommends evaluating one resident's awareness of potential risks from another's romantic advances and reporting the situation to their families. Nursing home staff often “view these relationships as taboo and they don't even let the family know until it's gotten to an advanced stage. The better approach is to let the family in on it earlier. But that brings up another ethical issue: Do you let the family make a decision or interfere in the love life or sex life of an elderly couple in your facility?”

Another complexity in evaluating sexual relationships between residents is the issue of their understanding of the involvement. A demented resident may be unaware of the situation altogether. “Sometimes they don't know the name of the person they're having the relationship with, which is fascinating,” Dr. Rosenzweig said. “Yet it's just as meaningful and emotionally rewarding to them.”

Nonpharmacologic interventions for dealing with sexually inappropriate behaviors include a nursing facility's medical director advising staff to maintain professional boundaries with residents, a concept that can be hard for some nurses to buy in to, Rosenzweig said. The certified nurse assistants see themselves as the resident's friend and confidant as opposed to having that professional boundary,” he said.

Other strategies include coworkers consulting with one another to establish a consistent approach to dealing with the behavior; fostering social stimulation and recreational activities, modifying the clothing of a resident acting inappropriately, such as dressing a man in a one- piece jump suit with back snaps and clasps, or discouraging revealing clothing for staff members, avoiding explicit television shows, encouraging appropriate behavior through rewards and attention, and isolating an offending resident from potential targets of inappropriate behavior.

Pharmacologic interventions for sexually inappropriate behaviors are poorly studied and ethically controversial, Dr. Rosenzweig said. Medications that have been studied but are without clear indications in this area include hormonal agents, serotonergic agents, antipsychotics, and mood stabilizers. Despite several recent successes with oral estrogen, any drug should generally be “an intervention of last resort,” he said.

“You have to be thoughtful and you have to use common sense and trial and error approaches,” he concluded.

Dr. Rosenzweig disclosed that he is a member of the speakers' bureaus for Abbott Laboratories, Eli Lilly and Company, Bristol-Myers Squibb, Novartis Pharmaceuticals, and Astra-Zeneca.

'Do you let the family make a decision or interfere in the love life … of an elderly couple in your facility?' DR. ROSENZWEIG

SALT LAKE CITY – Most Americans find it difficult to accept late-life sexuality, according to Dr. Andrew S. Rosenzweig.

“Our culture still has this pervasive negative attitude about late-life sexuality in terms of discreet silence, distaste, and tunnel vision,” said Dr. Rosenzweig, an assistant clinical professor of psychiatry at Brown University, Providence, R.I.

Nevertheless, sexual desires among residents are normal and should be accepted, he said at the annual symposium of the American Medical Directors Association.

Not only family members of residents, but health professionals also have biases and can be judgmental on the topic, said Rosenzweig, medical director of MedOptions, a company based in Old Saybrook, Conn., that provides behavioral and primary care consulting services to nursing homes and assisted living facilities.

For instance, one Israeli study observed that nursing staff caring for Alzheimer's residents at a nursing home categorized residents' sexual behaviors in three ways: love and care, romance, and eroticism (Nursing Forum 2006;41:158–66).

The nursing staff showed acceptance and support of love and care, mixed reactions to romance, and strong reactions of anger and resentment to erotic behavior. That some staff found romance between residents troublesome and that most were appalled by erotic behavior reflects narrow biases, Dr. Rosenzweig said. “So clearly there's a lot of staff confusion and ignorance, and lack of training about late-life sexuality. … We should not underestimate the need for affection, for touch, for a connection with someone else.”

The goal for nursing facility professionals should be to create an environment that will help residents fulfill their sexual needs and desires while maintaining dignity and protecting rights of competent and incompetent residents. Some of the competing principles and values include the right to privacy, the right to experience a loving relationship, and the right to make one's own decision. Beyond that, however, staff members need to refrain from being judgmental. “It's very easy to project one's own religious, cultural, and personal beliefs on another,” Dr. Rosenzweig said.

Sexually inappropriate behavior may include genital exposure, masturbating in public, propositions to others for sexual intercourse, fondling another resident's genitals or breasts, requesting unnecessary genital care from staff, touching a caregiver in a sexually suggestive manner, and openly reading pornographic material. Sexually provocative but less problematic behaviors in nursing home and assisted living settings may include flirting, excessive flattery, commenting on a caregiver's behavior or appearance, and asking staff members personal questions.

The prevalence of sexual-behavior reports among dementia patients in nursing homes ranges from 3%–15% of reports of inappropriate behaviors, “but there have been very few studies,” Dr. Rosenzweig said. However, some evidence has linked those behaviors to frontal and temporal lobe pathology, especially disinhibited types of behaviors, he said. Acute onset of sexually inappropriate behaviors may follow stroke, vascular insult, and head injury. Differential diagnosis includes delirium, mania, seizure disorder, dopaminergic drugs, social isolation, and boredom.

Dr. Rosenzweig urged those attending the meeting to consider the barriers that nursing facilities residents face in making intimate human connections.

“Imagine your typical nursing home or assisted living facility, where the amount of privacy is zero and opportunities for expressing sexual desires are zero,” he said. “The literature on geriatric sexuality is showing that even with all these obstacles, there is a high amount of sexual desire in our residents, regardless of medical or psychosocial comorbidities.”

He cautioned, however, that physicians and staff can underestimate intimacy needs in residents that do not involve sex. “Many people view late-life sexuality as all about genital sex as opposed to intimacy and affection. Older people adapt and reprioritize sex, expressing sexuality in more diffuse ways.”

To determine whether a sexual behavior is inappropriate, Dr. Rosenzweig recommends that staff describe and document the behavior accurately, consider the reactions of other residents, identify why the behavior is occurring, and evaluate the competency and consent of all parties. “Many times, nursing home staff doesn't have a problem if the two residents engaging in a relationship are in a similar stage of dementia, but if one of the two is less cognitively impaired that creates a lot of ethical issues,” he said.

He also recommends evaluating one resident's awareness of potential risks from another's romantic advances and reporting the situation to their families. Nursing home staff often “view these relationships as taboo and they don't even let the family know until it's gotten to an advanced stage. The better approach is to let the family in on it earlier. But that brings up another ethical issue: Do you let the family make a decision or interfere in the love life or sex life of an elderly couple in your facility?”

Another complexity in evaluating sexual relationships between residents is the issue of their understanding of the involvement. A demented resident may be unaware of the situation altogether. “Sometimes they don't know the name of the person they're having the relationship with, which is fascinating,” Dr. Rosenzweig said. “Yet it's just as meaningful and emotionally rewarding to them.”

Nonpharmacologic interventions for dealing with sexually inappropriate behaviors include a nursing facility's medical director advising staff to maintain professional boundaries with residents, a concept that can be hard for some nurses to buy in to, Rosenzweig said. The certified nurse assistants see themselves as the resident's friend and confidant as opposed to having that professional boundary,” he said.

Other strategies include coworkers consulting with one another to establish a consistent approach to dealing with the behavior; fostering social stimulation and recreational activities, modifying the clothing of a resident acting inappropriately, such as dressing a man in a one- piece jump suit with back snaps and clasps, or discouraging revealing clothing for staff members, avoiding explicit television shows, encouraging appropriate behavior through rewards and attention, and isolating an offending resident from potential targets of inappropriate behavior.

Pharmacologic interventions for sexually inappropriate behaviors are poorly studied and ethically controversial, Dr. Rosenzweig said. Medications that have been studied but are without clear indications in this area include hormonal agents, serotonergic agents, antipsychotics, and mood stabilizers. Despite several recent successes with oral estrogen, any drug should generally be “an intervention of last resort,” he said.

“You have to be thoughtful and you have to use common sense and trial and error approaches,” he concluded.

Dr. Rosenzweig disclosed that he is a member of the speakers' bureaus for Abbott Laboratories, Eli Lilly and Company, Bristol-Myers Squibb, Novartis Pharmaceuticals, and Astra-Zeneca.

'Do you let the family make a decision or interfere in the love life … of an elderly couple in your facility?' DR. ROSENZWEIG

SALT LAKE CITY – Geriatric psychiatrist consultants can relieve some of the burden on nursing homes and help provide optimal care, the medical director of a large system of senior-living facilities said.

Good geriatric psychiatrists are hard to find, but it's important to convince administrators that timely psychiatric consultations and appropriate recommendations may reduce litigation risks and help nursing homes with risk management, Dr. Jeffrey B. Burl, medical director of Overlook Masonic Health System in Charlton, Mass., said at the annual symposium of the American Medical Directors Association.

Today, up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. “We're all seeing these types of patients admitted to our facilities [from] assisted living programs,” Dr. Burl said. “They nurture these people until it finally reaches the point where the behavior is so untenable that they are admitted to a nursing home.”

He noted that mental health issues are some of the most difficult problems in the nursing home setting. Lack of good research, potential adverse effects of medications such as atypical antipsychotics, and difficult-to-quantify end points for progress with patients “make care of these issues problematic,” he said. “Provider and staffing issues may complicate the picture.”

Dr. Burl said he is aware of a few skilled nursing facilities that offer a stipend to consultant psychiatrists and assign them the title of associate director of dementia units. Duties include educating staff about behavioral problems, reviewing policies, and developing behavior plans for residents.

“It took a little bit of effort to convince these nursing homes to pay for the stipend, but once they saw the number of antipsychotic medications going down and the number of psychoactive medications going down [after psychiatrists' interventions], that got their attention,” said Dr. Burl, whose system offers a continuum of services that includes independent housing, assisted living, a skilled nursing facility, subacute care, a visiting nurse association, and hospice care.

Other facilities have used the services of specially trained nurse practitioners with skills and expertise in geriatric mental health. They usually collaborate with consultant psychiatrists in providing timely care in facilities.

Overlook Masonic Health Care recognizes six indications for a geriatric psychiatry consultation: recurrent depression or being nonresponsive to medications for depression, suicidal ideation or hopelessness, depression with psychotic features, aggressive behaviors that result in harm to staff or to other residents, refusal to eat or drink despite no obvious medical problems, and displays of acute or chronic psychosis including paranoia, hallucinations, and personality changes.

