Doug Brunk

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting. But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone said at the annual meeting of the Infectious Diseases Society of America.

A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese. The Centers for Disease Control and Prevention says that 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “We believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension. They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of them met the strictest criteria for wasting, a BMI of 18.5 or less. At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“People who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity in HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

In another study presented at the meeting, researchers from Washington University in St. Louis found HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

Dr. Nur Onen and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 years and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher in HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group).

HIV patients now look like the general population in terms of weight. Doctors should help them maintain their weight. DR. CRUM-CIANFLONE

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting. But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone said at the annual meeting of the Infectious Diseases Society of America.

A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese. The Centers for Disease Control and Prevention says that 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “We believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension. They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of them met the strictest criteria for wasting, a BMI of 18.5 or less. At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“People who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity in HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

In another study presented at the meeting, researchers from Washington University in St. Louis found HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

Dr. Nur Onen and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 years and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher in HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group).

HIV patients now look like the general population in terms of weight. Doctors should help them maintain their weight. DR. CRUM-CIANFLONE

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting. But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone said at the annual meeting of the Infectious Diseases Society of America.

A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese. The Centers for Disease Control and Prevention says that 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “We believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension. They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of them met the strictest criteria for wasting, a BMI of 18.5 or less. At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“People who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity in HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

In another study presented at the meeting, researchers from Washington University in St. Louis found HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

Dr. Nur Onen and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 years and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher in HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group).

HIV patients now look like the general population in terms of weight. Doctors should help them maintain their weight. DR. CRUM-CIANFLONE

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion. “There are several exceptions, one of which is someone who has obtained an infection from a pedicure,” said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

“You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure,” she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. “This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients,” she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. “We underuse this drug in dermatology,” she said. “It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients.”

She usually instructs her patients to take fluconazole on Fridays and uses the term “fungal Fridays” as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, “Toesdays.”

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. “You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal,” said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. “Thick nails could come from trauma, from running or skiing, or from runner's toe,” she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon “that may supersede itraconazole in this situation,” Dr. Elewski said. These include posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

Currently, itraconazole given in a pulse fashion is preferred. The recommended dose is 400 mg/day for 1 week per month. “I generally use it for 4 months or longer if it's a nondermatophyte mold,” she said.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. She discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. “Is this eczema? Stasis dermatitis?” she asked. “If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs.”

Diagnosis of onychomycosis is made by a microscopy with potassium hydroxide test (KOH), culture, and nail biopsy. Dr. Elewski warned, however, that culture can be the most variable of the three. “Even in the perfect situation you may not grow a dermatophyte, or you may grow a contaminant that is unrelated to the true infection that is in the nail,” she said. “Think of your KOH nail biopsy as yielding about the same information. If KOH is positive, the diagnosis is made.”

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Factors that have been identified to be associated with a bad prognosis for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. Courtesy Dr. Boni E. Elewski

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion. “There are several exceptions, one of which is someone who has obtained an infection from a pedicure,” said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

“You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure,” she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. “This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients,” she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. “We underuse this drug in dermatology,” she said. “It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients.”

She usually instructs her patients to take fluconazole on Fridays and uses the term “fungal Fridays” as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, “Toesdays.”

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. “You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal,” said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. “Thick nails could come from trauma, from running or skiing, or from runner's toe,” she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon “that may supersede itraconazole in this situation,” Dr. Elewski said. These include posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

Currently, itraconazole given in a pulse fashion is preferred. The recommended dose is 400 mg/day for 1 week per month. “I generally use it for 4 months or longer if it's a nondermatophyte mold,” she said.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. She discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. “Is this eczema? Stasis dermatitis?” she asked. “If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs.”

Diagnosis of onychomycosis is made by a microscopy with potassium hydroxide test (KOH), culture, and nail biopsy. Dr. Elewski warned, however, that culture can be the most variable of the three. “Even in the perfect situation you may not grow a dermatophyte, or you may grow a contaminant that is unrelated to the true infection that is in the nail,” she said. “Think of your KOH nail biopsy as yielding about the same information. If KOH is positive, the diagnosis is made.”

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Factors that have been identified to be associated with a bad prognosis for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. Courtesy Dr. Boni E. Elewski

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion. “There are several exceptions, one of which is someone who has obtained an infection from a pedicure,” said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

“You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure,” she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. “This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients,” she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. “We underuse this drug in dermatology,” she said. “It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients.”

She usually instructs her patients to take fluconazole on Fridays and uses the term “fungal Fridays” as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, “Toesdays.”

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. “You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal,” said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. “Thick nails could come from trauma, from running or skiing, or from runner's toe,” she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon “that may supersede itraconazole in this situation,” Dr. Elewski said. These include posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

Currently, itraconazole given in a pulse fashion is preferred. The recommended dose is 400 mg/day for 1 week per month. “I generally use it for 4 months or longer if it's a nondermatophyte mold,” she said.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. She discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. “Is this eczema? Stasis dermatitis?” she asked. “If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs.”

Diagnosis of onychomycosis is made by a microscopy with potassium hydroxide test (KOH), culture, and nail biopsy. Dr. Elewski warned, however, that culture can be the most variable of the three. “Even in the perfect situation you may not grow a dermatophyte, or you may grow a contaminant that is unrelated to the true infection that is in the nail,” she said. “Think of your KOH nail biopsy as yielding about the same information. If KOH is positive, the diagnosis is made.”

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Factors that have been identified to be associated with a bad prognosis for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. Courtesy Dr. Boni E. Elewski

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting.

But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone reported at the annual meeting of the Infectious Diseases Society of America. A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese.

According to the Centers for Disease Control and Prevention, 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said lead author Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “Because of our study findings, we believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension.

They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of the study participants met the strictest criteria for wasting, which is a BMI of 18.5 or less.

At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“We also learned that people who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity among HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

HIV patients are living “healthier lives and are not dying from life-threatening infections or developing wasting,” she noted. “Rather, they have now become like the general population in terms of their weight.”

In another study presented at the meeting, researchers from Washington University in St. Louis found that HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

“Although our study was small, we can probably begin to reassure people living with HIV who are over the age of 50 and clinicians looking after them that comorbidities and toxicities to medications, such as dyslipidemia, diabetes mellitus, and osteoporosis, may not be increased compared to the general U.S. population as it ages,” lead study author Dr. Nur Onen said in an interview at the meeting. “Therefore, other factors such as lifestyle and aging itself may be the most important in long-term health.”

She and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, ?and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher among HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group). The 10-year risk for coronary heart disease based on the Framingham risk scores also was similar between the groups.

The researchers found that HIV-infected patients had significantly higher triglyceride levels, compared with controls, but lower LDL cholesterol and glucose levels.

Older patients with HIV represent “an increasingly important population,” Dr. Onen said. “By 2015, one in two people with HIV will be over the age of 50. Expect a large increase. They're here to stay, the treatments are good, and the treatments are becoming less and less toxic.”

HIV patients 'are not dying from life-threatening infections or developing wasting.' DR. CRUM-CIANFLONE

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting.

But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone reported at the annual meeting of the Infectious Diseases Society of America. A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese.

According to the Centers for Disease Control and Prevention, 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said lead author Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “Because of our study findings, we believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension.

They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of the study participants met the strictest criteria for wasting, which is a BMI of 18.5 or less.

At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“We also learned that people who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity among HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

HIV patients are living “healthier lives and are not dying from life-threatening infections or developing wasting,” she noted. “Rather, they have now become like the general population in terms of their weight.”

In another study presented at the meeting, researchers from Washington University in St. Louis found that HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

“Although our study was small, we can probably begin to reassure people living with HIV who are over the age of 50 and clinicians looking after them that comorbidities and toxicities to medications, such as dyslipidemia, diabetes mellitus, and osteoporosis, may not be increased compared to the general U.S. population as it ages,” lead study author Dr. Nur Onen said in an interview at the meeting. “Therefore, other factors such as lifestyle and aging itself may be the most important in long-term health.”

She and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, ?and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher among HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group). The 10-year risk for coronary heart disease based on the Framingham risk scores also was similar between the groups.

The researchers found that HIV-infected patients had significantly higher triglyceride levels, compared with controls, but lower LDL cholesterol and glucose levels.

Older patients with HIV represent “an increasingly important population,” Dr. Onen said. “By 2015, one in two people with HIV will be over the age of 50. Expect a large increase. They're here to stay, the treatments are good, and the treatments are becoming less and less toxic.”

HIV patients 'are not dying from life-threatening infections or developing wasting.' DR. CRUM-CIANFLONE

SAN DIEGO — In the 1980s, patients with HIV/AIDS commonly lost an excessive amount of weight, a process known as wasting.

But today, these patients are becoming just as overweight and obese as the general population of the United States, Dr. Nancy F. Crum-Cianflone reported at the annual meeting of the Infectious Diseases Society of America. A study of 663 HIV-positive patients treated at two U.S. Navy clinics revealed that 63% were overweight or obese.

According to the Centers for Disease Control and Prevention, 66% of the general population in the United States is overweight or obese.

“HIV patients now look like the general population in terms of weight,” said lead author Dr. Crum-Cianflone, an HIV research physician with the TriService AIDS Clinical Consortium in San Diego. “Because of our study findings, we believe that HIV physicians should be advised to watch the weight of their patients very carefully and help them maintain normal, healthy weight.”

In 2005, she and her associates collected data from 663 HIV patients at Naval Medical Center in San Diego and National Naval Medical Center in Bethesda, Md., including duration of HIV infection, CD4 count, viral load, antiretroviral therapy, diabetes, and hypertension.

They defined wasting as a body mass index of less than 20 kg/m

The mean age of patients was 41 years, and 50% were white, 26% had hypertension, and 8% had diabetes. Some had been followed in the clinics since 1986.

Of the 663 patients, 46% were overweight, 17% were obese, and 3% met the definition of wasting. None of the study participants met the strictest criteria for wasting, which is a BMI of 18.5 or less.

