Doug Brunk

LONG BEACH, CALIF. — So little is known about effective interventions for delirium that efforts to help elderly patients with the condition leave many providers, well, delirious.

The goal of treating delirium is not just to control agitation or hallucinations, but to reverse the delirium and thereby mitigate associated morbidity and mortality risks, Dr. Jay S. Luxenberg said at the annual meeting of the California Association of Long Term Care Medicine.

“The modern concepts of delirium emphasize that delirium can be a persistent issue for a given patient, persisting months and even years,” said Dr. Luxenberg, an internist and geriatrician who is medical director of the Jewish Home in San Francisco. “It may actually reflect a current decline in cognitive functions.”

Another emerging concept about delirium is that it markedly and independently affects patient outcomes such as length of stay, functional decline, and loss of independent living.

“What we need to be thinking of is baseline vulnerability to delirium: what pushes people over the edge,” said Dr. Luxenberg, also of the University of California, San Francisco. “Ultimately, the precipitating factor is just that: the precipitating factor. Of course if they have a urinary tract infection, we're going to treat it. If they have bronchitis, we're going to treat it.”

The exact incidence of delirium among the elderly is not known, but Dr. Luxenberg said that it is surely higher than the national average of 2% reported by Medicare for the period of July 1, 2006, through Dec. 31, 2006. “It isn't being identified as clearly as it should be,” he asserted.

He recommended being specific about delirium symptoms of risk factors during admission assessments (see sidebar). “On your problem list, identify things explicitly because the people who do the [Minimum Data Set] look for written data from the doctor,” he said. “Anytime a patient is on a lot of medications we should list polypharmacy as one of their problems, even if they need every one of those drugs. Similarly, if the person has delirium, we should write it, not imply it.”

In a study of 2,158 patients with an average age of 84, admitted to a skilled nursing facility from a hospital, 16% had delirium as defined by the Confusion Assessment Method (J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M441–5). In addition, about 13% of patients had two or more symptoms of delirium and about 40% had one symptom of delirium.

Unresolved, delirium can have significant impact on mortality. One study of 393 postacute care patients (with an average age of 84 years) found that functional recovery differed significantly by delirium resolution status (J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:204–8). Specifically, patients who resolved their delirium within 2 weeks without recurrence regained 100% of their prehospital functional level, while those who did not retained less than 50% of their prehospital functional level.

In a more recent study, researchers used the Memorial Delirium Assessment Scale to assess psychomotor activity in 457 newly admitted delirious postacute care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:174–9). The patients were classified as hyperactive, hypoactive, mixed, or normal.

Hypoactive patients were 1.6 times more likely to die during 1 year of follow-up compared with patients who had normal psychomotor activity, a difference that was statistically significant. Patients with the hyperactive and mixed subtypes had an increased risk of dying during 1 year of follow-up compared with patients who had normal psychomotor activity, but the elevations were not statistically significant.

The current data on treatment options for delirium “makes you yearn for more data and better studies,” he said.

A Cochrane review that Dr. Luxenberg helped assemble on the use of antipsychotics for delirium found only three studies suitable for inclusion (Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI:10.1002/14651858.CD005594.pub2.) Meta-analysis was only possible in comparing risperidone vs. haloperidol and olanzapine vs. haloperidol. The results showed no significant difference in overall effect on delirium with olanzapine or risperidone compared with haloperidol.

Data on the use of cholinesterase inhibitors and benzodiazepines for delirium are even more sparse.

One controlled study of haloperidol as a delirium prophylaxis in hip surgery patients found that while there was no effect on the postoperative incidence of acute confusion, patients in the haloperidol arm had earlier improvement of delirium scores and had less severe delirium compared with patients who did not take the drug. The average age of study participants was 79 years (J. Am. Geriatr. Soc. 2005;53:1658–66).

“Somebody should do this study again,” Dr. Luxenberg said. “This is potentially interesting.”

Until more is known about medical interventions for delirium, other approaches are worthy of consideration, including the use of bright or blue light for circadian rhythm disturbances, complementary and alternative medicine, and minimizing the need for restraints by using clysis and by using intramuscular injections instead of intravenous injections, he said.

“Deemphasize the idea that you have to search for an underlying cause of delirium, such as [ordering] a CT scan to look for intra-abdominal abscesses,” he said. “Looking for the common things—the drugs, the [urinary tract infections]—suffices. If the patients aren't coughing, they're not short of breath, and their oxygen saturation is fine, they probably don't need a chest CT to look for occult pneumonia as the cause of their delirium.”

'Deemphasize the idea that you have to search for an underlying cause of delirium.' Look at drugs, UTIs instead. DR. LUXENBURG

LONG BEACH, CALIF. — So little is known about effective interventions for delirium that efforts to help elderly patients with the condition leave many providers, well, delirious.

The goal of treating delirium is not just to control agitation or hallucinations, but to reverse the delirium and thereby mitigate associated morbidity and mortality risks, Dr. Jay S. Luxenberg said at the annual meeting of the California Association of Long Term Care Medicine.

“The modern concepts of delirium emphasize that delirium can be a persistent issue for a given patient, persisting months and even years,” said Dr. Luxenberg, an internist and geriatrician who is medical director of the Jewish Home in San Francisco. “It may actually reflect a current decline in cognitive functions.”