Outlining expectations for a psychiatric consultant is important, Dr. Burl said. For example, agree whether you'll notify the consultant by phone, fax, or e-mail. What processes do you have for regularly communicating with the consultant? What's your expected turnaround time for such communications?

It's also essential to delineate how recommendations from the consulting psychiatrist will be transmitted to an attending physician and to devise a procedure for addressing the consultant's recommendations when the attending isn't available or refuses the recommendations.

Dr. Burl reminded his audience that as stated in the Centers for Medicare and Medicaid Services' F-tag 150 language, medical directors are ultimately responsible for coordination of care and implementation of resident-care policies and procedures. They might need to intervene to make sure that all consultants to a nursing home are meeting expectations.

After all, he said: “Our cases are getting more complex. This is our challenge.”

Dr. Burl said that he had no relevant conflicts to disclose.

Up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. DR. BURL

SALT LAKE CITY – Geriatric psychiatrist consultants can relieve some of the burden on nursing homes and help provide optimal care, the medical director of a large system of senior-living facilities said.

Good geriatric psychiatrists are hard to find, but it's important to convince administrators that timely psychiatric consultations and appropriate recommendations may reduce litigation risks and help nursing homes with risk management, Dr. Jeffrey B. Burl, medical director of Overlook Masonic Health System in Charlton, Mass., said at the annual symposium of the American Medical Directors Association.

Today, up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. “We're all seeing these types of patients admitted to our facilities [from] assisted living programs,” Dr. Burl said. “They nurture these people until it finally reaches the point where the behavior is so untenable that they are admitted to a nursing home.”

He noted that mental health issues are some of the most difficult problems in the nursing home setting. Lack of good research, potential adverse effects of medications such as atypical antipsychotics, and difficult-to-quantify end points for progress with patients “make care of these issues problematic,” he said. “Provider and staffing issues may complicate the picture.”

Dr. Burl said he is aware of a few skilled nursing facilities that offer a stipend to consultant psychiatrists and assign them the title of associate director of dementia units. Duties include educating staff about behavioral problems, reviewing policies, and developing behavior plans for residents.

“It took a little bit of effort to convince these nursing homes to pay for the stipend, but once they saw the number of antipsychotic medications going down and the number of psychoactive medications going down [after psychiatrists' interventions], that got their attention,” said Dr. Burl, whose system offers a continuum of services that includes independent housing, assisted living, a skilled nursing facility, subacute care, a visiting nurse association, and hospice care.

Other facilities have used the services of specially trained nurse practitioners with skills and expertise in geriatric mental health. They usually collaborate with consultant psychiatrists in providing timely care in facilities.

Overlook Masonic Health Care recognizes six indications for a geriatric psychiatry consultation: recurrent depression or being nonresponsive to medications for depression, suicidal ideation or hopelessness, depression with psychotic features, aggressive behaviors that result in harm to staff or to other residents, refusal to eat or drink despite no obvious medical problems, and displays of acute or chronic psychosis including paranoia, hallucinations, and personality changes.

Outlining expectations for a psychiatric consultant is important, Dr. Burl said. For example, agree whether you'll notify the consultant by phone, fax, or e-mail. What processes do you have for regularly communicating with the consultant? What's your expected turnaround time for such communications?

It's also essential to delineate how recommendations from the consulting psychiatrist will be transmitted to an attending physician and to devise a procedure for addressing the consultant's recommendations when the attending isn't available or refuses the recommendations.

Dr. Burl reminded his audience that as stated in the Centers for Medicare and Medicaid Services' F-tag 150 language, medical directors are ultimately responsible for coordination of care and implementation of resident-care policies and procedures. They might need to intervene to make sure that all consultants to a nursing home are meeting expectations.

After all, he said: “Our cases are getting more complex. This is our challenge.”

Dr. Burl said that he had no relevant conflicts to disclose.

Up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. DR. BURL

SALT LAKE CITY – Geriatric psychiatrist consultants can relieve some of the burden on nursing homes and help provide optimal care, the medical director of a large system of senior-living facilities said.

Good geriatric psychiatrists are hard to find, but it's important to convince administrators that timely psychiatric consultations and appropriate recommendations may reduce litigation risks and help nursing homes with risk management, Dr. Jeffrey B. Burl, medical director of Overlook Masonic Health System in Charlton, Mass., said at the annual symposium of the American Medical Directors Association.

Today, up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. “We're all seeing these types of patients admitted to our facilities [from] assisted living programs,” Dr. Burl said. “They nurture these people until it finally reaches the point where the behavior is so untenable that they are admitted to a nursing home.”

He noted that mental health issues are some of the most difficult problems in the nursing home setting. Lack of good research, potential adverse effects of medications such as atypical antipsychotics, and difficult-to-quantify end points for progress with patients “make care of these issues problematic,” he said. “Provider and staffing issues may complicate the picture.”

Dr. Burl said he is aware of a few skilled nursing facilities that offer a stipend to consultant psychiatrists and assign them the title of associate director of dementia units. Duties include educating staff about behavioral problems, reviewing policies, and developing behavior plans for residents.

“It took a little bit of effort to convince these nursing homes to pay for the stipend, but once they saw the number of antipsychotic medications going down and the number of psychoactive medications going down [after psychiatrists' interventions], that got their attention,” said Dr. Burl, whose system offers a continuum of services that includes independent housing, assisted living, a skilled nursing facility, subacute care, a visiting nurse association, and hospice care.

Other facilities have used the services of specially trained nurse practitioners with skills and expertise in geriatric mental health. They usually collaborate with consultant psychiatrists in providing timely care in facilities.

Overlook Masonic Health Care recognizes six indications for a geriatric psychiatry consultation: recurrent depression or being nonresponsive to medications for depression, suicidal ideation or hopelessness, depression with psychotic features, aggressive behaviors that result in harm to staff or to other residents, refusal to eat or drink despite no obvious medical problems, and displays of acute or chronic psychosis including paranoia, hallucinations, and personality changes.

Outlining expectations for a psychiatric consultant is important, Dr. Burl said. For example, agree whether you'll notify the consultant by phone, fax, or e-mail. What processes do you have for regularly communicating with the consultant? What's your expected turnaround time for such communications?

It's also essential to delineate how recommendations from the consulting psychiatrist will be transmitted to an attending physician and to devise a procedure for addressing the consultant's recommendations when the attending isn't available or refuses the recommendations.

Dr. Burl reminded his audience that as stated in the Centers for Medicare and Medicaid Services' F-tag 150 language, medical directors are ultimately responsible for coordination of care and implementation of resident-care policies and procedures. They might need to intervene to make sure that all consultants to a nursing home are meeting expectations.

After all, he said: “Our cases are getting more complex. This is our challenge.”

Dr. Burl said that he had no relevant conflicts to disclose.

Up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. DR. BURL

Ever wonder what it would be like to live and work in a remote village in New Zealand, or to travel around the United States practicing medicine along the way?

Since leaving his practice in June 2006 for a locum tenens position, Dr. Joshua Gutman said he has become more energized.

Currently living in Providence, R.I., Dr. Gutman practiced in South Attleboro, Mass., before taking up a locum tenens lifestyle. “After 29 years of practice, it was much easier for me to get down in the dumps and discouraged about the medical environment, or about issues with patients, or referrals or billing or personnel issues at work. With the administrative burdens gone, I feel much happier taking care of patients.”

Locum tenens work allows him to fulfill a lifelong dream to travel while maintaining and stretching his clinical skills. His assignments have included a 7-week stint working in a health center on a remote Navajo reservation in Arizona, where he learned splinting techniques that are typically performed by orthopedists, and a 4.5-month assignment working in a health clinic in Reefton, a small town in New Zealand, where he learned how to use an electronic medical record and how to remove foreign bodies from a cornea. His wife, Eva, who teaches English, French, and Spanish, traveled with him for the assignments and found teaching work in both locales.

Dr. Gutman said he was impressed with the universal health care system in New Zealand, where every citizen receives basic primary care. “They do have limitations of access to tertiary care and elective surgical procedures, but the health care system works so much better than here and it's so much less expensive,” he remarked.

It also helps that medical malpractice is virtually nonexistent. “Patients there don't sue doctors,” he said. By contrast, the litigious nature of Americans is renowned. On learning he was from the United States, his patients' reaction was often: “Don't worry, doc. We're not going to sue you.”

A locum tenens recruitment organization (VISTA Staffing Solutions) arranged the assignment, and Dr. Gutman worked under a contract with the New Zealand government, which provided a week of paid vacation for every 8 weeks he worked. This enabled him and Eva to enjoy a 2-week paid vacation traveling the country.

Dr. Gutman noted that locum tenens work isn't suitable for everyone; flexibility is essential. “When you move into locum tenens, you have to be willing to do things their way,” he said. “I've found people have been wonderful mostly because I'm willing to function within their system.”

In summer 2008, they will travel to Fairbanks, Alaska, for a 9-week assignment. Meanwhile, he keeps busy doing locum tenens work locally 2–3 days a week.

Dr. Gutman's annual income is about two-thirds of what it was when he was in full-time private practice, “but I haven't made an effort to work 48–49 weeks as I did when I was in my own practice,” he explained. “I have taken a few weeks' break between assignments.”

That allows him more time to read, a favorite pastime. “I've also been spending much more time in the gym,” he said. “I'm much more [physically] fit than I was when I was in my own practice. We rediscovered skiing this winter, which we hadn't done for the last 8 years.”

Dr. Monica Speicher entered locum tenens work right out of residency in 2003 because she was not sure where she wanted to work. It “gave me a chance to bounce around and see several different areas of the country,” said Dr. Speicher, who spent 4 years on assignments in Alaska, Arizona, Maine, Washington state, and New Zealand before accepting a full-time position on the clinical faculty at Washington (Pa.) Hospital. “Almost everywhere I worked, I was offered a permanent job, so it's a good way to test-run a practice,” she said.

She accepted assignments primarily in rural locations where specialists were sparse. As a result, she said, she quickly gained confidence in her clinical skills, although she admits to being rattled during her assignment at the same clinic in Reefton, New Zealand, where Dr. Gutman worked. There, she routinely rode along with emergency medical staff on ambulance calls, responding to car accidents and other emergencies.