At the time of diagnosis, 46% were overweight or obese. Over the course of their infection, 72% gained weight.

On multivariate analysis, two significant predictors of increasing BMI emerged: younger age at HIV diagnosis and longer duration of HIV infection.

“We also learned that people who gained weight were more likely to have high blood pressure,” Dr. Crum-Cianflone said during a press briefing. “We believe that the excessive weight gain that they experienced contributed to the development of high blood pressure.”

Patients with high CD4 counts also were more likely to be overweight than were those with lower CD4 counts.

No association was observed between the use of highly active antiretroviral treatment (HAART) and weight gain.

Specific reasons for the rise in obesity among HIV patients are unclear. Dr. Crum-Cianflone said it may partly have to do with the fact that with improved HAART, HIV has essentially become a chronic condition with lower rates of comorbid infections and a longer expected life span.

HIV patients are living “healthier lives and are not dying from life-threatening infections or developing wasting,” she noted. “Rather, they have now become like the general population in terms of their weight.”

In another study presented at the meeting, researchers from Washington University in St. Louis found that HIV-positive patients aged 50 and older were no more likely to have heart disease or diabetes, compared with a group of age-matched HIV-negative controls from the general population.

“Although our study was small, we can probably begin to reassure people living with HIV who are over the age of 50 and clinicians looking after them that comorbidities and toxicities to medications, such as dyslipidemia, diabetes mellitus, and osteoporosis, may not be increased compared to the general U.S. population as it ages,” lead study author Dr. Nur Onen said in an interview at the meeting. “Therefore, other factors such as lifestyle and aging itself may be the most important in long-term health.”

She and her associates compared the incidence of heart disease, diabetes, high blood pressure, osteoporosis, and other conditions between a group of 70 HIV-positive patients aged 50 and older on HAART and a group of HIV-negative controls from the National Health and Nutrition Examination Survey matched by age, gender, race, smoking status, ?and BMI.

The mean age of patients was 56 years, 86% were male, and 66% were white. Their mean BMI was 25, and 90% were on HAART (a mean duration of 7 years, 91% with full viral suppression).

Dr. Onen, an infectious diseases fellow at the university, reported that although the prevalence of hypertension was significantly higher among HIV-positive patients, compared with controls (51% vs. 31%, respectively), there were no differences in the prevalence of heart disease (10% vs. 14%), diabetes (13% vs. 11%), or osteoporosis (2% in each group). The 10-year risk for coronary heart disease based on the Framingham risk scores also was similar between the groups.

The researchers found that HIV-infected patients had significantly higher triglyceride levels, compared with controls, but lower LDL cholesterol and glucose levels.

Older patients with HIV represent “an increasingly important population,” Dr. Onen said. “By 2015, one in two people with HIV will be over the age of 50. Expect a large increase. They're here to stay, the treatments are good, and the treatments are becoming less and less toxic.”

HIV patients 'are not dying from life-threatening infections or developing wasting.' DR. CRUM-CIANFLONE

Dr. Steve S. Sommer can't recall feeling more alone than in 1997, when he became a single father after separating from his wife of many years. The couple's older daughter was 9 years old at the time, and their boy-girl twins were 4 years old.

"It was hard," said Dr. Sommer, who chairs the departments of molecular diagnosis and molecular genetics at the City of Hope National Medical Center in Duarte, Calif. "My dad was a fantastic dad. It had never occurred to me that I wouldn't have the same role with my kids. Instead, I found my close relationship to my children threatened. I had to fight hard for equal parenting time, losing most of my life savings in the process. I walked a tightrope between professional responsibilities and spending time with my children on the custody schedule."

The marriage fell apart a few months after Dr. Sommer and his family had moved to Southern California from Minnesota. Because he was new to the area, Dr. Sommer lacked a strong social support network. "My aging parents and two good friends provided emotional support long distance, and I found a fantastic nanny/housekeeper, who helped me to support the needs of the children," he recalled.

For many years, the children commuted the 15 minutes between their two homes. During most of that period, Dr. Sommer had the children after school on weekdays through dinner time and on Friday night through Saturday. "There was a level of continuity that seldom occurs with court custody orders," he said.

Nowadays, he sees his children much less frequently because his former spouse moved away from the area about 4 years ago. "Millions of children of divorce experience the family tragedy of move aways," he said. "Some move aways are motivated by diminishment or exclusion of the role of the other parent or by various personal choices, without necessarily prioritizing the children's need for frequent contact with both parents."

Dr. Sommer noted that better navigational tools for single fathers have emerged over the last decade, including Fathers and Families (www.fathersandfamilies.orgwww.breakthroughparentingservices.comwww.stopparentalalienation.orgwww.hisside.com

He also recommends the independent film "Jake's Closet," written and directed by Shelli Ryan (www.jakesclosetmovie.com

Looking back over this period, Dr. Sommer reflects: "My children somehow managed to overcome the emotional stress of the family break; they're great kids and I am proud of them. I'm grateful for this outcome, and I consider myself luckier than many."

Prioritized for His Daughter

When Dr. Lloyd Axelrod separated from his wife in 1991, time management took on a new meaning as he orchestrated his new role as single father of a then-31/2-year-old daughter in a joint custody arrangement.

"I used to say that I went 171/2 hours a day nonstop," said Dr. Axelrod, an endocrinologist at Massachusetts General Hospital, Boston. "But what I did in those 171/2 hours switched a lot when I had a little child."

To compensate, he stopped doing research and closed down his diabetes research lab at the hospital. He also stopped working evenings at home on articles and grants. "I made a decision that my daughter was more important than becoming a professor of medicine," he said. "It was the right decision then, and it was the right decision now."

His effort to secure shared custody was "a brutal battle that shouldn't have been necessary. It should have been automatic, the way it is in the United Kingdom. The presumption should have been shared custody. But in our regressive society, that wasn't the presumption, so it was extremely difficult, expensive, and time consuming."

During the early stages of the divorce, Dr. Axelrod heard about a support group for single fathers that had formed in the Boston area, but it never got off the ground. "I had certain friends who were supportive at the time," he recalled. "I got to know a lot of the parents of kids my daughter's age at school events or soccer. So, in some ways, the parents were part of my support system when this was starting."

The experience "heightened my awareness that there were a lot of issues about single fathers that weren't addressed in the public forum—the legal issues and financial issues and support issues. What was most striking was the lack of appreciation in the public and in the workplace about the role of single fathers. I encountered some of that."

Dr. Axelrod, whose daughter is now attending college, was quick to note that resources for single fathers are at an all-time high in the form of support groups, advocacy groups, blogs, and books on the topic.

He advises physicians who find themselves in the role of a single father to "be prepared for some rapid changes, get the appropriate legal and professional counseling, and read books on the subject. Get up to speed as quickly as possible, recognizing that the decisions you make will last your child's entire childhood. Expect that you are going to have to make some accommodations in your career. You have to make some adjustments."

A Big Dose of Humility

In 2001, Dr. John Whelan was stunned to learn that his former spouse would have provisional custody of their 2-year-old son, Olivier, while their divorce was pending.

"I subsequently discovered that's routine," said Dr. Whelan, a pediatric rheumatologist at the MassGeneral Hospital for Children in Boston. "Unless a mother has a drug use history or is imprisoned, my understanding is that the mother always gets provisional physical custody and the father becomes the noncustodial parent while the divorce is pending. For a period of about 2 years, I was basically the second-class parent until the whole divorce was resolved. This is one of the cruelest things about the family law system in our state: One day a child has two parents who are important in his life, and the next day, he has one important parent and one unimportant parent."

The court ultimately ruled that the parents would have joint physical custody, "but that is a rare thing in Massachusetts," he said. "Only 6% of divorces involving children in Massachusetts are said to result in joint physical custody."

Today, Olivier resides with Dr. Whelan 3 nights a week, mostly on weekends, and for vacations. His former spouse watches their son generally after school during the week.

"My son and I have a close relationship," Dr. Whelan said. "Part of it is a result of the fact that when he's with me, I do nothing else: I spend whole weekends at a time with him. I do take him on rounds with me occasionally when I'm covering call on the weekend. He enjoys going to the hospital and it helps that I'm in pediatrics. I can come into a room with a child patient and it's very reassuring to these young kids to see that I have a 'child assistant.' "

Olivier, who turns 8 in October, plays soccer and Little League baseball, and is starting his third year of piano lessons. "Before that, he took weekly music classes at a local music conservatory," Dr. Whelan said. "Music has been a big part of our life. He's been to Boston Symphony Hall a couple of dozen times. He can sit through a 2-hour Wagner concert, which is amazing."

Last year, they took a weekly Mandarin Chinese class together, and Olivier is fully fluent in French.

Dr. Whelan described his relationship with his former spouse as "conciliatory," which "is so critical to the well-being of children who are living in a two-household situation. Do whatever you can to remain on good terms with your former spouse."

He advised physicians new to the single father role to assemble "several tiers of babysitters and contingency plans for those times when you get called into the emergency room in the middle of the night. Who can you call to come into your house and watch your child while you're in the ER evaluating somebody?"

For him, the road to becoming a single father brought a big dose of humility. "As a doctor, you are used to being treated with deference," he said. "People trust your judgment; they look up to you. To be in a situation where your judgment often is questioned and you're not respected can be somewhat humiliating. If you are able to go at it [in] a humble frame of mind and keep your sense of humor, then you'll probably come out a lot better off than if you follow the human instinct to fight back and constantly defend your honor. A life in medicine is stressful enough, family issues aside. It seems to me that doing what's best for your child and nurturing that strong relationship is the deepest balm for all the other challenges we face as doctors."

'I had to fight hard for equal parenting time, losing most of my life savings in the process.' DR. SOMMER

Dr. Steve S. Sommer can't recall feeling more alone than in 1997, when he became a single father after separating from his wife of many years. The couple's older daughter was 9 years old at the time, and their boy-girl twins were 4 years old.