Working at a remote clinic on Prince of Wales Island, Alaska, also tested her mettle. The clinic receives so few critical cases that when one came in, the support staff “tended to panic,” she said.

She echoed Dr. Gutman's sentiment that locum tenens work best suits physicians who are flexible. “If you're a flexible, more laid-back type of person, you will really enjoy it,” she said.

For more information, visit the Web site of the National Association of Locum Tenens Organizations at www.nalto.orghttp://locumlife.modernmedicine.com

Dr. Joshua Gutman and his wife, Eva, kayaking in New Zealand, where he did locum tenens work at a clinic. Courtesy Dr. Joshua Gutman

Ever wonder what it would be like to live and work in a remote village in New Zealand, or to travel around the United States practicing medicine along the way?

Since leaving his practice in June 2006 for a locum tenens position, Dr. Joshua Gutman said he has become more energized.

Currently living in Providence, R.I., Dr. Gutman practiced in South Attleboro, Mass., before taking up a locum tenens lifestyle. “After 29 years of practice, it was much easier for me to get down in the dumps and discouraged about the medical environment, or about issues with patients, or referrals or billing or personnel issues at work. With the administrative burdens gone, I feel much happier taking care of patients.”

Locum tenens work allows him to fulfill a lifelong dream to travel while maintaining and stretching his clinical skills. His assignments have included a 7-week stint working in a health center on a remote Navajo reservation in Arizona, where he learned splinting techniques that are typically performed by orthopedists, and a 4.5-month assignment working in a health clinic in Reefton, a small town in New Zealand, where he learned how to use an electronic medical record and how to remove foreign bodies from a cornea. His wife, Eva, who teaches English, French, and Spanish, traveled with him for the assignments and found teaching work in both locales.

Dr. Gutman said he was impressed with the universal health care system in New Zealand, where every citizen receives basic primary care. “They do have limitations of access to tertiary care and elective surgical procedures, but the health care system works so much better than here and it's so much less expensive,” he remarked.

It also helps that medical malpractice is virtually nonexistent. “Patients there don't sue doctors,” he said. By contrast, the litigious nature of Americans is renowned. On learning he was from the United States, his patients' reaction was often: “Don't worry, doc. We're not going to sue you.”

A locum tenens recruitment organization (VISTA Staffing Solutions) arranged the assignment, and Dr. Gutman worked under a contract with the New Zealand government, which provided a week of paid vacation for every 8 weeks he worked. This enabled him and Eva to enjoy a 2-week paid vacation traveling the country.

Dr. Gutman noted that locum tenens work isn't suitable for everyone; flexibility is essential. “When you move into locum tenens, you have to be willing to do things their way,” he said. “I've found people have been wonderful mostly because I'm willing to function within their system.”

In summer 2008, they will travel to Fairbanks, Alaska, for a 9-week assignment. Meanwhile, he keeps busy doing locum tenens work locally 2–3 days a week.

Dr. Gutman's annual income is about two-thirds of what it was when he was in full-time private practice, “but I haven't made an effort to work 48–49 weeks as I did when I was in my own practice,” he explained. “I have taken a few weeks' break between assignments.”

That allows him more time to read, a favorite pastime. “I've also been spending much more time in the gym,” he said. “I'm much more [physically] fit than I was when I was in my own practice. We rediscovered skiing this winter, which we hadn't done for the last 8 years.”

Dr. Monica Speicher entered locum tenens work right out of residency in 2003 because she was not sure where she wanted to work. It “gave me a chance to bounce around and see several different areas of the country,” said Dr. Speicher, who spent 4 years on assignments in Alaska, Arizona, Maine, Washington state, and New Zealand before accepting a full-time position on the clinical faculty at Washington (Pa.) Hospital. “Almost everywhere I worked, I was offered a permanent job, so it's a good way to test-run a practice,” she said.

She accepted assignments primarily in rural locations where specialists were sparse. As a result, she said, she quickly gained confidence in her clinical skills, although she admits to being rattled during her assignment at the same clinic in Reefton, New Zealand, where Dr. Gutman worked. There, she routinely rode along with emergency medical staff on ambulance calls, responding to car accidents and other emergencies.

Working at a remote clinic on Prince of Wales Island, Alaska, also tested her mettle. The clinic receives so few critical cases that when one came in, the support staff “tended to panic,” she said.

She echoed Dr. Gutman's sentiment that locum tenens work best suits physicians who are flexible. “If you're a flexible, more laid-back type of person, you will really enjoy it,” she said.

For more information, visit the Web site of the National Association of Locum Tenens Organizations at www.nalto.orghttp://locumlife.modernmedicine.com

Dr. Joshua Gutman and his wife, Eva, kayaking in New Zealand, where he did locum tenens work at a clinic. Courtesy Dr. Joshua Gutman

Ever wonder what it would be like to live and work in a remote village in New Zealand, or to travel around the United States practicing medicine along the way?

Since leaving his practice in June 2006 for a locum tenens position, Dr. Joshua Gutman said he has become more energized.

Currently living in Providence, R.I., Dr. Gutman practiced in South Attleboro, Mass., before taking up a locum tenens lifestyle. “After 29 years of practice, it was much easier for me to get down in the dumps and discouraged about the medical environment, or about issues with patients, or referrals or billing or personnel issues at work. With the administrative burdens gone, I feel much happier taking care of patients.”

Locum tenens work allows him to fulfill a lifelong dream to travel while maintaining and stretching his clinical skills. His assignments have included a 7-week stint working in a health center on a remote Navajo reservation in Arizona, where he learned splinting techniques that are typically performed by orthopedists, and a 4.5-month assignment working in a health clinic in Reefton, a small town in New Zealand, where he learned how to use an electronic medical record and how to remove foreign bodies from a cornea. His wife, Eva, who teaches English, French, and Spanish, traveled with him for the assignments and found teaching work in both locales.

Dr. Gutman said he was impressed with the universal health care system in New Zealand, where every citizen receives basic primary care. “They do have limitations of access to tertiary care and elective surgical procedures, but the health care system works so much better than here and it's so much less expensive,” he remarked.

It also helps that medical malpractice is virtually nonexistent. “Patients there don't sue doctors,” he said. By contrast, the litigious nature of Americans is renowned. On learning he was from the United States, his patients' reaction was often: “Don't worry, doc. We're not going to sue you.”

A locum tenens recruitment organization (VISTA Staffing Solutions) arranged the assignment, and Dr. Gutman worked under a contract with the New Zealand government, which provided a week of paid vacation for every 8 weeks he worked. This enabled him and Eva to enjoy a 2-week paid vacation traveling the country.

Dr. Gutman noted that locum tenens work isn't suitable for everyone; flexibility is essential. “When you move into locum tenens, you have to be willing to do things their way,” he said. “I've found people have been wonderful mostly because I'm willing to function within their system.”

In summer 2008, they will travel to Fairbanks, Alaska, for a 9-week assignment. Meanwhile, he keeps busy doing locum tenens work locally 2–3 days a week.

Dr. Gutman's annual income is about two-thirds of what it was when he was in full-time private practice, “but I haven't made an effort to work 48–49 weeks as I did when I was in my own practice,” he explained. “I have taken a few weeks' break between assignments.”

That allows him more time to read, a favorite pastime. “I've also been spending much more time in the gym,” he said. “I'm much more [physically] fit than I was when I was in my own practice. We rediscovered skiing this winter, which we hadn't done for the last 8 years.”

Dr. Monica Speicher entered locum tenens work right out of residency in 2003 because she was not sure where she wanted to work. It “gave me a chance to bounce around and see several different areas of the country,” said Dr. Speicher, who spent 4 years on assignments in Alaska, Arizona, Maine, Washington state, and New Zealand before accepting a full-time position on the clinical faculty at Washington (Pa.) Hospital. “Almost everywhere I worked, I was offered a permanent job, so it's a good way to test-run a practice,” she said.

She accepted assignments primarily in rural locations where specialists were sparse. As a result, she said, she quickly gained confidence in her clinical skills, although she admits to being rattled during her assignment at the same clinic in Reefton, New Zealand, where Dr. Gutman worked. There, she routinely rode along with emergency medical staff on ambulance calls, responding to car accidents and other emergencies.

Working at a remote clinic on Prince of Wales Island, Alaska, also tested her mettle. The clinic receives so few critical cases that when one came in, the support staff “tended to panic,” she said.

She echoed Dr. Gutman's sentiment that locum tenens work best suits physicians who are flexible. “If you're a flexible, more laid-back type of person, you will really enjoy it,” she said.

For more information, visit the Web site of the National Association of Locum Tenens Organizations at www.nalto.orghttp://locumlife.modernmedicine.com

Dr. Joshua Gutman and his wife, Eva, kayaking in New Zealand, where he did locum tenens work at a clinic. Courtesy Dr. Joshua Gutman

LA JOLLA, CALIF. — The way Dr. Lynne M. Bird sees it, the $1,500 gene sequencing test for neurofibromatosis type 1 in children is rarely necessary because it usually does not change clinical management.

She favors a watchful waiting approach in children who present with the hallmark symptom of at least six café au lait macules that are at least 5 mm in size, "and [I] wait for the second criterion to appear," she said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "I follow these children as if I already knew they had NF1, monitoring them for potential complications without doing gene testing."

The prevalence of neurofibromatosis type 1 (NF1) is 1:3,000, making it the most common neurocutaneous disorder in children. Diagnosis is made if the child meets two of seven criteria: café au lait macules; axillary or inguinal freckling; two or more neurofibromas or one plexiform neurofibroma; optic nerve glioma; two or more Lisch nodules of the iris; a distinctive osseous lesion such as pseudarthrosis or sphenoid wing dysplasia; or a family history of the disease.

About half of cases with no family history meet criteria for the disorder by 1 year of age; 97% meet the criteria by 8 years of age.

NF1 is an autosomal, dominantly inherited disorder due to mutations in a gene on chromosome 17, which encodes the protein neurofibromin, a tumor suppressor. "Finding a mutation of the gene would also allow you to make this diagnosis," said Dr. Bird of the division of genetics and dysmorphology at Rady Children's Hospital, San Diego.

"If you have a parent with NF1 and you can determine their mutation through genetic testing, then you can offer them prenatal diagnosis. In my experience, most parents aren't concerned enough about passing NF1 on to their children that they would consider interrupting a pregnancy. But there are some families that have experienced major complications associated with NF1, and they are very interested in not passing the gene on to their children," she said.

A study of nearly 1,900 patients with NF1 found that the features of the disease typically appear in a characteristic order, beginning with café au lait macules (Pediatrics 2000;105:608–14).

Sometimes macules are present at birth "but others will appear in the first few months of life and certainly by the first couple of years of age," Dr. Bird said. "Typically the next feature is axillary freckling, which is usually evident in the school-age child. Lisch nodules will appear gradually after that, followed by neurofibromas as a sign that the child is entering puberty."

Another clue is the presence of the Riccardi sign, a tuft of hair along the back near the spine. "This sign will often be present at birth and may be there before any of the café au lait macules show up, so you will look really smart if you make a tentative diagnosis upon seeing this," Dr. Bird said.

Optic glioma almost always appears by 3 years of age "and certainly by 6 years of age," she said. "In addition, there is frequent thickening of the optic nerves, which is asymptomatic and doesn't cause disease."

A rare feature of NF1 is juvenile xanthogranuloma, which occurs in 1%–2% of cases. This skin lesion usually resolves spontaneously but is associated with an increased incidence of juvenile myeloid leukemia (JML). "When you see this you want to at least do a complete blood count and be thinking about JML, and maybe contact your local oncologist to see if they have further recommendations for monitoring," she advised.

In most cases, the diagnosis of NF1 is made on clinical exam, including a careful evaluation of both parents. "This condition is present in 1 in 3,000 in the general population, but I don't see anywhere near the equivalent number of kids in my clinic," Dr. Bird said. "That tells me there is a lot of undiagnosed NF1 out there. Most parents [with NF1] are healthy; they just have spots and a few lumps on their skin."

The best way to follow children with NF1 is to see them regularly for a complete physical examination and review of systems. There is no way to screen for every single complication of NF1 except by talking to families, said Dr. Bird. "Families should be told that symptoms which are not self-limited need to be brought to your attention," she said. "If there is a symptom that hangs on, that's nagging and doesn't go away in a reasonable amount of time, they need to come in so we can explore whether it is related to NF1 or not."

Basic follow-up tests should include checking blood pressure and monitoring for scoliosis as well as an ophthalmology evaluation and an assessment of developmental skills. "Learning disabilities are common," she said. "Expressive language delay is the area of development most commonly affected."

Many parents ask Dr. Bird if an MRI of the brain and optic nerves is needed in children who present with multiple café au lait macules. "There is probably no correct answer to that question," she said. "There is no evidence that detecting optic gliomas before they're symptomatic translates into better outcome. So you could argue that doing an MRI, which requires anesthesia, is not worth the money or the risk."

NF1 patients with neurofibromas have a 10% lifetime risk of developing a malignant peripheral nerve sheath tumor within one of the lesions. Signs of malignant degeneration include persistent pain, a change in texture, a rapid increase in size, or development of a neurologic deficit associated with the neurofibroma.

Dr. Bird had no relevant conflicts to disclose.

Café au lait macules are usually the first sign of neurofibromatosis type 1.

The next sign, axillary freckling, is often evident in the school-aged child.

The Riccardi sign, a tuft of hair near the spine, may be present at birth and can even appear before macules. Photos courtesy Dr. Lynne M. Bird and Dr. Marilyn C. Jones

LA JOLLA, CALIF. — The way Dr. Lynne M. Bird sees it, the $1,500 gene sequencing test for neurofibromatosis type 1 in children is rarely necessary because it usually does not change clinical management.

She favors a watchful waiting approach in children who present with the hallmark symptom of at least six café au lait macules that are at least 5 mm in size, "and [I] wait for the second criterion to appear," she said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "I follow these children as if I already knew they had NF1, monitoring them for potential complications without doing gene testing."

The prevalence of neurofibromatosis type 1 (NF1) is 1:3,000, making it the most common neurocutaneous disorder in children. Diagnosis is made if the child meets two of seven criteria: café au lait macules; axillary or inguinal freckling; two or more neurofibromas or one plexiform neurofibroma; optic nerve glioma; two or more Lisch nodules of the iris; a distinctive osseous lesion such as pseudarthrosis or sphenoid wing dysplasia; or a family history of the disease.

About half of cases with no family history meet criteria for the disorder by 1 year of age; 97% meet the criteria by 8 years of age.

NF1 is an autosomal, dominantly inherited disorder due to mutations in a gene on chromosome 17, which encodes the protein neurofibromin, a tumor suppressor. "Finding a mutation of the gene would also allow you to make this diagnosis," said Dr. Bird of the division of genetics and dysmorphology at Rady Children's Hospital, San Diego.

"If you have a parent with NF1 and you can determine their mutation through genetic testing, then you can offer them prenatal diagnosis. In my experience, most parents aren't concerned enough about passing NF1 on to their children that they would consider interrupting a pregnancy. But there are some families that have experienced major complications associated with NF1, and they are very interested in not passing the gene on to their children," she said.

A study of nearly 1,900 patients with NF1 found that the features of the disease typically appear in a characteristic order, beginning with café au lait macules (Pediatrics 2000;105:608–14).

Sometimes macules are present at birth "but others will appear in the first few months of life and certainly by the first couple of years of age," Dr. Bird said. "Typically the next feature is axillary freckling, which is usually evident in the school-age child. Lisch nodules will appear gradually after that, followed by neurofibromas as a sign that the child is entering puberty."

Another clue is the presence of the Riccardi sign, a tuft of hair along the back near the spine. "This sign will often be present at birth and may be there before any of the café au lait macules show up, so you will look really smart if you make a tentative diagnosis upon seeing this," Dr. Bird said.

Optic glioma almost always appears by 3 years of age "and certainly by 6 years of age," she said. "In addition, there is frequent thickening of the optic nerves, which is asymptomatic and doesn't cause disease."

A rare feature of NF1 is juvenile xanthogranuloma, which occurs in 1%–2% of cases. This skin lesion usually resolves spontaneously but is associated with an increased incidence of juvenile myeloid leukemia (JML). "When you see this you want to at least do a complete blood count and be thinking about JML, and maybe contact your local oncologist to see if they have further recommendations for monitoring," she advised.

In most cases, the diagnosis of NF1 is made on clinical exam, including a careful evaluation of both parents. "This condition is present in 1 in 3,000 in the general population, but I don't see anywhere near the equivalent number of kids in my clinic," Dr. Bird said. "That tells me there is a lot of undiagnosed NF1 out there. Most parents [with NF1] are healthy; they just have spots and a few lumps on their skin."

The best way to follow children with NF1 is to see them regularly for a complete physical examination and review of systems. There is no way to screen for every single complication of NF1 except by talking to families, said Dr. Bird. "Families should be told that symptoms which are not self-limited need to be brought to your attention," she said. "If there is a symptom that hangs on, that's nagging and doesn't go away in a reasonable amount of time, they need to come in so we can explore whether it is related to NF1 or not."

Basic follow-up tests should include checking blood pressure and monitoring for scoliosis as well as an ophthalmology evaluation and an assessment of developmental skills. "Learning disabilities are common," she said. "Expressive language delay is the area of development most commonly affected."

Many parents ask Dr. Bird if an MRI of the brain and optic nerves is needed in children who present with multiple café au lait macules. "There is probably no correct answer to that question," she said. "There is no evidence that detecting optic gliomas before they're symptomatic translates into better outcome. So you could argue that doing an MRI, which requires anesthesia, is not worth the money or the risk."

NF1 patients with neurofibromas have a 10% lifetime risk of developing a malignant peripheral nerve sheath tumor within one of the lesions. Signs of malignant degeneration include persistent pain, a change in texture, a rapid increase in size, or development of a neurologic deficit associated with the neurofibroma.

Dr. Bird had no relevant conflicts to disclose.

Café au lait macules are usually the first sign of neurofibromatosis type 1.

The next sign, axillary freckling, is often evident in the school-aged child.

The Riccardi sign, a tuft of hair near the spine, may be present at birth and can even appear before macules. Photos courtesy Dr. Lynne M. Bird and Dr. Marilyn C. Jones

LA JOLLA, CALIF. — The way Dr. Lynne M. Bird sees it, the $1,500 gene sequencing test for neurofibromatosis type 1 in children is rarely necessary because it usually does not change clinical management.

She favors a watchful waiting approach in children who present with the hallmark symptom of at least six café au lait macules that are at least 5 mm in size, "and [I] wait for the second criterion to appear," she said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "I follow these children as if I already knew they had NF1, monitoring them for potential complications without doing gene testing."

The prevalence of neurofibromatosis type 1 (NF1) is 1:3,000, making it the most common neurocutaneous disorder in children. Diagnosis is made if the child meets two of seven criteria: café au lait macules; axillary or inguinal freckling; two or more neurofibromas or one plexiform neurofibroma; optic nerve glioma; two or more Lisch nodules of the iris; a distinctive osseous lesion such as pseudarthrosis or sphenoid wing dysplasia; or a family history of the disease.

About half of cases with no family history meet criteria for the disorder by 1 year of age; 97% meet the criteria by 8 years of age.

NF1 is an autosomal, dominantly inherited disorder due to mutations in a gene on chromosome 17, which encodes the protein neurofibromin, a tumor suppressor. "Finding a mutation of the gene would also allow you to make this diagnosis," said Dr. Bird of the division of genetics and dysmorphology at Rady Children's Hospital, San Diego.

"If you have a parent with NF1 and you can determine their mutation through genetic testing, then you can offer them prenatal diagnosis. In my experience, most parents aren't concerned enough about passing NF1 on to their children that they would consider interrupting a pregnancy. But there are some families that have experienced major complications associated with NF1, and they are very interested in not passing the gene on to their children," she said.

A study of nearly 1,900 patients with NF1 found that the features of the disease typically appear in a characteristic order, beginning with café au lait macules (Pediatrics 2000;105:608–14).