"It was hard," said Dr. Sommer, who chairs the departments of molecular diagnosis and molecular genetics at the City of Hope National Medical Center in Duarte, Calif. "My dad was a fantastic dad. It had never occurred to me that I wouldn't have the same role with my kids. Instead, I found my close relationship to my children threatened. I had to fight hard for equal parenting time, losing most of my life savings in the process. I walked a tightrope between professional responsibilities and spending time with my children on the custody schedule."

The marriage fell apart a few months after Dr. Sommer and his family had moved to Southern California from Minnesota. Because he was new to the area, Dr. Sommer lacked a strong social support network. "My aging parents and two good friends provided emotional support long distance, and I found a fantastic nanny/housekeeper, who helped me to support the needs of the children," he recalled.

For many years, the children commuted the 15 minutes between their two homes. During most of that period, Dr. Sommer had the children after school on weekdays through dinner time and on Friday night through Saturday. "There was a level of continuity that seldom occurs with court custody orders," he said.

Nowadays, he sees his children much less frequently because his former spouse moved away from the area about 4 years ago. "Millions of children of divorce experience the family tragedy of move aways," he said. "Some move aways are motivated by diminishment or exclusion of the role of the other parent or by various personal choices, without necessarily prioritizing the children's need for frequent contact with both parents."

Dr. Sommer noted that better navigational tools for single fathers have emerged over the last decade, including Fathers and Families (www.fathersandfamilies.orgwww.breakthroughparentingservices.comwww.stopparentalalienation.orgwww.hisside.com

He also recommends the independent film "Jake's Closet," written and directed by Shelli Ryan (www.jakesclosetmovie.com

Looking back over this period, Dr. Sommer reflects: "My children somehow managed to overcome the emotional stress of the family break; they're great kids and I am proud of them. I'm grateful for this outcome, and I consider myself luckier than many."

Prioritized for His Daughter

When Dr. Lloyd Axelrod separated from his wife in 1991, time management took on a new meaning as he orchestrated his new role as single father of a then-31/2-year-old daughter in a joint custody arrangement.

"I used to say that I went 171/2 hours a day nonstop," said Dr. Axelrod, an endocrinologist at Massachusetts General Hospital, Boston. "But what I did in those 171/2 hours switched a lot when I had a little child."

To compensate, he stopped doing research and closed down his diabetes research lab at the hospital. He also stopped working evenings at home on articles and grants. "I made a decision that my daughter was more important than becoming a professor of medicine," he said. "It was the right decision then, and it was the right decision now."

His effort to secure shared custody was "a brutal battle that shouldn't have been necessary. It should have been automatic, the way it is in the United Kingdom. The presumption should have been shared custody. But in our regressive society, that wasn't the presumption, so it was extremely difficult, expensive, and time consuming."

During the early stages of the divorce, Dr. Axelrod heard about a support group for single fathers that had formed in the Boston area, but it never got off the ground. "I had certain friends who were supportive at the time," he recalled. "I got to know a lot of the parents of kids my daughter's age at school events or soccer. So, in some ways, the parents were part of my support system when this was starting."

The experience "heightened my awareness that there were a lot of issues about single fathers that weren't addressed in the public forum—the legal issues and financial issues and support issues. What was most striking was the lack of appreciation in the public and in the workplace about the role of single fathers. I encountered some of that."

Dr. Axelrod, whose daughter is now attending college, was quick to note that resources for single fathers are at an all-time high in the form of support groups, advocacy groups, blogs, and books on the topic.

He advises physicians who find themselves in the role of a single father to "be prepared for some rapid changes, get the appropriate legal and professional counseling, and read books on the subject. Get up to speed as quickly as possible, recognizing that the decisions you make will last your child's entire childhood. Expect that you are going to have to make some accommodations in your career. You have to make some adjustments."

A Big Dose of Humility

In 2001, Dr. John Whelan was stunned to learn that his former spouse would have provisional custody of their 2-year-old son, Olivier, while their divorce was pending.

"I subsequently discovered that's routine," said Dr. Whelan, a pediatric rheumatologist at the MassGeneral Hospital for Children in Boston. "Unless a mother has a drug use history or is imprisoned, my understanding is that the mother always gets provisional physical custody and the father becomes the noncustodial parent while the divorce is pending. For a period of about 2 years, I was basically the second-class parent until the whole divorce was resolved. This is one of the cruelest things about the family law system in our state: One day a child has two parents who are important in his life, and the next day, he has one important parent and one unimportant parent."

The court ultimately ruled that the parents would have joint physical custody, "but that is a rare thing in Massachusetts," he said. "Only 6% of divorces involving children in Massachusetts are said to result in joint physical custody."

Today, Olivier resides with Dr. Whelan 3 nights a week, mostly on weekends, and for vacations. His former spouse watches their son generally after school during the week.

"My son and I have a close relationship," Dr. Whelan said. "Part of it is a result of the fact that when he's with me, I do nothing else: I spend whole weekends at a time with him. I do take him on rounds with me occasionally when I'm covering call on the weekend. He enjoys going to the hospital and it helps that I'm in pediatrics. I can come into a room with a child patient and it's very reassuring to these young kids to see that I have a 'child assistant.' "

Olivier, who turns 8 in October, plays soccer and Little League baseball, and is starting his third year of piano lessons. "Before that, he took weekly music classes at a local music conservatory," Dr. Whelan said. "Music has been a big part of our life. He's been to Boston Symphony Hall a couple of dozen times. He can sit through a 2-hour Wagner concert, which is amazing."

Last year, they took a weekly Mandarin Chinese class together, and Olivier is fully fluent in French.

Dr. Whelan described his relationship with his former spouse as "conciliatory," which "is so critical to the well-being of children who are living in a two-household situation. Do whatever you can to remain on good terms with your former spouse."

He advised physicians new to the single father role to assemble "several tiers of babysitters and contingency plans for those times when you get called into the emergency room in the middle of the night. Who can you call to come into your house and watch your child while you're in the ER evaluating somebody?"

For him, the road to becoming a single father brought a big dose of humility. "As a doctor, you are used to being treated with deference," he said. "People trust your judgment; they look up to you. To be in a situation where your judgment often is questioned and you're not respected can be somewhat humiliating. If you are able to go at it [in] a humble frame of mind and keep your sense of humor, then you'll probably come out a lot better off than if you follow the human instinct to fight back and constantly defend your honor. A life in medicine is stressful enough, family issues aside. It seems to me that doing what's best for your child and nurturing that strong relationship is the deepest balm for all the other challenges we face as doctors."

'I had to fight hard for equal parenting time, losing most of my life savings in the process.' DR. SOMMER

Dr. Steve S. Sommer can't recall feeling more alone than in 1997, when he became a single father after separating from his wife of many years. The couple's older daughter was 9 years old at the time, and their boy-girl twins were 4 years old.

"It was hard," said Dr. Sommer, who chairs the departments of molecular diagnosis and molecular genetics at the City of Hope National Medical Center in Duarte, Calif. "My dad was a fantastic dad. It had never occurred to me that I wouldn't have the same role with my kids. Instead, I found my close relationship to my children threatened. I had to fight hard for equal parenting time, losing most of my life savings in the process. I walked a tightrope between professional responsibilities and spending time with my children on the custody schedule."

The marriage fell apart a few months after Dr. Sommer and his family had moved to Southern California from Minnesota. Because he was new to the area, Dr. Sommer lacked a strong social support network. "My aging parents and two good friends provided emotional support long distance, and I found a fantastic nanny/housekeeper, who helped me to support the needs of the children," he recalled.

For many years, the children commuted the 15 minutes between their two homes. During most of that period, Dr. Sommer had the children after school on weekdays through dinner time and on Friday night through Saturday. "There was a level of continuity that seldom occurs with court custody orders," he said.

Nowadays, he sees his children much less frequently because his former spouse moved away from the area about 4 years ago. "Millions of children of divorce experience the family tragedy of move aways," he said. "Some move aways are motivated by diminishment or exclusion of the role of the other parent or by various personal choices, without necessarily prioritizing the children's need for frequent contact with both parents."

Dr. Sommer noted that better navigational tools for single fathers have emerged over the last decade, including Fathers and Families (www.fathersandfamilies.orgwww.breakthroughparentingservices.comwww.stopparentalalienation.orgwww.hisside.com

He also recommends the independent film "Jake's Closet," written and directed by Shelli Ryan (www.jakesclosetmovie.com

Looking back over this period, Dr. Sommer reflects: "My children somehow managed to overcome the emotional stress of the family break; they're great kids and I am proud of them. I'm grateful for this outcome, and I consider myself luckier than many."

Prioritized for His Daughter

When Dr. Lloyd Axelrod separated from his wife in 1991, time management took on a new meaning as he orchestrated his new role as single father of a then-31/2-year-old daughter in a joint custody arrangement.

"I used to say that I went 171/2 hours a day nonstop," said Dr. Axelrod, an endocrinologist at Massachusetts General Hospital, Boston. "But what I did in those 171/2 hours switched a lot when I had a little child."

To compensate, he stopped doing research and closed down his diabetes research lab at the hospital. He also stopped working evenings at home on articles and grants. "I made a decision that my daughter was more important than becoming a professor of medicine," he said. "It was the right decision then, and it was the right decision now."

His effort to secure shared custody was "a brutal battle that shouldn't have been necessary. It should have been automatic, the way it is in the United Kingdom. The presumption should have been shared custody. But in our regressive society, that wasn't the presumption, so it was extremely difficult, expensive, and time consuming."

During the early stages of the divorce, Dr. Axelrod heard about a support group for single fathers that had formed in the Boston area, but it never got off the ground. "I had certain friends who were supportive at the time," he recalled. "I got to know a lot of the parents of kids my daughter's age at school events or soccer. So, in some ways, the parents were part of my support system when this was starting."

The experience "heightened my awareness that there were a lot of issues about single fathers that weren't addressed in the public forum—the legal issues and financial issues and support issues. What was most striking was the lack of appreciation in the public and in the workplace about the role of single fathers. I encountered some of that."

Dr. Axelrod, whose daughter is now attending college, was quick to note that resources for single fathers are at an all-time high in the form of support groups, advocacy groups, blogs, and books on the topic.

He advises physicians who find themselves in the role of a single father to "be prepared for some rapid changes, get the appropriate legal and professional counseling, and read books on the subject. Get up to speed as quickly as possible, recognizing that the decisions you make will last your child's entire childhood. Expect that you are going to have to make some accommodations in your career. You have to make some adjustments."

A Big Dose of Humility

In 2001, Dr. John Whelan was stunned to learn that his former spouse would have provisional custody of their 2-year-old son, Olivier, while their divorce was pending.

"I subsequently discovered that's routine," said Dr. Whelan, a pediatric rheumatologist at the MassGeneral Hospital for Children in Boston. "Unless a mother has a drug use history or is imprisoned, my understanding is that the mother always gets provisional physical custody and the father becomes the noncustodial parent while the divorce is pending. For a period of about 2 years, I was basically the second-class parent until the whole divorce was resolved. This is one of the cruelest things about the family law system in our state: One day a child has two parents who are important in his life, and the next day, he has one important parent and one unimportant parent."

The court ultimately ruled that the parents would have joint physical custody, "but that is a rare thing in Massachusetts," he said. "Only 6% of divorces involving children in Massachusetts are said to result in joint physical custody."

Today, Olivier resides with Dr. Whelan 3 nights a week, mostly on weekends, and for vacations. His former spouse watches their son generally after school during the week.

"My son and I have a close relationship," Dr. Whelan said. "Part of it is a result of the fact that when he's with me, I do nothing else: I spend whole weekends at a time with him. I do take him on rounds with me occasionally when I'm covering call on the weekend. He enjoys going to the hospital and it helps that I'm in pediatrics. I can come into a room with a child patient and it's very reassuring to these young kids to see that I have a 'child assistant.' "

Olivier, who turns 8 in October, plays soccer and Little League baseball, and is starting his third year of piano lessons. "Before that, he took weekly music classes at a local music conservatory," Dr. Whelan said. "Music has been a big part of our life. He's been to Boston Symphony Hall a couple of dozen times. He can sit through a 2-hour Wagner concert, which is amazing."

Last year, they took a weekly Mandarin Chinese class together, and Olivier is fully fluent in French.

Dr. Whelan described his relationship with his former spouse as "conciliatory," which "is so critical to the well-being of children who are living in a two-household situation. Do whatever you can to remain on good terms with your former spouse."

He advised physicians new to the single father role to assemble "several tiers of babysitters and contingency plans for those times when you get called into the emergency room in the middle of the night. Who can you call to come into your house and watch your child while you're in the ER evaluating somebody?"

For him, the road to becoming a single father brought a big dose of humility. "As a doctor, you are used to being treated with deference," he said. "People trust your judgment; they look up to you. To be in a situation where your judgment often is questioned and you're not respected can be somewhat humiliating. If you are able to go at it [in] a humble frame of mind and keep your sense of humor, then you'll probably come out a lot better off than if you follow the human instinct to fight back and constantly defend your honor. A life in medicine is stressful enough, family issues aside. It seems to me that doing what's best for your child and nurturing that strong relationship is the deepest balm for all the other challenges we face as doctors."

'I had to fight hard for equal parenting time, losing most of my life savings in the process.' DR. SOMMER

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion.

"There are several exceptions, one of which is someone who has obtained an infection from a pedicure," said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

"You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure," she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. "This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients," she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. "We underuse this drug in dermatology," she said. "It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients."

She usually instructs her patients to take fluconazole on Fridays and uses the term "fungal Fridays" as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, "Toesdays."

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. "You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal," said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. "Thick nails could come from trauma, from running or skiing, or from runner's toe," she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream, and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon "that may supersede itraconazole in this situation," Dr. Elewski said. These are posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. To illustrate, she discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. "Is this eczema? Stasis dermatitis?" she asked. "If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs."

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Bad prognostic factors for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. COURTESY DR. BONI E. ELEWSKI

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion.

"There are several exceptions, one of which is someone who has obtained an infection from a pedicure," said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

"You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure," she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. "This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients," she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. "We underuse this drug in dermatology," she said. "It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients."

She usually instructs her patients to take fluconazole on Fridays and uses the term "fungal Fridays" as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, "Toesdays."

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. "You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal," said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. "Thick nails could come from trauma, from running or skiing, or from runner's toe," she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream, and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon "that may supersede itraconazole in this situation," Dr. Elewski said. These are posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. To illustrate, she discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. "Is this eczema? Stasis dermatitis?" she asked. "If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs."

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Bad prognostic factors for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. COURTESY DR. BONI E. ELEWSKI

CORONADO, CALIF. — A patient who has abnormal-looking nails with a normal plantar and web surface is unlikely to have onychomycosis, Dr. Boni E. Elewski said at the annual meeting of the Pacific Dermatologic Association.

The presence of tinea pedis on the plantar surface or web space confirms that clinical suspicion.

"There are several exceptions, one of which is someone who has obtained an infection from a pedicure," said Dr. Elewski, professor of dermatology at the University of Alabama, Birmingham.

"You can't eliminate that. So if you have a patient with pristine feet and they have no [previous] history of tinea pedis, ask if they get regular pedicures, because you can get a direct infection of the nail plate from a pedicure," she explained.

The other exceptions are white superficial onychomycosis and proximal white subungual onychomycosis, two subtypes in which the fungus directly attacks the nail plate rather than the skin first.

Dr. Elewski provided several other clinical pearls regarding onychomycosis:

▸ A patient with abnormal fingernails and normal toenails is unlikely to have onychomycosis. The exception is Candida onycholysis. "This occurs commonly in women who have Raynaud's syndrome and other patients who have collagen vascular disease, but that's a very small minority of patients," she said.

▸ Fluconazole 200–400 mg once a week is effective for Candida onychomycosis or paronychia. "We underuse this drug in dermatology," she said. "It is a good antifungal and it's very cheap, about 25 cents per tablet. You only need to treat for 6–8 weeks in most patients."

She usually instructs her patients to take fluconazole on Fridays and uses the term "fungal Fridays" as a catchy reminder. Some of her dermatology residents prefer Tuesdays or, as they call it, "Toesdays."

▸ Know the bad prognostic factors of onychomycosis. These include dermatophytoma, thick nail, a total dystrophic nail, predominantly lateral nail involvement, and immunocompromised and/or diabetic patients.

Physicians can improve the prognosis in patients with dermatophytoma by debriding the area as much as possible. "You can give patients antifungal cream, lotion, or gel to smear under it, and then treat it with an oral antifungal," said Dr. Elewski, a past president of the American Academy of Dermatology.

She also noted that patients with thick nails require careful evaluation because not all of them will have onychomycosis. "Thick nails could come from trauma, from running or skiing, or from runner's toe," she explained.

In patients with lateral nail involvement, she clips away at the lateral edge, smears in antifungal cream, and continues treatment with oral antifungals.

Most patients with a bad prognostic factor will require treatment with oral terbinafine 250 mg daily or itraconazole 400 mg daily for 1 week per month for 4 months or longer.

▸ Itraconazole is the choice in nondermatophyte mold infections of the nail. There are two other drugs on the horizon "that may supersede itraconazole in this situation," Dr. Elewski said. These are posaconazole (Noxafil), which is not approved for this indication but is under investigation, and a drug in development called albaconazole.

▸ Topical antimycotic agents may be sufficient to treat onychomycosis in certain situations. The only topical agent that is approved by the Food and Drug Administration for onychomycosis is 8% ciclopirox olamine lacquer. Dr. Elewski said that she also finds it useful in white superficial onychomycosis and in minimal nail disease.

▸ The nail can provide clues to skin disease. To illustrate, she discussed the case of a patient who presented with a scaly dermatosis on the pretibial area. "Is this eczema? Stasis dermatitis?" she asked. "If the toes are abnormal and the patient has onychomycosis, there is a high likelihood that a scaly rash on the lower legs could be a dermatophyte infection. If the toes are normal, the patient probably does not have a dermatophyte infection on the lower legs."

Dr. Elewski disclosed that she has conducted clinical research for Novartis, Barrier Therapeutics, and Stiefel Laboratories.

Bad prognostic factors for onychomycosis include dermatophytoma, thick nail, and a total dystrophic nail. COURTESY DR. BONI E. ELEWSKI

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of dermatology practice, but sometimes that's easier said than done.

At the annual meeting of the Pacific Dermatologic Association, Dr. Anna L. Bruckner discussed three cases to illustrate that point.

In the first case, a 6-year-old girl with suspected loose anagen syndrome was referred to Dr. Bruckner, who is director of pediatric dermatology at Lucile Packard Children's Hospital in Palo Alto, Calif. In this condition, the anagen hairs are loosely anchored into the scalp so that the hair will fall out with very minor trauma. The hair is short, sparse, and seldom cut. It typically is seen in blond girls aged 2–5 years, but can affect boys and brunettes as well.

Many of the girl's friends at school "had long, flowing hair and she wanted to see if there was something we could do about her hair," Dr. Bruckner said. She did a gentle hair pull test and only two hairs came out. The girl's hair was very short and had a matted appearance in the back.

Dr. Bruckner prescribed 5% minoxidil lotion and scheduled a 3-month follow-up visit. On follow-up the girl's hair was fuller but it remained short and gentle hair pull tests remained negative.

"We obtained some additional history," Dr. Bruckner recalled. "Her nails were thin, often peeled, and never required trimming. She had no history of dental anomalies, and she'd had a coarse, deep voice since age 2. Her mother said that she looked different from her siblings."

She also had sparse lateral eyebrows, a pear-shaped nose, and a thin upper lip.

The combination of short, sparse hair and abnormal facial features led Dr. Bruckner to consider trichorhinophalangeal syndrome (TRPS) type 1 as the diagnosis. An x-ray of the girl's hand performed after her follow-up visit revealed cone-shaped epiphyses of the phalanges, which confirmed the diagnosis. TRPS type 1 is an autosomal dominant disorder characterized by craniofacial and bony abnormalities that include sparse, slow-growing hair and thin lateral eyebrows, a pear-shaped nose, elongated philtrum and thin upper lip, prominent ears, and cone-shaped epiphyses of the phalanges.