Sometimes macules are present at birth "but others will appear in the first few months of life and certainly by the first couple of years of age," Dr. Bird said. "Typically the next feature is axillary freckling, which is usually evident in the school-age child. Lisch nodules will appear gradually after that, followed by neurofibromas as a sign that the child is entering puberty."

Another clue is the presence of the Riccardi sign, a tuft of hair along the back near the spine. "This sign will often be present at birth and may be there before any of the café au lait macules show up, so you will look really smart if you make a tentative diagnosis upon seeing this," Dr. Bird said.

Optic glioma almost always appears by 3 years of age "and certainly by 6 years of age," she said. "In addition, there is frequent thickening of the optic nerves, which is asymptomatic and doesn't cause disease."

A rare feature of NF1 is juvenile xanthogranuloma, which occurs in 1%–2% of cases. This skin lesion usually resolves spontaneously but is associated with an increased incidence of juvenile myeloid leukemia (JML). "When you see this you want to at least do a complete blood count and be thinking about JML, and maybe contact your local oncologist to see if they have further recommendations for monitoring," she advised.

In most cases, the diagnosis of NF1 is made on clinical exam, including a careful evaluation of both parents. "This condition is present in 1 in 3,000 in the general population, but I don't see anywhere near the equivalent number of kids in my clinic," Dr. Bird said. "That tells me there is a lot of undiagnosed NF1 out there. Most parents [with NF1] are healthy; they just have spots and a few lumps on their skin."

The best way to follow children with NF1 is to see them regularly for a complete physical examination and review of systems. There is no way to screen for every single complication of NF1 except by talking to families, said Dr. Bird. "Families should be told that symptoms which are not self-limited need to be brought to your attention," she said. "If there is a symptom that hangs on, that's nagging and doesn't go away in a reasonable amount of time, they need to come in so we can explore whether it is related to NF1 or not."

Basic follow-up tests should include checking blood pressure and monitoring for scoliosis as well as an ophthalmology evaluation and an assessment of developmental skills. "Learning disabilities are common," she said. "Expressive language delay is the area of development most commonly affected."

Many parents ask Dr. Bird if an MRI of the brain and optic nerves is needed in children who present with multiple café au lait macules. "There is probably no correct answer to that question," she said. "There is no evidence that detecting optic gliomas before they're symptomatic translates into better outcome. So you could argue that doing an MRI, which requires anesthesia, is not worth the money or the risk."

NF1 patients with neurofibromas have a 10% lifetime risk of developing a malignant peripheral nerve sheath tumor within one of the lesions. Signs of malignant degeneration include persistent pain, a change in texture, a rapid increase in size, or development of a neurologic deficit associated with the neurofibroma.

Dr. Bird had no relevant conflicts to disclose.

Café au lait macules are usually the first sign of neurofibromatosis type 1.

The next sign, axillary freckling, is often evident in the school-aged child.

The Riccardi sign, a tuft of hair near the spine, may be present at birth and can even appear before macules. Photos courtesy Dr. Lynne M. Bird and Dr. Marilyn C. Jones

LA JOLLA, CALIF. — How has your sleep been? When's the last time your skin was totally clear? Those are the two questions Dr. Lawrence F. Eichenfield asks his atopic dermatitis patients.

"It's amazing how families don't tell you about sleep disturbance unless you ask," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "At least 20% of families say they've lost sleep because of their child's scratching. … I view sleep disturbance as a marker for out-of-control disease."

Another way to gauge the severity of disease is to ask patients or their parents when the last time the patient's skin was totally clear as well as asking how the skin has been over time, so that you can assess the skin between office visits.

He also makes it a point to ask about the quantity and use of topical corticosteroids and other medications. "I want to know if they're using 30 g, 50 g, or even 90 g of medication a month so I can let them know whether I'm worried about the quantity of use or not," said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital and the University of California, San Diego.

The first phase of treating atopic dermatitis is what he termed "induction therapy," or getting the disease under control. He recommends a course of topical corticosteroids for 1–3 weeks, "depending on how bad it is" as a first line of treatment. Three products have received Food and Drug Administration approval for use in patients as young as 3 months of age: desonide nonethanolic foam (Verdeso, Stiefel Laboratories Inc.), desonide aqueous gel (Desonate, SkinMedica Inc.), and fluocinolone acetonide oil (Derma-Smoothe, Hill Dermaceuticals Inc.).

"Generally, we use 'strength as needed' to get the disease under control," said Dr. Eichenfield, who was involved in clinical studies of the topical agents but has no financial interest in their manufacturers.

Another option is generic topical corticosteroids. "It's nice that I can send my patients to Wal-Mart or Target and for $4 they can get 80 g of triamcinolone 0.1% ointment," he commented.

Using wet wraps—an intensive therapy applying steroids under hydrated gauze wraps, covered by dry wraps—for 3–4 days yields the same results as using topical corticosteroids for 2–3 weeks, he said.

Dr. Eichenfield uses topical calcineurin inhibitors (TCIs) as second-line agents in patients with persistent or frequently recurrent atopic dermatitis. He noted that use of TCIs has dropped about 50% since the FDA issued a black box warning in 2005 concerning the potential for oncogenesis.

"There have been no further data confirming any true risk associated with the use of these medicines topically," he noted. "There have been multiple negative studies showing generally very low blood levels of these topical agents when used appropriately."

The second phase in treating atopic dermatitis is maintenance therapy. With severe cases, Dr. Eichenfield prefers clearly defined regimens; in some patients this may be intermittent topical corticosteroids, in others TCIs intermittently or daily, and in some a mixture of corticosteroids, TCIs, and nonsteroidal barrier creams.

The last phase in treatment is "stepped maintenance," in which the agent or agents are decreased as tolerated. "That is the time to step backward in frequency of application of medications," he advised. "A slow withdrawal of medications allows you to titrate how little is needed to keep the skin in good shape, the patient not itchy, and the family sleeping through the night."

Dr. Eichenfield disclosed that he has been a clinical investigator in trials conducted by Amgen Inc., Astellas Pharma Inc., Ferndale Laboratories Inc., Galderma Laboratories, Graceway Pharmaceuticals, Hill Dermaceuticals Inc., Johnson & Johnson, Novartis Pharmaceuticals Corp., and Medicis Pharmaceutical Corp. He stated that he has no relevant financial interest in any of the companies.

'I want to knowif they're using30 g, 50 g, or even 90 g of medication a month.' DR. EICHENFIELD

LA JOLLA, CALIF. — How has your sleep been? When's the last time your skin was totally clear? Those are the two questions Dr. Lawrence F. Eichenfield asks his atopic dermatitis patients.

"It's amazing how families don't tell you about sleep disturbance unless you ask," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "At least 20% of families say they've lost sleep because of their child's scratching. … I view sleep disturbance as a marker for out-of-control disease."

Another way to gauge the severity of disease is to ask patients or their parents when the last time the patient's skin was totally clear as well as asking how the skin has been over time, so that you can assess the skin between office visits.

He also makes it a point to ask about the quantity and use of topical corticosteroids and other medications. "I want to know if they're using 30 g, 50 g, or even 90 g of medication a month so I can let them know whether I'm worried about the quantity of use or not," said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital and the University of California, San Diego.

The first phase of treating atopic dermatitis is what he termed "induction therapy," or getting the disease under control. He recommends a course of topical corticosteroids for 1–3 weeks, "depending on how bad it is" as a first line of treatment. Three products have received Food and Drug Administration approval for use in patients as young as 3 months of age: desonide nonethanolic foam (Verdeso, Stiefel Laboratories Inc.), desonide aqueous gel (Desonate, SkinMedica Inc.), and fluocinolone acetonide oil (Derma-Smoothe, Hill Dermaceuticals Inc.).

"Generally, we use 'strength as needed' to get the disease under control," said Dr. Eichenfield, who was involved in clinical studies of the topical agents but has no financial interest in their manufacturers.

Another option is generic topical corticosteroids. "It's nice that I can send my patients to Wal-Mart or Target and for $4 they can get 80 g of triamcinolone 0.1% ointment," he commented.

Using wet wraps—an intensive therapy applying steroids under hydrated gauze wraps, covered by dry wraps—for 3–4 days yields the same results as using topical corticosteroids for 2–3 weeks, he said.

Dr. Eichenfield uses topical calcineurin inhibitors (TCIs) as second-line agents in patients with persistent or frequently recurrent atopic dermatitis. He noted that use of TCIs has dropped about 50% since the FDA issued a black box warning in 2005 concerning the potential for oncogenesis.

"There have been no further data confirming any true risk associated with the use of these medicines topically," he noted. "There have been multiple negative studies showing generally very low blood levels of these topical agents when used appropriately."

The second phase in treating atopic dermatitis is maintenance therapy. With severe cases, Dr. Eichenfield prefers clearly defined regimens; in some patients this may be intermittent topical corticosteroids, in others TCIs intermittently or daily, and in some a mixture of corticosteroids, TCIs, and nonsteroidal barrier creams.

The last phase in treatment is "stepped maintenance," in which the agent or agents are decreased as tolerated. "That is the time to step backward in frequency of application of medications," he advised. "A slow withdrawal of medications allows you to titrate how little is needed to keep the skin in good shape, the patient not itchy, and the family sleeping through the night."

Dr. Eichenfield disclosed that he has been a clinical investigator in trials conducted by Amgen Inc., Astellas Pharma Inc., Ferndale Laboratories Inc., Galderma Laboratories, Graceway Pharmaceuticals, Hill Dermaceuticals Inc., Johnson & Johnson, Novartis Pharmaceuticals Corp., and Medicis Pharmaceutical Corp. He stated that he has no relevant financial interest in any of the companies.

'I want to knowif they're using30 g, 50 g, or even 90 g of medication a month.' DR. EICHENFIELD

LA JOLLA, CALIF. — How has your sleep been? When's the last time your skin was totally clear? Those are the two questions Dr. Lawrence F. Eichenfield asks his atopic dermatitis patients.

"It's amazing how families don't tell you about sleep disturbance unless you ask," he said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. "At least 20% of families say they've lost sleep because of their child's scratching. … I view sleep disturbance as a marker for out-of-control disease."