Variable findings include short stature (the patient was in the 25th percentile for height), nail abnormalities, teeth abnormalities, and a deep voice. The condition is caused by mutations in the TRPS1 gene.

Although there is no specific treatment for TRPS type 1, the parents were happy to better understand why their daughter's hair failed to grow normally. She has continued to use 5% minoxidil for 6 months with some improvement.

In another challenging case, a 16-year-old African American boy presented with a 1-year history of a rapidly enlarging, pink to brown, scaly plaque on the right lower extremity. The lesion extended onto the thigh, shin, and toes.

He had been seen by other dermatologists, and previous diagnoses included epidermal nevus and linear psoriasis. Topical treatment with clobetasol, calcipotriene, and tazarotene led to minimal improvement, but the patient was concerned that he was developing significant postinflammatory hyperpigmentation.

Close examination of the skin change revealed a thread-like hyperkeratotic border. Biopsy of this area showed a cornoid lamella, which is seen in porokeratosis.

Ultimately, Dr. Bruckner diagnosed linear porokeratosis, which presents in infancy or childhood. The lesions follow the line of Blaschko.

"The presumed pathogenesis is dysregulation of the keratinocytes, which leads to premature apoptosis of keratinocytes," said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. "The clinical concerns are for cosmesis and the potential for developing squamous cell carcinoma within the lesion."

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. "However, in many of these cases recurrence of the lesion is common and all of these treatments have potential adverse effects," she noted. "This raises the question: Is treatment necessary?"

After the diagnosis was made they tried a course of imiquimod. "The boy did not feel that there was any improvement, and he developed significant postinflammatory hyperpigmentation," she said.

In this case, Dr. Bruckner and her associates ultimately decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes.

This decision "was controversial, but it was a decision that was made with the family," she said. "It's something that they're comfortable with at this point."

The third case Dr. Bruckner discussed was that of a 9-year-old girl who was referred by a rheumatologist for evaluation of possible dermatomyositis. The patient had a 4-month history of intermittent redness and swelling of the hands that worsened after prolonged outdoor activities.

The girl was healthy and described one remote episode of burning hands following a hike several years before. She was on naproxen and ranitidine, which had been prescribed by the rheumatologist as treatment for the redness and swelling.

Her family history was unremarkable. "She had no muscular weakness or abdominal pain," Dr. Bruckner said. "The work-up by the rheumatologist was negative for autoimmune disease."

Clinical exam revealed a few waxy papules and plaques distributed over the knuckles. Her hands also had a slightly weather-beaten appearance. A skin biopsy showed cuffs of hyaline material around the superficial blood vessels in the upper dermis, suggesting a diagnosis of erythropoietic protoporphyria (EPP). Confirmatory studies demonstrated that the patient had elevated total red blood cell porphyrins with a predominance of free protoporphyrin.

EPP is the most common type of porphyria in children. It presents between 1 and 6 years of age and symptoms include burning, stinging, redness, and edema, which all occur after sun exposure.

The condition is caused by a deficiency of ferrochelatase, which leads to accumulation of protoporphyrin IX.

Treatment involves sun avoidance, sunscreens, and beta-carotene 30–150 mg/day.

The girl developed a sense of social isolation because she attended a school where the children ate lunch and played outside. "She had to eat lunch off in a corner by herself, so she really was not able to interact with her peers when she was at school," Dr. Bruckner said. "This was very distressing for her. In addition, the beta-carotene pills were large and difficult to swallow."

Luckily, she said, the girl had a "tenacious" mother who worked with school officials to create opportunities for her daughter to socialize in shaded or indoor areas during lunch and recess.

"We need to have parents who are willing to be advocates for their children," Dr. Bruckner said.

When skin conditions lead to social isolation, we need 'parents who are willing to be advocates for their children.' DR. BRUCKNER

A 9-year-old girl with erythropoietic protoporphyria presented with waxy papules and plaques on her knuckles.

Scaly plaque is seen on the right lower extremity of a 16-year-old boy diagnosed with linear porokeratosis. PHOTOS COURTESY DR. ANNA L. BRUCKNER

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of dermatology practice, but sometimes that's easier said than done.

At the annual meeting of the Pacific Dermatologic Association, Dr. Anna L. Bruckner discussed three cases to illustrate that point.

In the first case, a 6-year-old girl with suspected loose anagen syndrome was referred to Dr. Bruckner, who is director of pediatric dermatology at Lucile Packard Children's Hospital in Palo Alto, Calif. In this condition, the anagen hairs are loosely anchored into the scalp so that the hair will fall out with very minor trauma. The hair is short, sparse, and seldom cut. It typically is seen in blond girls aged 2–5 years, but can affect boys and brunettes as well.

Many of the girl's friends at school "had long, flowing hair and she wanted to see if there was something we could do about her hair," Dr. Bruckner said. She did a gentle hair pull test and only two hairs came out. The girl's hair was very short and had a matted appearance in the back.

Dr. Bruckner prescribed 5% minoxidil lotion and scheduled a 3-month follow-up visit. On follow-up the girl's hair was fuller but it remained short and gentle hair pull tests remained negative.

"We obtained some additional history," Dr. Bruckner recalled. "Her nails were thin, often peeled, and never required trimming. She had no history of dental anomalies, and she'd had a coarse, deep voice since age 2. Her mother said that she looked different from her siblings."

She also had sparse lateral eyebrows, a pear-shaped nose, and a thin upper lip.

The combination of short, sparse hair and abnormal facial features led Dr. Bruckner to consider trichorhinophalangeal syndrome (TRPS) type 1 as the diagnosis. An x-ray of the girl's hand performed after her follow-up visit revealed cone-shaped epiphyses of the phalanges, which confirmed the diagnosis. TRPS type 1 is an autosomal dominant disorder characterized by craniofacial and bony abnormalities that include sparse, slow-growing hair and thin lateral eyebrows, a pear-shaped nose, elongated philtrum and thin upper lip, prominent ears, and cone-shaped epiphyses of the phalanges.

Variable findings include short stature (the patient was in the 25th percentile for height), nail abnormalities, teeth abnormalities, and a deep voice. The condition is caused by mutations in the TRPS1 gene.

Although there is no specific treatment for TRPS type 1, the parents were happy to better understand why their daughter's hair failed to grow normally. She has continued to use 5% minoxidil for 6 months with some improvement.

In another challenging case, a 16-year-old African American boy presented with a 1-year history of a rapidly enlarging, pink to brown, scaly plaque on the right lower extremity. The lesion extended onto the thigh, shin, and toes.

He had been seen by other dermatologists, and previous diagnoses included epidermal nevus and linear psoriasis. Topical treatment with clobetasol, calcipotriene, and tazarotene led to minimal improvement, but the patient was concerned that he was developing significant postinflammatory hyperpigmentation.

Close examination of the skin change revealed a thread-like hyperkeratotic border. Biopsy of this area showed a cornoid lamella, which is seen in porokeratosis.

Ultimately, Dr. Bruckner diagnosed linear porokeratosis, which presents in infancy or childhood. The lesions follow the line of Blaschko.

"The presumed pathogenesis is dysregulation of the keratinocytes, which leads to premature apoptosis of keratinocytes," said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. "The clinical concerns are for cosmesis and the potential for developing squamous cell carcinoma within the lesion."

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. "However, in many of these cases recurrence of the lesion is common and all of these treatments have potential adverse effects," she noted. "This raises the question: Is treatment necessary?"

After the diagnosis was made they tried a course of imiquimod. "The boy did not feel that there was any improvement, and he developed significant postinflammatory hyperpigmentation," she said.

In this case, Dr. Bruckner and her associates ultimately decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes.

This decision "was controversial, but it was a decision that was made with the family," she said. "It's something that they're comfortable with at this point."

The third case Dr. Bruckner discussed was that of a 9-year-old girl who was referred by a rheumatologist for evaluation of possible dermatomyositis. The patient had a 4-month history of intermittent redness and swelling of the hands that worsened after prolonged outdoor activities.

The girl was healthy and described one remote episode of burning hands following a hike several years before. She was on naproxen and ranitidine, which had been prescribed by the rheumatologist as treatment for the redness and swelling.

Her family history was unremarkable. "She had no muscular weakness or abdominal pain," Dr. Bruckner said. "The work-up by the rheumatologist was negative for autoimmune disease."

Clinical exam revealed a few waxy papules and plaques distributed over the knuckles. Her hands also had a slightly weather-beaten appearance. A skin biopsy showed cuffs of hyaline material around the superficial blood vessels in the upper dermis, suggesting a diagnosis of erythropoietic protoporphyria (EPP). Confirmatory studies demonstrated that the patient had elevated total red blood cell porphyrins with a predominance of free protoporphyrin.

EPP is the most common type of porphyria in children. It presents between 1 and 6 years of age and symptoms include burning, stinging, redness, and edema, which all occur after sun exposure.

The condition is caused by a deficiency of ferrochelatase, which leads to accumulation of protoporphyrin IX.

Treatment involves sun avoidance, sunscreens, and beta-carotene 30–150 mg/day.

The girl developed a sense of social isolation because she attended a school where the children ate lunch and played outside. "She had to eat lunch off in a corner by herself, so she really was not able to interact with her peers when she was at school," Dr. Bruckner said. "This was very distressing for her. In addition, the beta-carotene pills were large and difficult to swallow."

Luckily, she said, the girl had a "tenacious" mother who worked with school officials to create opportunities for her daughter to socialize in shaded or indoor areas during lunch and recess.

"We need to have parents who are willing to be advocates for their children," Dr. Bruckner said.

When skin conditions lead to social isolation, we need 'parents who are willing to be advocates for their children.' DR. BRUCKNER

A 9-year-old girl with erythropoietic protoporphyria presented with waxy papules and plaques on her knuckles.

Scaly plaque is seen on the right lower extremity of a 16-year-old boy diagnosed with linear porokeratosis. PHOTOS COURTESY DR. ANNA L. BRUCKNER

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of dermatology practice, but sometimes that's easier said than done.

At the annual meeting of the Pacific Dermatologic Association, Dr. Anna L. Bruckner discussed three cases to illustrate that point.

In the first case, a 6-year-old girl with suspected loose anagen syndrome was referred to Dr. Bruckner, who is director of pediatric dermatology at Lucile Packard Children's Hospital in Palo Alto, Calif. In this condition, the anagen hairs are loosely anchored into the scalp so that the hair will fall out with very minor trauma. The hair is short, sparse, and seldom cut. It typically is seen in blond girls aged 2–5 years, but can affect boys and brunettes as well.

Many of the girl's friends at school "had long, flowing hair and she wanted to see if there was something we could do about her hair," Dr. Bruckner said. She did a gentle hair pull test and only two hairs came out. The girl's hair was very short and had a matted appearance in the back.

Dr. Bruckner prescribed 5% minoxidil lotion and scheduled a 3-month follow-up visit. On follow-up the girl's hair was fuller but it remained short and gentle hair pull tests remained negative.

"We obtained some additional history," Dr. Bruckner recalled. "Her nails were thin, often peeled, and never required trimming. She had no history of dental anomalies, and she'd had a coarse, deep voice since age 2. Her mother said that she looked different from her siblings."

She also had sparse lateral eyebrows, a pear-shaped nose, and a thin upper lip.

The combination of short, sparse hair and abnormal facial features led Dr. Bruckner to consider trichorhinophalangeal syndrome (TRPS) type 1 as the diagnosis. An x-ray of the girl's hand performed after her follow-up visit revealed cone-shaped epiphyses of the phalanges, which confirmed the diagnosis. TRPS type 1 is an autosomal dominant disorder characterized by craniofacial and bony abnormalities that include sparse, slow-growing hair and thin lateral eyebrows, a pear-shaped nose, elongated philtrum and thin upper lip, prominent ears, and cone-shaped epiphyses of the phalanges.

Variable findings include short stature (the patient was in the 25th percentile for height), nail abnormalities, teeth abnormalities, and a deep voice. The condition is caused by mutations in the TRPS1 gene.

Although there is no specific treatment for TRPS type 1, the parents were happy to better understand why their daughter's hair failed to grow normally. She has continued to use 5% minoxidil for 6 months with some improvement.

In another challenging case, a 16-year-old African American boy presented with a 1-year history of a rapidly enlarging, pink to brown, scaly plaque on the right lower extremity. The lesion extended onto the thigh, shin, and toes.

He had been seen by other dermatologists, and previous diagnoses included epidermal nevus and linear psoriasis. Topical treatment with clobetasol, calcipotriene, and tazarotene led to minimal improvement, but the patient was concerned that he was developing significant postinflammatory hyperpigmentation.

Close examination of the skin change revealed a thread-like hyperkeratotic border. Biopsy of this area showed a cornoid lamella, which is seen in porokeratosis.

Ultimately, Dr. Bruckner diagnosed linear porokeratosis, which presents in infancy or childhood. The lesions follow the line of Blaschko.

"The presumed pathogenesis is dysregulation of the keratinocytes, which leads to premature apoptosis of keratinocytes," said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. "The clinical concerns are for cosmesis and the potential for developing squamous cell carcinoma within the lesion."

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. "However, in many of these cases recurrence of the lesion is common and all of these treatments have potential adverse effects," she noted. "This raises the question: Is treatment necessary?"

After the diagnosis was made they tried a course of imiquimod. "The boy did not feel that there was any improvement, and he developed significant postinflammatory hyperpigmentation," she said.

In this case, Dr. Bruckner and her associates ultimately decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes.

This decision "was controversial, but it was a decision that was made with the family," she said. "It's something that they're comfortable with at this point."

The third case Dr. Bruckner discussed was that of a 9-year-old girl who was referred by a rheumatologist for evaluation of possible dermatomyositis. The patient had a 4-month history of intermittent redness and swelling of the hands that worsened after prolonged outdoor activities.

The girl was healthy and described one remote episode of burning hands following a hike several years before. She was on naproxen and ranitidine, which had been prescribed by the rheumatologist as treatment for the redness and swelling.

Her family history was unremarkable. "She had no muscular weakness or abdominal pain," Dr. Bruckner said. "The work-up by the rheumatologist was negative for autoimmune disease."

Clinical exam revealed a few waxy papules and plaques distributed over the knuckles. Her hands also had a slightly weather-beaten appearance. A skin biopsy showed cuffs of hyaline material around the superficial blood vessels in the upper dermis, suggesting a diagnosis of erythropoietic protoporphyria (EPP). Confirmatory studies demonstrated that the patient had elevated total red blood cell porphyrins with a predominance of free protoporphyrin.

EPP is the most common type of porphyria in children. It presents between 1 and 6 years of age and symptoms include burning, stinging, redness, and edema, which all occur after sun exposure.

The condition is caused by a deficiency of ferrochelatase, which leads to accumulation of protoporphyrin IX.

Treatment involves sun avoidance, sunscreens, and beta-carotene 30–150 mg/day.

The girl developed a sense of social isolation because she attended a school where the children ate lunch and played outside. "She had to eat lunch off in a corner by herself, so she really was not able to interact with her peers when she was at school," Dr. Bruckner said. "This was very distressing for her. In addition, the beta-carotene pills were large and difficult to swallow."

Luckily, she said, the girl had a "tenacious" mother who worked with school officials to create opportunities for her daughter to socialize in shaded or indoor areas during lunch and recess.

"We need to have parents who are willing to be advocates for their children," Dr. Bruckner said.

When skin conditions lead to social isolation, we need 'parents who are willing to be advocates for their children.' DR. BRUCKNER

A 9-year-old girl with erythropoietic protoporphyria presented with waxy papules and plaques on her knuckles.

Scaly plaque is seen on the right lower extremity of a 16-year-old boy diagnosed with linear porokeratosis. PHOTOS COURTESY DR. ANNA L. BRUCKNER

CORONADO, CALIF. — Over the next 2 decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, said Dr. Ronald Moy at the annual meeting of the Pacific Dermatologic Association.

“What we're doing today is going to be considered barbaric if we look 15–20 years down the road,” said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. “We've done projects in our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate,” he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos. “Lasers will be handheld and will be used by patients,” he added.

Dr. Moy also expects that Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers, such as those derived from stem cells, will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, after the American Academy of Dermatology, and “dermatologic surgery procedures are the fastest growing and most commonly preferred procedures,” he said. “The future promises that new technology will make these procedures better.”

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as “our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery.”

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

“That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need.”

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, “where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis.”

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. “They're going to be better trained, and they'll be embracing new technology,” he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before use of Sculptra, a filler for improving facial volume.

The patient is shown 2 months later, after 2 shots of the long-lasting treatment. Photos courtesy Dr. Ronald Moy

CORONADO, CALIF. — Over the next 2 decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, said Dr. Ronald Moy at the annual meeting of the Pacific Dermatologic Association.

“What we're doing today is going to be considered barbaric if we look 15–20 years down the road,” said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. “We've done projects in our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate,” he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos. “Lasers will be handheld and will be used by patients,” he added.

Dr. Moy also expects that Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers, such as those derived from stem cells, will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, after the American Academy of Dermatology, and “dermatologic surgery procedures are the fastest growing and most commonly preferred procedures,” he said. “The future promises that new technology will make these procedures better.”

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as “our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery.”

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

“That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need.”

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, “where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis.”

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. “They're going to be better trained, and they'll be embracing new technology,” he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before use of Sculptra, a filler for improving facial volume.

The patient is shown 2 months later, after 2 shots of the long-lasting treatment. Photos courtesy Dr. Ronald Moy

CORONADO, CALIF. — Over the next 2 decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, said Dr. Ronald Moy at the annual meeting of the Pacific Dermatologic Association.

“What we're doing today is going to be considered barbaric if we look 15–20 years down the road,” said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. “We've done projects in our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate,” he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos. “Lasers will be handheld and will be used by patients,” he added.

Dr. Moy also expects that Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers, such as those derived from stem cells, will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, after the American Academy of Dermatology, and “dermatologic surgery procedures are the fastest growing and most commonly preferred procedures,” he said. “The future promises that new technology will make these procedures better.”

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as “our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery.”

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

“That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need.”

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, “where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis.”

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. “They're going to be better trained, and they'll be embracing new technology,” he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before use of Sculptra, a filler for improving facial volume.

The patient is shown 2 months later, after 2 shots of the long-lasting treatment. Photos courtesy Dr. Ronald Moy

SAN DIEGO — Preoperative elevated levels of N-terminal pro-B-type natriuretic peptide are an excellent predictor of mortality in patients undergoing cardiac surgery, even when adjusted for currently used scoring systems, Dr. Brian H. Cuthbertson reported during a poster session at the annual meeting of the American Association for Clinical Chemistry.

Dr. Cuthbertson and his associates measured the preoperative NT-proBNP levels from blood samples in 541 consecutive patients who underwent cardiac surgery at Aberdeen Royal Infirmary, Aberdeen, Scotland. They followed the patients postoperatively for a median of 18 months to assess mortality.

The researchers found that the median NT-proBNP levels were significantly higher in the patients who died, compared with those who survived (1,173 pg/mL and 282 pg/mL, respectively).

In addition, patients who died were significantly older than those who survived (median 73 years and 67 years, respectively). They also had significantly higher scores on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) than did survivors (median 6.6 and 2.9, respectively).

Median estimated glomerular filtration (eGFR) rate was significantly lower in patients who died, compared with survivors (62 mL/min per 1.73 m

In a Kaplan Meier analysis for survival, patients in the highest tertile for NT-proBNP showed the highest mortality, compared with those in the lower two tertiles (12.8% vs. 2.2%).