Another way to gauge the severity of disease is to ask patients or their parents when the last time the patient's skin was totally clear as well as asking how the skin has been over time, so that you can assess the skin between office visits.

He also makes it a point to ask about the quantity and use of topical corticosteroids and other medications. "I want to know if they're using 30 g, 50 g, or even 90 g of medication a month so I can let them know whether I'm worried about the quantity of use or not," said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital and the University of California, San Diego.

The first phase of treating atopic dermatitis is what he termed "induction therapy," or getting the disease under control. He recommends a course of topical corticosteroids for 1–3 weeks, "depending on how bad it is" as a first line of treatment. Three products have received Food and Drug Administration approval for use in patients as young as 3 months of age: desonide nonethanolic foam (Verdeso, Stiefel Laboratories Inc.), desonide aqueous gel (Desonate, SkinMedica Inc.), and fluocinolone acetonide oil (Derma-Smoothe, Hill Dermaceuticals Inc.).

"Generally, we use 'strength as needed' to get the disease under control," said Dr. Eichenfield, who was involved in clinical studies of the topical agents but has no financial interest in their manufacturers.

Another option is generic topical corticosteroids. "It's nice that I can send my patients to Wal-Mart or Target and for $4 they can get 80 g of triamcinolone 0.1% ointment," he commented.

Using wet wraps—an intensive therapy applying steroids under hydrated gauze wraps, covered by dry wraps—for 3–4 days yields the same results as using topical corticosteroids for 2–3 weeks, he said.

Dr. Eichenfield uses topical calcineurin inhibitors (TCIs) as second-line agents in patients with persistent or frequently recurrent atopic dermatitis. He noted that use of TCIs has dropped about 50% since the FDA issued a black box warning in 2005 concerning the potential for oncogenesis.

"There have been no further data confirming any true risk associated with the use of these medicines topically," he noted. "There have been multiple negative studies showing generally very low blood levels of these topical agents when used appropriately."

The second phase in treating atopic dermatitis is maintenance therapy. With severe cases, Dr. Eichenfield prefers clearly defined regimens; in some patients this may be intermittent topical corticosteroids, in others TCIs intermittently or daily, and in some a mixture of corticosteroids, TCIs, and nonsteroidal barrier creams.

The last phase in treatment is "stepped maintenance," in which the agent or agents are decreased as tolerated. "That is the time to step backward in frequency of application of medications," he advised. "A slow withdrawal of medications allows you to titrate how little is needed to keep the skin in good shape, the patient not itchy, and the family sleeping through the night."

Dr. Eichenfield disclosed that he has been a clinical investigator in trials conducted by Amgen Inc., Astellas Pharma Inc., Ferndale Laboratories Inc., Galderma Laboratories, Graceway Pharmaceuticals, Hill Dermaceuticals Inc., Johnson & Johnson, Novartis Pharmaceuticals Corp., and Medicis Pharmaceutical Corp. He stated that he has no relevant financial interest in any of the companies.

'I want to knowif they're using30 g, 50 g, or even 90 g of medication a month.' DR. EICHENFIELD

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

"When a child visits your office and has [Escherichia]coli 0157 or Campylobacter or Salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home," Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets. "In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents," added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. "Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, "but the number of cases is probably higher," Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6). Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million Salmonella infections are reported "but we don't know what percent is due to contact with baby poultry," Dr. Pickering said.

Certain Salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all Salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61).

The chances of a child acquiring Salmonella, E. coli 0157 or some other infectious disease at a public zoo are "very low, because most zoos are well maintained," Dr. Pickering said. "Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site."

Diseases that have been reported associated with pet store animals include Salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

ELSEVIER GLOBAL MEDICAL NEWS

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

"When a child visits your office and has [Escherichia]coli 0157 or Campylobacter or Salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home," Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets. "In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents," added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. "Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, "but the number of cases is probably higher," Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6). Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million Salmonella infections are reported "but we don't know what percent is due to contact with baby poultry," Dr. Pickering said.

Certain Salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all Salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61).

The chances of a child acquiring Salmonella, E. coli 0157 or some other infectious disease at a public zoo are "very low, because most zoos are well maintained," Dr. Pickering said. "Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site."

Diseases that have been reported associated with pet store animals include Salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

ELSEVIER GLOBAL MEDICAL NEWS

LA JOLLA, CALIF. — Parrots, baby chicks, and turtles may be endearing to young children, but exposure to such exotic and nontraditional pets in the home and in public settings puts children at risk for serious infectious diseases.

"When a child visits your office and has [Escherichia]coli 0157 or Campylobacter or Salmonella, a thorough history should be performed to determine whether or not he or she has been exposed to an animal in a public setting or whether [there are] some of these pets at home," Dr. Larry K. Pickering said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

In 2007, about 63% of households in the United States contained one or more pets. Of these, 3% contained exotic or nontraditional pets. "In 2005, approximately 88,000 mammals were imported legally into the United States, including 29 species of rodents," added Dr. Pickering, executive secretary of the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention, Atlanta. "Exposure to parrots, parakeets, and cockatiels can lead to Chlamydia psittaci, an intracellular bacterial pathogen that causes acute febrile respiratory tract illness. In the United States, there were 12–19 cases per year reported annually from 2002 to 2006, "but the number of cases is probably higher," Dr. Pickering said. If you see a child or an adult with atypical pneumonia, ask if there is a bird in the home.

Contact with baby poultry such as chicks, duckling, goslings, and turkeys increases the risk of developing salmonellosis. Children, the elderly, and immunocompromised people are especially vulnerable (MMWR 2007;56:273–6). Salmonella can be found in chicken feces, feathers, or their environment. Each year, 1.4 million Salmonella infections are reported "but we don't know what percent is due to contact with baby poultry," Dr. Pickering said.

Certain Salmonella serotypes are isolated from specific animals, so if a child presents with salmonellosis, the organism should be serotyped to determine if it is an unusual species. Salmonellosis from turtles, lizards, and other reptiles represents 6% of all Salmonella infections in the United States and 11% of infections in people less than 21 years of age (Clin. Infect. Dis. 2004;38:5353–61).

The chances of a child acquiring Salmonella, E. coli 0157 or some other infectious disease at a public zoo are "very low, because most zoos are well maintained," Dr. Pickering said. "Petting zoos can be a problem, as can animal swap meets where children can handle animals and there are no hand-washing facilities on site."

Diseases that have been reported associated with pet store animals include Salmonella in hamsters, mice, and rats; rabies in kittens; tularemia and lymphocytic choriomeningitis in hamsters; and monkeypox in prairie dogs.

ELSEVIER GLOBAL MEDICAL NEWS

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

"There are several areas of overlap between the skin and the GI tract," Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. If you pick up on these cutaneous signs, you may find an underlying GI disease.

Diseases of the GI tract that commonly involve some form of cutaneous manifestation noted by Dr. Dohil include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity "really depends on the underlying molecular defect," said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego.

"GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type," [in which] almost 80% of children are affected [by dysphagia]. The dysphagia that these children often suffer from can be so severe that they are unable to swallow their own saliva," she said. In fact, the lumen of the esophagus might be obliterated to 2 mm in these patients, whereas a normal lumen is 15–20 mm wide. Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. "But when you palpate these lesions, they are soft and compressible," she said.

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

"Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon," explained Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy "facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment."

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema. The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method. "In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate," Dr. Dohil said. "Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for."

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous.

These lesions "are fairly uncommon in children, and when they do occur they may not be very distinct," she said. Recently conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. Since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis.

Dr. Dohil reported having no relevant disclosures to make.

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

"There are several areas of overlap between the skin and the GI tract," Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. If you pick up on these cutaneous signs, you may find an underlying GI disease.

Diseases of the GI tract that commonly involve some form of cutaneous manifestation noted by Dr. Dohil include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity "really depends on the underlying molecular defect," said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego.

"GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type," [in which] almost 80% of children are affected [by dysphagia]. The dysphagia that these children often suffer from can be so severe that they are unable to swallow their own saliva," she said. In fact, the lumen of the esophagus might be obliterated to 2 mm in these patients, whereas a normal lumen is 15–20 mm wide. Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. "But when you palpate these lesions, they are soft and compressible," she said.

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

"Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon," explained Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy "facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment."

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema. The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method. "In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate," Dr. Dohil said. "Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for."

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous.

These lesions "are fairly uncommon in children, and when they do occur they may not be very distinct," she said. Recently conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. Since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis.

Dr. Dohil reported having no relevant disclosures to make.

LA JOLLA, CALIF. — Certain skin conditions may provide clues to the diagnosis of underlying gastrointestinal disease in children, ranging from epithelial defects, polyposis, or vascular syndromes to autoimmune and allergic disease.

"There are several areas of overlap between the skin and the GI tract," Dr. Magdalene A. Dohil said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. If you pick up on these cutaneous signs, you may find an underlying GI disease.

Diseases of the GI tract that commonly involve some form of cutaneous manifestation noted by Dr. Dohil include:

▸ Epidermolysis bullosa. This condition presents with different degrees of skin fragility and blister formation. The severity "really depends on the underlying molecular defect," said Dr. Dohil, who is a pediatric dermatologist at Rady Children's Hospital, San Diego.

"GI disease in epidermolysis bullosa is extremely common, particularly in the recessive dystrophic type," [in which] almost 80% of children are affected [by dysphagia]. The dysphagia that these children often suffer from can be so severe that they are unable to swallow their own saliva," she said. In fact, the lumen of the esophagus might be obliterated to 2 mm in these patients, whereas a normal lumen is 15–20 mm wide. Other symptoms may include lingual adhesions and microstomia; esophageal disease including strictures, webs, herniation, atony, and pseudodiverticula leading to feeding problems and ultimately protein-energy malnutrition; anemia; and vitamin and mineral deficiency.

▸ Blue-rubber bleb nevus syndrome (BRBNS). This disease causes multifocal venous malformations in the skin and GI tract. Most cases are sporadic, and histology demonstrates intact epithelium but insufficient smooth muscle. Dr. Dohil described the case of a child who presented with venous malformations on the bottom of the foot, which resembled common warts at first glance. "But when you palpate these lesions, they are soft and compressible," she said.