A multivariate model that included NT-ProBNP, EuroSCORE, age, gender, previous myocardial infarction, hypertension, diabetes, smoking, and eGFR showed that only elevated levels of NT-ProBNP and older age remained significant predictors of mortality.

“Preoperative measurement of NT-proBNP may help identify patients at higher risk who would benefit from further optimization of clinical status prior to surgery,” the researchers concluded.

The study, which is the largest of its kind, will eventually enroll 1,000 patients, according to Dr. Cuthbertson.

SAN DIEGO — Preoperative elevated levels of N-terminal pro-B-type natriuretic peptide are an excellent predictor of mortality in patients undergoing cardiac surgery, even when adjusted for currently used scoring systems, Dr. Brian H. Cuthbertson reported during a poster session at the annual meeting of the American Association for Clinical Chemistry.

Dr. Cuthbertson and his associates measured the preoperative NT-proBNP levels from blood samples in 541 consecutive patients who underwent cardiac surgery at Aberdeen Royal Infirmary, Aberdeen, Scotland. They followed the patients postoperatively for a median of 18 months to assess mortality.

The researchers found that the median NT-proBNP levels were significantly higher in the patients who died, compared with those who survived (1,173 pg/mL and 282 pg/mL, respectively).

In addition, patients who died were significantly older than those who survived (median 73 years and 67 years, respectively). They also had significantly higher scores on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) than did survivors (median 6.6 and 2.9, respectively).

Median estimated glomerular filtration (eGFR) rate was significantly lower in patients who died, compared with survivors (62 mL/min per 1.73 m

In a Kaplan Meier analysis for survival, patients in the highest tertile for NT-proBNP showed the highest mortality, compared with those in the lower two tertiles (12.8% vs. 2.2%).

A multivariate model that included NT-ProBNP, EuroSCORE, age, gender, previous myocardial infarction, hypertension, diabetes, smoking, and eGFR showed that only elevated levels of NT-ProBNP and older age remained significant predictors of mortality.

“Preoperative measurement of NT-proBNP may help identify patients at higher risk who would benefit from further optimization of clinical status prior to surgery,” the researchers concluded.

The study, which is the largest of its kind, will eventually enroll 1,000 patients, according to Dr. Cuthbertson.

SAN DIEGO — Preoperative elevated levels of N-terminal pro-B-type natriuretic peptide are an excellent predictor of mortality in patients undergoing cardiac surgery, even when adjusted for currently used scoring systems, Dr. Brian H. Cuthbertson reported during a poster session at the annual meeting of the American Association for Clinical Chemistry.

Dr. Cuthbertson and his associates measured the preoperative NT-proBNP levels from blood samples in 541 consecutive patients who underwent cardiac surgery at Aberdeen Royal Infirmary, Aberdeen, Scotland. They followed the patients postoperatively for a median of 18 months to assess mortality.

The researchers found that the median NT-proBNP levels were significantly higher in the patients who died, compared with those who survived (1,173 pg/mL and 282 pg/mL, respectively).

In addition, patients who died were significantly older than those who survived (median 73 years and 67 years, respectively). They also had significantly higher scores on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) than did survivors (median 6.6 and 2.9, respectively).

Median estimated glomerular filtration (eGFR) rate was significantly lower in patients who died, compared with survivors (62 mL/min per 1.73 m

In a Kaplan Meier analysis for survival, patients in the highest tertile for NT-proBNP showed the highest mortality, compared with those in the lower two tertiles (12.8% vs. 2.2%).

A multivariate model that included NT-ProBNP, EuroSCORE, age, gender, previous myocardial infarction, hypertension, diabetes, smoking, and eGFR showed that only elevated levels of NT-ProBNP and older age remained significant predictors of mortality.

“Preoperative measurement of NT-proBNP may help identify patients at higher risk who would benefit from further optimization of clinical status prior to surgery,” the researchers concluded.

The study, which is the largest of its kind, will eventually enroll 1,000 patients, according to Dr. Cuthbertson.

SAN DIEGO — Elevated baseline cystatin C levels in patients who present with acute coronary syndrome are strongly linked with adverse cardiovascular outcomes, results from a large study showed.

“Cystatin C has been shown to be a strong and independent predictor of cardiovascular events and overall mortality in elderly subjects, but its prognostic performance in patients with acute coronary syndrome is less well studied,” reported Dr. Stacy E. Melanson on behalf of coauthor Dr. Steven D. Wiviott and researchers from the Thrombolysis In Myocardial Infarction (TIMI) Group at Brigham and Women's Hospital, Boston.

In a poster presented at the annual meeting of the American Association for Clinical Chemistry, the researchers analyzed levels of cystatin C in blood samples from 3,754 patients that were collected within 10 days of presentation with ACS. The primary end points were death, MI, and heart failure. The researchers determined cardiovascular outcomes for each quintile of cystatin C. Cut points for cystatin C, in mg/L, were: less than 0.82 for quintile 1; 0.83–0.91 for quintile 2; 0.92–1.00 for quintile 3; 1.01–1.14 for quintile 4; and 1.15 or more for quintile 5.

Patients who had elevated cystatin C levels were more likely to have hypertension, diabetes, and a history of MI. They were also more likely to be older. Specifically, the median age of patients in quintile 5 was 68 years, while the median ages of patients in quintiles 1, 2, 3, and 4, were 52, 54, 57, and 61 years.

Between cystatin C quintiles 1 and 5, the risk of death rose from 0.7% to 4.8%; the risk of MI rose from 5.4% to 10.6%; the risk of heart failure rose from 1.0% to 8.3%; and the risk of a composite of death and heart failure rose from 1.7% to 11.6%.

After the researchers adjusted for clinical variables, they found that cystatin C levels in quintile 5 independently predicted recurrent events, compared with the levels in quintile 1. Specifically, the hazard ratios between quintile 5 and quintile 1 were 2.5 for death, 1.6 for MI, 4.2 for heart failure, and 3.1 for a composite of death and heart failure.

When other markers of hemodynamic stress were added to the model, including C-reactive protein and B-type natriuretic peptide, cystatin C remained a significant predictor of recurrent cardiovascular events.

Dr. Melanson is associate medical director of clinical chemistry at Brigham and Women's Hospital.

SAN DIEGO — Elevated baseline cystatin C levels in patients who present with acute coronary syndrome are strongly linked with adverse cardiovascular outcomes, results from a large study showed.

“Cystatin C has been shown to be a strong and independent predictor of cardiovascular events and overall mortality in elderly subjects, but its prognostic performance in patients with acute coronary syndrome is less well studied,” reported Dr. Stacy E. Melanson on behalf of coauthor Dr. Steven D. Wiviott and researchers from the Thrombolysis In Myocardial Infarction (TIMI) Group at Brigham and Women's Hospital, Boston.

In a poster presented at the annual meeting of the American Association for Clinical Chemistry, the researchers analyzed levels of cystatin C in blood samples from 3,754 patients that were collected within 10 days of presentation with ACS. The primary end points were death, MI, and heart failure. The researchers determined cardiovascular outcomes for each quintile of cystatin C. Cut points for cystatin C, in mg/L, were: less than 0.82 for quintile 1; 0.83–0.91 for quintile 2; 0.92–1.00 for quintile 3; 1.01–1.14 for quintile 4; and 1.15 or more for quintile 5.

Patients who had elevated cystatin C levels were more likely to have hypertension, diabetes, and a history of MI. They were also more likely to be older. Specifically, the median age of patients in quintile 5 was 68 years, while the median ages of patients in quintiles 1, 2, 3, and 4, were 52, 54, 57, and 61 years.

Between cystatin C quintiles 1 and 5, the risk of death rose from 0.7% to 4.8%; the risk of MI rose from 5.4% to 10.6%; the risk of heart failure rose from 1.0% to 8.3%; and the risk of a composite of death and heart failure rose from 1.7% to 11.6%.

After the researchers adjusted for clinical variables, they found that cystatin C levels in quintile 5 independently predicted recurrent events, compared with the levels in quintile 1. Specifically, the hazard ratios between quintile 5 and quintile 1 were 2.5 for death, 1.6 for MI, 4.2 for heart failure, and 3.1 for a composite of death and heart failure.

When other markers of hemodynamic stress were added to the model, including C-reactive protein and B-type natriuretic peptide, cystatin C remained a significant predictor of recurrent cardiovascular events.

Dr. Melanson is associate medical director of clinical chemistry at Brigham and Women's Hospital.

SAN DIEGO — Elevated baseline cystatin C levels in patients who present with acute coronary syndrome are strongly linked with adverse cardiovascular outcomes, results from a large study showed.

“Cystatin C has been shown to be a strong and independent predictor of cardiovascular events and overall mortality in elderly subjects, but its prognostic performance in patients with acute coronary syndrome is less well studied,” reported Dr. Stacy E. Melanson on behalf of coauthor Dr. Steven D. Wiviott and researchers from the Thrombolysis In Myocardial Infarction (TIMI) Group at Brigham and Women's Hospital, Boston.

In a poster presented at the annual meeting of the American Association for Clinical Chemistry, the researchers analyzed levels of cystatin C in blood samples from 3,754 patients that were collected within 10 days of presentation with ACS. The primary end points were death, MI, and heart failure. The researchers determined cardiovascular outcomes for each quintile of cystatin C. Cut points for cystatin C, in mg/L, were: less than 0.82 for quintile 1; 0.83–0.91 for quintile 2; 0.92–1.00 for quintile 3; 1.01–1.14 for quintile 4; and 1.15 or more for quintile 5.

Patients who had elevated cystatin C levels were more likely to have hypertension, diabetes, and a history of MI. They were also more likely to be older. Specifically, the median age of patients in quintile 5 was 68 years, while the median ages of patients in quintiles 1, 2, 3, and 4, were 52, 54, 57, and 61 years.

Between cystatin C quintiles 1 and 5, the risk of death rose from 0.7% to 4.8%; the risk of MI rose from 5.4% to 10.6%; the risk of heart failure rose from 1.0% to 8.3%; and the risk of a composite of death and heart failure rose from 1.7% to 11.6%.