Common complications of BRBNS include bleeding, chronic anemia, and the need for blood transfusion. Treatment often involves different degrees of surgical intervention including wedge resection, polypectomy, suture ligation, band ligation, and sometimes bowel resection.

"Medical treatment attempts haven't been very successful because these are not proliferative tumors, so we don't expect them to respond to corticosteroids or interferon," explained Dr. Dohil, also of the University of California, San Diego. Capsule endoscopy "facilitates the diagnosis and follow-up of children who need endoscopic intervention and assessment."

▸ Peutz-Jeghers syndrome. The hallmark skin-related characteristics of this disease include mucocutaneous pigmentation due to melanin deposition. A GI work-up often reveals polyps that may reach into the antral part of the stomach or present throughout the duodenum. These polyps can cause significant morbidity including obstruction, intussusception, pain, hematochezia, and prolapse.

Children with Peutz-Jeghers also carry a high risk of developing invasive carcinoma. In fact, their cumulative risk of developing cancer is 93%, most commonly cancers of the breast, colon, and pancreas, noted Dr. Dohil.

▸ Cowden's disease. This condition, also known as multiple hamartoma-neoplasia syndrome, causes hamartomas that involve the skin, intestine, breast, and thyroid. It is autosomal dominant and has near complete penetrance by age 20 years. Only 40% of cases will have GI polyposis, but about 80% of cases will present with dermatologic tumors. Consider the diagnosis if you spot more than one trichilemmoma.

▸ Henoch-Schöenlein purpura. The most common skin presentation is a petechial rash that may develop into multiple raised purpuric lesions. GI symptoms occur in 50%–85% of cases and include abdominal pain, bleeding, vomiting, and bowel edema. The GI effects include mucosal redness, as well as duodenal petechiae and hematomalike protrusions. Most of these changes can be detected with ultrasound.

▸ Celiac disease. Classic GI symptoms include abdominal distention, weight loss, failure to thrive, and diarrhea. Although serology has facilitated the diagnosis, small-bowel biopsy remains the preferred method. "In these cases you will see villous atrophy, crypt hyperplasia, and lymphocytic infiltrate," Dr. Dohil said. "Such a blunted GI tract doesn't bode well for the absorptive functions that it's intended for."

Dermatitis herpetiformis (Duhring's disease) is considered a cutaneous manifestation. This condition affects about 25% of celiac disease patients and is marked by a pruritic eruption of lesions that may be symmetrical, erythematous, papular, vesicular, or bullous.

These lesions "are fairly uncommon in children, and when they do occur they may not be very distinct," she said. Recently conditions such as xerosis, urticaria, vitiligo, and alopecia areata have been linked to celiac disease. Since they are fairly nonspecific, skin biopsies with direct immunofluorescence and antibody studies of gliadin, endomysium, and transglutaminase are often needed to confirm the diagnosis.

Dr. Dohil reported having no relevant disclosures to make.

SAN DIEGO — Extracutaneous melanomas are rare—they make up only 15% of all melanomas—but small primary lesions can be easily overlooked during a routine skin exam, according to one expert.

Sites that require close inspection include the scalp, nail beds, interdigital folds, and perianal skin. These areas "are easily accessible to clinical exam and can make a big difference for your patients," Dr. Terence C. O'Grady said at an update on melanoma sponsored by the Scripps Clinic.

The most commonly affected sites for extracutaneous melanoma include the ocular or juxtacutaneous mucosal membranes, said Dr. O'Grady, who directs the dermatology residency program at the University of California, San Diego.

The three most common metastatic locations include the lungs (70%), the liver (68%), and the bowels (58%). Other sites include the pancreas (50%), the adrenal gland (50%), the heart (49%), kidneys (45%), brain (39%), thyroid (39%), and spleen (36%), he said.

Melanoma can metastasize to these sites in a number of ways. A melanoma could have been completely removed without histologic examination.

"You could also have a completely regressed melanoma at another site that was not treated," he said.

"This can be a real problem because there is no evidence of a pre-existing lesion. In our clinic, if we don't see a primary lesion we do a Wood's light exam and look for hypopigmented areas that may represent previously regressed lesions. Unfortunately, when you biopsy these regressed areas, the only thing you usually see is pigment incontinence on the histology, so there's no evidence that the melanoma was ever there," Dr. O'Grady said.

Because it's rare to find primary melanomas in these locations, he continued, "it's more probable that these lesions are metastatic to that site rather than being a primary lesion."

The five most common locations of primary extracutaneous melanoma include the eye (79%), the vulva (7%), soft tissues (3%), anorectum (2%), and the vagina (2%), according to Dr. O'Grady. "Many of us loathe to do an exam of the genitalia, but [lesions in this area] do occur," he said. "I usually tell patients that have had a melanoma or are at high risk for melanoma to bring this point up with other physicians they [may see], so they can have those areas examined."

Dr. O'Grady said that he begins his skin examinations at the scalp and works his way down to the feet.

"I always tell patients who wear nail polish to have that removed for the exam so I can see the nail bed," he said. "I look at the interdigital folds and at the bottom of the feet. Patients always wonder, 'What are you looking for in between my toes?' I tell them, 'You can get pigmented lesions in those areas. You can also get melanomas in those areas.'"

He also emphasized the importance of biopsying lesions detected in subungual areas. "These lesions can be impossible to diagnose without a biopsy, but a lot of [clinicians] don't feel comfortably doing a nail biopsy," said Dr. O'Grady.

"Not only is that a problem, but when you send it to pathology and you don't have someone who knows how to handle nail specimens, you're going to end up with a very nondiagnostic specimen. You want to see the skin on top of the nail, the nail plate, and the subungual tissue," he said.

SAN DIEGO — Extracutaneous melanomas are rare—they make up only 15% of all melanomas—but small primary lesions can be easily overlooked during a routine skin exam, according to one expert.

Sites that require close inspection include the scalp, nail beds, interdigital folds, and perianal skin. These areas "are easily accessible to clinical exam and can make a big difference for your patients," Dr. Terence C. O'Grady said at an update on melanoma sponsored by the Scripps Clinic.

The most commonly affected sites for extracutaneous melanoma include the ocular or juxtacutaneous mucosal membranes, said Dr. O'Grady, who directs the dermatology residency program at the University of California, San Diego.

The three most common metastatic locations include the lungs (70%), the liver (68%), and the bowels (58%). Other sites include the pancreas (50%), the adrenal gland (50%), the heart (49%), kidneys (45%), brain (39%), thyroid (39%), and spleen (36%), he said.

Melanoma can metastasize to these sites in a number of ways. A melanoma could have been completely removed without histologic examination.

"You could also have a completely regressed melanoma at another site that was not treated," he said.

"This can be a real problem because there is no evidence of a pre-existing lesion. In our clinic, if we don't see a primary lesion we do a Wood's light exam and look for hypopigmented areas that may represent previously regressed lesions. Unfortunately, when you biopsy these regressed areas, the only thing you usually see is pigment incontinence on the histology, so there's no evidence that the melanoma was ever there," Dr. O'Grady said.

Because it's rare to find primary melanomas in these locations, he continued, "it's more probable that these lesions are metastatic to that site rather than being a primary lesion."

The five most common locations of primary extracutaneous melanoma include the eye (79%), the vulva (7%), soft tissues (3%), anorectum (2%), and the vagina (2%), according to Dr. O'Grady. "Many of us loathe to do an exam of the genitalia, but [lesions in this area] do occur," he said. "I usually tell patients that have had a melanoma or are at high risk for melanoma to bring this point up with other physicians they [may see], so they can have those areas examined."

Dr. O'Grady said that he begins his skin examinations at the scalp and works his way down to the feet.

"I always tell patients who wear nail polish to have that removed for the exam so I can see the nail bed," he said. "I look at the interdigital folds and at the bottom of the feet. Patients always wonder, 'What are you looking for in between my toes?' I tell them, 'You can get pigmented lesions in those areas. You can also get melanomas in those areas.'"

He also emphasized the importance of biopsying lesions detected in subungual areas. "These lesions can be impossible to diagnose without a biopsy, but a lot of [clinicians] don't feel comfortably doing a nail biopsy," said Dr. O'Grady.

"Not only is that a problem, but when you send it to pathology and you don't have someone who knows how to handle nail specimens, you're going to end up with a very nondiagnostic specimen. You want to see the skin on top of the nail, the nail plate, and the subungual tissue," he said.

SAN DIEGO — Extracutaneous melanomas are rare—they make up only 15% of all melanomas—but small primary lesions can be easily overlooked during a routine skin exam, according to one expert.

Sites that require close inspection include the scalp, nail beds, interdigital folds, and perianal skin. These areas "are easily accessible to clinical exam and can make a big difference for your patients," Dr. Terence C. O'Grady said at an update on melanoma sponsored by the Scripps Clinic.

The most commonly affected sites for extracutaneous melanoma include the ocular or juxtacutaneous mucosal membranes, said Dr. O'Grady, who directs the dermatology residency program at the University of California, San Diego.

The three most common metastatic locations include the lungs (70%), the liver (68%), and the bowels (58%). Other sites include the pancreas (50%), the adrenal gland (50%), the heart (49%), kidneys (45%), brain (39%), thyroid (39%), and spleen (36%), he said.

Melanoma can metastasize to these sites in a number of ways. A melanoma could have been completely removed without histologic examination.

"You could also have a completely regressed melanoma at another site that was not treated," he said.

"This can be a real problem because there is no evidence of a pre-existing lesion. In our clinic, if we don't see a primary lesion we do a Wood's light exam and look for hypopigmented areas that may represent previously regressed lesions. Unfortunately, when you biopsy these regressed areas, the only thing you usually see is pigment incontinence on the histology, so there's no evidence that the melanoma was ever there," Dr. O'Grady said.

Because it's rare to find primary melanomas in these locations, he continued, "it's more probable that these lesions are metastatic to that site rather than being a primary lesion."

The five most common locations of primary extracutaneous melanoma include the eye (79%), the vulva (7%), soft tissues (3%), anorectum (2%), and the vagina (2%), according to Dr. O'Grady. "Many of us loathe to do an exam of the genitalia, but [lesions in this area] do occur," he said. "I usually tell patients that have had a melanoma or are at high risk for melanoma to bring this point up with other physicians they [may see], so they can have those areas examined."

Dr. O'Grady said that he begins his skin examinations at the scalp and works his way down to the feet.

"I always tell patients who wear nail polish to have that removed for the exam so I can see the nail bed," he said. "I look at the interdigital folds and at the bottom of the feet. Patients always wonder, 'What are you looking for in between my toes?' I tell them, 'You can get pigmented lesions in those areas. You can also get melanomas in those areas.'"

He also emphasized the importance of biopsying lesions detected in subungual areas. "These lesions can be impossible to diagnose without a biopsy, but a lot of [clinicians] don't feel comfortably doing a nail biopsy," said Dr. O'Grady.

"Not only is that a problem, but when you send it to pathology and you don't have someone who knows how to handle nail specimens, you're going to end up with a very nondiagnostic specimen. You want to see the skin on top of the nail, the nail plate, and the subungual tissue," he said.

“Evidence is insufficient to draw firm conclusions” … “We did not find any head-to-head randomized controlled trials.”

Those are phrases that appear frequently in a 151-page report, based on a literature review and released by the Agency for Healthcare Research and Quality, titled “Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults.”

“The gaps in information for specific RA therapies are substantial,” wrote the researchers of the RTI International-University of North Carolina Evidence-Based Practice Center, under contract to AHRQ.

Despite the paucity of data, the researchers draw some conclusions from the best available medical literature about the benefits and harms of three classes of medications for RA and psoriatic arthritis: synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and corticosteroids. For example, they found that combining the synthetic DMARD methotrexate with one of the biologic DMARDs (abatacept, adalimumab, anakinra, etanercept, infliximab, or rituximab) works better than using methotrexate or one of the biologic DMARDs alone.

In addition, they found that methotrexate works as effectively as adalimumab and etanercept for patients with early RA. “Radiographic outcomes, however, were statistically significantly better in patients treated with biologic DMARDs than [in] patients treated with methotrexate,” the researchers wrote. “How such intermediate outcomes translate to the long-term clinical progression of the disease remains unclear.”

Dr. Steven B. Abramson, director of the division of rheumatology at New York University Medical Center, called the report “very comprehensive and useful” and “reflective of what I think is our common practice. It tries not to tilt toward one therapy or another. It's a good summation of several years of literature.”

The team of researchers, led by Dr. Katrina E. Donahue of the department of family medicine at the University of North Carolina at Chapel Hill, reviewed 156 articles in the medical literature based on 103 studies of synthetic DMARDs, biologic DMARDs, and corticosteroids. Of these studies, 50% were supported by pharmaceutical companies, 20% were supported by government or independent funds, and 11% had a combination of pharmaceutical and government funding. The source of funding could not be determined in the remaining 19% of the studies.

Most of the studies were found to be of fair quality, which was defined as susceptible to some bias but probably not sufficient to invalidate their results. Only one-quarter of the studies were rated good quality, which was defined as having the least bias and results that are considered to be valid.

The researchers found that combining prednisone with hydroxychloroquine, methotrexate, or sulfasalazine works better than using only a synthetic DMARD to reduce joint swelling and tenderness and to improve function. There are also no meaningful differences between methotrexate and either leflunomide or sulfasalazine.

Other findings include the following:

▸ There is not enough evidence to conclude that combining two biologic DMARDs is better than using one biologic DMARD.

▸ An estimated 17 out of every 1,000 people who take a biologic DMARD for 3–12 months develop serious infection. Combining biologic DMARDs increases this risk.

▸ Painful injection-site reactions occur more often among patients who take anakinra (67%), compared with those who take etanercept (22%) or adalimumab (18%).

In the report's conclusion, the researchers emphasized the need for long-term studies of arthritis medications, including head-to-head trials “assessing combination therapies involving synthetic DMARDs in comparison with those involving biologic DMARDs,” they wrote.

The report is reflective of common practice. 'It tries not to tilt toward one therapy or another.' DR. ABRAMSON

“Evidence is insufficient to draw firm conclusions” … “We did not find any head-to-head randomized controlled trials.”

Those are phrases that appear frequently in a 151-page report, based on a literature review and released by the Agency for Healthcare Research and Quality, titled “Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults.”

“The gaps in information for specific RA therapies are substantial,” wrote the researchers of the RTI International-University of North Carolina Evidence-Based Practice Center, under contract to AHRQ.

Despite the paucity of data, the researchers draw some conclusions from the best available medical literature about the benefits and harms of three classes of medications for RA and psoriatic arthritis: synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and corticosteroids. For example, they found that combining the synthetic DMARD methotrexate with one of the biologic DMARDs (abatacept, adalimumab, anakinra, etanercept, infliximab, or rituximab) works better than using methotrexate or one of the biologic DMARDs alone.

In addition, they found that methotrexate works as effectively as adalimumab and etanercept for patients with early RA. “Radiographic outcomes, however, were statistically significantly better in patients treated with biologic DMARDs than [in] patients treated with methotrexate,” the researchers wrote. “How such intermediate outcomes translate to the long-term clinical progression of the disease remains unclear.”

Dr. Steven B. Abramson, director of the division of rheumatology at New York University Medical Center, called the report “very comprehensive and useful” and “reflective of what I think is our common practice. It tries not to tilt toward one therapy or another. It's a good summation of several years of literature.”

The team of researchers, led by Dr. Katrina E. Donahue of the department of family medicine at the University of North Carolina at Chapel Hill, reviewed 156 articles in the medical literature based on 103 studies of synthetic DMARDs, biologic DMARDs, and corticosteroids. Of these studies, 50% were supported by pharmaceutical companies, 20% were supported by government or independent funds, and 11% had a combination of pharmaceutical and government funding. The source of funding could not be determined in the remaining 19% of the studies.

Most of the studies were found to be of fair quality, which was defined as susceptible to some bias but probably not sufficient to invalidate their results. Only one-quarter of the studies were rated good quality, which was defined as having the least bias and results that are considered to be valid.

The researchers found that combining prednisone with hydroxychloroquine, methotrexate, or sulfasalazine works better than using only a synthetic DMARD to reduce joint swelling and tenderness and to improve function. There are also no meaningful differences between methotrexate and either leflunomide or sulfasalazine.

Other findings include the following:

▸ There is not enough evidence to conclude that combining two biologic DMARDs is better than using one biologic DMARD.

▸ An estimated 17 out of every 1,000 people who take a biologic DMARD for 3–12 months develop serious infection. Combining biologic DMARDs increases this risk.

▸ Painful injection-site reactions occur more often among patients who take anakinra (67%), compared with those who take etanercept (22%) or adalimumab (18%).

In the report's conclusion, the researchers emphasized the need for long-term studies of arthritis medications, including head-to-head trials “assessing combination therapies involving synthetic DMARDs in comparison with those involving biologic DMARDs,” they wrote.

The report is reflective of common practice. 'It tries not to tilt toward one therapy or another.' DR. ABRAMSON

“Evidence is insufficient to draw firm conclusions” … “We did not find any head-to-head randomized controlled trials.”

Those are phrases that appear frequently in a 151-page report, based on a literature review and released by the Agency for Healthcare Research and Quality, titled “Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults.”

“The gaps in information for specific RA therapies are substantial,” wrote the researchers of the RTI International-University of North Carolina Evidence-Based Practice Center, under contract to AHRQ.

Despite the paucity of data, the researchers draw some conclusions from the best available medical literature about the benefits and harms of three classes of medications for RA and psoriatic arthritis: synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and corticosteroids. For example, they found that combining the synthetic DMARD methotrexate with one of the biologic DMARDs (abatacept, adalimumab, anakinra, etanercept, infliximab, or rituximab) works better than using methotrexate or one of the biologic DMARDs alone.

In addition, they found that methotrexate works as effectively as adalimumab and etanercept for patients with early RA. “Radiographic outcomes, however, were statistically significantly better in patients treated with biologic DMARDs than [in] patients treated with methotrexate,” the researchers wrote. “How such intermediate outcomes translate to the long-term clinical progression of the disease remains unclear.”

Dr. Steven B. Abramson, director of the division of rheumatology at New York University Medical Center, called the report “very comprehensive and useful” and “reflective of what I think is our common practice. It tries not to tilt toward one therapy or another. It's a good summation of several years of literature.”

The team of researchers, led by Dr. Katrina E. Donahue of the department of family medicine at the University of North Carolina at Chapel Hill, reviewed 156 articles in the medical literature based on 103 studies of synthetic DMARDs, biologic DMARDs, and corticosteroids. Of these studies, 50% were supported by pharmaceutical companies, 20% were supported by government or independent funds, and 11% had a combination of pharmaceutical and government funding. The source of funding could not be determined in the remaining 19% of the studies.

Most of the studies were found to be of fair quality, which was defined as susceptible to some bias but probably not sufficient to invalidate their results. Only one-quarter of the studies were rated good quality, which was defined as having the least bias and results that are considered to be valid.

The researchers found that combining prednisone with hydroxychloroquine, methotrexate, or sulfasalazine works better than using only a synthetic DMARD to reduce joint swelling and tenderness and to improve function. There are also no meaningful differences between methotrexate and either leflunomide or sulfasalazine.

Other findings include the following:

▸ There is not enough evidence to conclude that combining two biologic DMARDs is better than using one biologic DMARD.

▸ An estimated 17 out of every 1,000 people who take a biologic DMARD for 3–12 months develop serious infection. Combining biologic DMARDs increases this risk.

▸ Painful injection-site reactions occur more often among patients who take anakinra (67%), compared with those who take etanercept (22%) or adalimumab (18%).

In the report's conclusion, the researchers emphasized the need for long-term studies of arthritis medications, including head-to-head trials “assessing combination therapies involving synthetic DMARDs in comparison with those involving biologic DMARDs,” they wrote.

The report is reflective of common practice. 'It tries not to tilt toward one therapy or another.' DR. ABRAMSON