After the researchers adjusted for clinical variables, they found that cystatin C levels in quintile 5 independently predicted recurrent events, compared with the levels in quintile 1. Specifically, the hazard ratios between quintile 5 and quintile 1 were 2.5 for death, 1.6 for MI, 4.2 for heart failure, and 3.1 for a composite of death and heart failure.

When other markers of hemodynamic stress were added to the model, including C-reactive protein and B-type natriuretic peptide, cystatin C remained a significant predictor of recurrent cardiovascular events.

Dr. Melanson is associate medical director of clinical chemistry at Brigham and Women's Hospital.

SAN DIEGO — Nearly 80% of patients with type 2 diabetes who had silent myocardial ischemia revealed by stress myocardial perfusion imaging had a reversal of exercise-induced myocardial perfusion abnormalities 3 years later.

The unexpected finding suggests that a substantial proportion of patients with type 2 diabetes and silent myocardial ischemia have the potential for improvement of stress myocardial perfusion imaging abnormalities with medical management, Dr. Frans J.Th. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven.

The study was a follow-up to the Detection of Ischemia in Asymptomatic Diabetics (DIAD)-1 study, which documented a 22% prevalence of silent myocardial ischemia during adenosine stress testing with sestamibi SPECT myocardial perfusion imaging. In the current study, known as DIAD-2, Dr. Wackers and associates performed repeat stress myocardial perfusion imaging in DIAD-1 study participants after 3 years to evaluate for progression of silent myocardial ischemia. Initial myocardial perfusion imaging was performed in 2003, and repeat myocardial perfusion imaging was performed in 2006.

Of the initial 522 patients, 356 underwent repeat myocardial perfusion imaging, 70 of whom had previously documented silent myocardial ischemia in DIAD-1. The mean age of the 356 patients was 61 years, and 44% were women.

Repeat myocardial perfusion imaging could not be performed in 166 patients because of an intervening cardiovascular event or death, in 29 patients; severe comorbidity, in 10; refusal by 108 patients; loss to follow-up in 17; and uninterpretable study in 2. The initial and repeat DIAD studies were read by the same blinded panel of experts, said Dr. Wackers.

The overall prevalence of silent myocardial ischemia in DIAD-2 was 12%, which is 10% lower than the overall prevalence in DIAD-1.

In addition, of the 286 patients who had normal DIAD-1 studies, 90% remained normal in DIAD-2, whereas 10% developed new myocardial ischemia.

Of the 71 patients who had abnormal DIAD-1 studies, 56 (79%) showed resolution of inducible ischemia, and 15 (21%) remained abnormal.

When the researchers compared patients who had resolution of ischemia with those who developed new inducible ischemia, they observed no significant baseline differences in age, gender, BMI, duration of diabetes, family history, blood pressure, hemoglobin A_1c, LDL or HDL cholesterol, or C-reactive protein.

In another part of the analysis, the researchers observed a significant increase among all patients in the use of aspirin, statins, and ACE inhibitors between 2003 and 2006. Specifically, the use of aspirin rose from 42% to 69%, the use of statins rose from 38% to 59%, and the use of ACE inhibitors rose from 34% to 42%.

DIAD-2 patients who had resolution of ischemia were exposed to cardiac medications for a significantly longer period of time, compared with those who developed new ischemia (59 months vs. 45 months).

Dr. Wackers has received research honoraria from Bristol-Myers Squibb, Astellas, and General Electric, and is a scientific adviser for General Electric and King Pharmaceuticals.

In 2001 (left), a 59-year-old asymptomatic man had a small defect in the anterior wall (arrows) on sestamibi SPECT imaging. By 2004 (right), the defect had normalized. During the interval, the patient was treated with aspirin, a statin, and an ACE inhibitor. Courtesy Dr. Frans J.Th. Wackers

SAN DIEGO — Nearly 80% of patients with type 2 diabetes who had silent myocardial ischemia revealed by stress myocardial perfusion imaging had a reversal of exercise-induced myocardial perfusion abnormalities 3 years later.

The unexpected finding suggests that a substantial proportion of patients with type 2 diabetes and silent myocardial ischemia have the potential for improvement of stress myocardial perfusion imaging abnormalities with medical management, Dr. Frans J.Th. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven.

The study was a follow-up to the Detection of Ischemia in Asymptomatic Diabetics (DIAD)-1 study, which documented a 22% prevalence of silent myocardial ischemia during adenosine stress testing with sestamibi SPECT myocardial perfusion imaging. In the current study, known as DIAD-2, Dr. Wackers and associates performed repeat stress myocardial perfusion imaging in DIAD-1 study participants after 3 years to evaluate for progression of silent myocardial ischemia. Initial myocardial perfusion imaging was performed in 2003, and repeat myocardial perfusion imaging was performed in 2006.

Of the initial 522 patients, 356 underwent repeat myocardial perfusion imaging, 70 of whom had previously documented silent myocardial ischemia in DIAD-1. The mean age of the 356 patients was 61 years, and 44% were women.

Repeat myocardial perfusion imaging could not be performed in 166 patients because of an intervening cardiovascular event or death, in 29 patients; severe comorbidity, in 10; refusal by 108 patients; loss to follow-up in 17; and uninterpretable study in 2. The initial and repeat DIAD studies were read by the same blinded panel of experts, said Dr. Wackers.

The overall prevalence of silent myocardial ischemia in DIAD-2 was 12%, which is 10% lower than the overall prevalence in DIAD-1.

In addition, of the 286 patients who had normal DIAD-1 studies, 90% remained normal in DIAD-2, whereas 10% developed new myocardial ischemia.

Of the 71 patients who had abnormal DIAD-1 studies, 56 (79%) showed resolution of inducible ischemia, and 15 (21%) remained abnormal.

When the researchers compared patients who had resolution of ischemia with those who developed new inducible ischemia, they observed no significant baseline differences in age, gender, BMI, duration of diabetes, family history, blood pressure, hemoglobin A_1c, LDL or HDL cholesterol, or C-reactive protein.

In another part of the analysis, the researchers observed a significant increase among all patients in the use of aspirin, statins, and ACE inhibitors between 2003 and 2006. Specifically, the use of aspirin rose from 42% to 69%, the use of statins rose from 38% to 59%, and the use of ACE inhibitors rose from 34% to 42%.

DIAD-2 patients who had resolution of ischemia were exposed to cardiac medications for a significantly longer period of time, compared with those who developed new ischemia (59 months vs. 45 months).

Dr. Wackers has received research honoraria from Bristol-Myers Squibb, Astellas, and General Electric, and is a scientific adviser for General Electric and King Pharmaceuticals.

In 2001 (left), a 59-year-old asymptomatic man had a small defect in the anterior wall (arrows) on sestamibi SPECT imaging. By 2004 (right), the defect had normalized. During the interval, the patient was treated with aspirin, a statin, and an ACE inhibitor. Courtesy Dr. Frans J.Th. Wackers

SAN DIEGO — Nearly 80% of patients with type 2 diabetes who had silent myocardial ischemia revealed by stress myocardial perfusion imaging had a reversal of exercise-induced myocardial perfusion abnormalities 3 years later.

The unexpected finding suggests that a substantial proportion of patients with type 2 diabetes and silent myocardial ischemia have the potential for improvement of stress myocardial perfusion imaging abnormalities with medical management, Dr. Frans J.Th. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven.

The study was a follow-up to the Detection of Ischemia in Asymptomatic Diabetics (DIAD)-1 study, which documented a 22% prevalence of silent myocardial ischemia during adenosine stress testing with sestamibi SPECT myocardial perfusion imaging. In the current study, known as DIAD-2, Dr. Wackers and associates performed repeat stress myocardial perfusion imaging in DIAD-1 study participants after 3 years to evaluate for progression of silent myocardial ischemia. Initial myocardial perfusion imaging was performed in 2003, and repeat myocardial perfusion imaging was performed in 2006.

Of the initial 522 patients, 356 underwent repeat myocardial perfusion imaging, 70 of whom had previously documented silent myocardial ischemia in DIAD-1. The mean age of the 356 patients was 61 years, and 44% were women.

Repeat myocardial perfusion imaging could not be performed in 166 patients because of an intervening cardiovascular event or death, in 29 patients; severe comorbidity, in 10; refusal by 108 patients; loss to follow-up in 17; and uninterpretable study in 2. The initial and repeat DIAD studies were read by the same blinded panel of experts, said Dr. Wackers.

The overall prevalence of silent myocardial ischemia in DIAD-2 was 12%, which is 10% lower than the overall prevalence in DIAD-1.

In addition, of the 286 patients who had normal DIAD-1 studies, 90% remained normal in DIAD-2, whereas 10% developed new myocardial ischemia.

Of the 71 patients who had abnormal DIAD-1 studies, 56 (79%) showed resolution of inducible ischemia, and 15 (21%) remained abnormal.

When the researchers compared patients who had resolution of ischemia with those who developed new inducible ischemia, they observed no significant baseline differences in age, gender, BMI, duration of diabetes, family history, blood pressure, hemoglobin A_1c, LDL or HDL cholesterol, or C-reactive protein.

In another part of the analysis, the researchers observed a significant increase among all patients in the use of aspirin, statins, and ACE inhibitors between 2003 and 2006. Specifically, the use of aspirin rose from 42% to 69%, the use of statins rose from 38% to 59%, and the use of ACE inhibitors rose from 34% to 42%.

DIAD-2 patients who had resolution of ischemia were exposed to cardiac medications for a significantly longer period of time, compared with those who developed new ischemia (59 months vs. 45 months).

Dr. Wackers has received research honoraria from Bristol-Myers Squibb, Astellas, and General Electric, and is a scientific adviser for General Electric and King Pharmaceuticals.

In 2001 (left), a 59-year-old asymptomatic man had a small defect in the anterior wall (arrows) on sestamibi SPECT imaging. By 2004 (right), the defect had normalized. During the interval, the patient was treated with aspirin, a statin, and an ACE inhibitor. Courtesy Dr. Frans J.Th. Wackers