Another emerging concept about delirium is that it markedly and independently affects patient outcomes such as length of stay, functional decline, and loss of independent living.

“What we need to be thinking of is baseline vulnerability to delirium: what pushes people over the edge,” said Dr. Luxenberg, also of the University of California, San Francisco. “Ultimately, the precipitating factor is just that: the precipitating factor. Of course if they have a urinary tract infection, we're going to treat it. If they have bronchitis, we're going to treat it.”

The exact incidence of delirium among the elderly is not known, but Dr. Luxenberg said that it is surely higher than the national average of 2% reported by Medicare for the period of July 1, 2006, through Dec. 31, 2006. “It isn't being identified as clearly as it should be,” he asserted.

He recommended being specific about delirium symptoms of risk factors during admission assessments (see sidebar). “On your problem list, identify things explicitly because the people who do the [Minimum Data Set] look for written data from the doctor,” he said. “Anytime a patient is on a lot of medications we should list polypharmacy as one of their problems, even if they need every one of those drugs. Similarly, if the person has delirium, we should write it, not imply it.”

In a study of 2,158 patients with an average age of 84, admitted to a skilled nursing facility from a hospital, 16% had delirium as defined by the Confusion Assessment Method (J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M441–5). In addition, about 13% of patients had two or more symptoms of delirium and about 40% had one symptom of delirium.

Unresolved, delirium can have significant impact on mortality. One study of 393 postacute care patients (with an average age of 84 years) found that functional recovery differed significantly by delirium resolution status (J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:204–8). Specifically, patients who resolved their delirium within 2 weeks without recurrence regained 100% of their prehospital functional level, while those who did not retained less than 50% of their prehospital functional level.

In a more recent study, researchers used the Memorial Delirium Assessment Scale to assess psychomotor activity in 457 newly admitted delirious postacute care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:174–9). The patients were classified as hyperactive, hypoactive, mixed, or normal.

Hypoactive patients were 1.6 times more likely to die during 1 year of follow-up compared with patients who had normal psychomotor activity, a difference that was statistically significant. Patients with the hyperactive and mixed subtypes had an increased risk of dying during 1 year of follow-up compared with patients who had normal psychomotor activity, but the elevations were not statistically significant.

The current data on treatment options for delirium “makes you yearn for more data and better studies,” he said.

A Cochrane review that Dr. Luxenberg helped assemble on the use of antipsychotics for delirium found only three studies suitable for inclusion (Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI:10.1002/14651858.CD005594.pub2.) Meta-analysis was only possible in comparing risperidone vs. haloperidol and olanzapine vs. haloperidol. The results showed no significant difference in overall effect on delirium with olanzapine or risperidone compared with haloperidol.

Data on the use of cholinesterase inhibitors and benzodiazepines for delirium are even more sparse.

One controlled study of haloperidol as a delirium prophylaxis in hip surgery patients found that while there was no effect on the postoperative incidence of acute confusion, patients in the haloperidol arm had earlier improvement of delirium scores and had less severe delirium compared with patients who did not take the drug. The average age of study participants was 79 years (J. Am. Geriatr. Soc. 2005;53:1658–66).

“Somebody should do this study again,” Dr. Luxenberg said. “This is potentially interesting.”

Until more is known about medical interventions for delirium, other approaches are worthy of consideration, including the use of bright or blue light for circadian rhythm disturbances, complementary and alternative medicine, and minimizing the need for restraints by using clysis and by using intramuscular injections instead of intravenous injections, he said.

“Deemphasize the idea that you have to search for an underlying cause of delirium, such as [ordering] a CT scan to look for intra-abdominal abscesses,” he said. “Looking for the common things—the drugs, the [urinary tract infections]—suffices. If the patients aren't coughing, they're not short of breath, and their oxygen saturation is fine, they probably don't need a chest CT to look for occult pneumonia as the cause of their delirium.”

'Deemphasize the idea that you have to search for an underlying cause of delirium.' Look at drugs, UTIs instead. DR. LUXENBURG

LONG BEACH, CALIF. — So little is known about effective interventions for delirium that efforts to help elderly patients with the condition leave many providers, well, delirious.

The goal of treating delirium is not just to control agitation or hallucinations, but to reverse the delirium and thereby mitigate associated morbidity and mortality risks, Dr. Jay S. Luxenberg said at the annual meeting of the California Association of Long Term Care Medicine.

“The modern concepts of delirium emphasize that delirium can be a persistent issue for a given patient, persisting months and even years,” said Dr. Luxenberg, an internist and geriatrician who is medical director of the Jewish Home in San Francisco. “It may actually reflect a current decline in cognitive functions.”

Another emerging concept about delirium is that it markedly and independently affects patient outcomes such as length of stay, functional decline, and loss of independent living.

“What we need to be thinking of is baseline vulnerability to delirium: what pushes people over the edge,” said Dr. Luxenberg, also of the University of California, San Francisco. “Ultimately, the precipitating factor is just that: the precipitating factor. Of course if they have a urinary tract infection, we're going to treat it. If they have bronchitis, we're going to treat it.”

The exact incidence of delirium among the elderly is not known, but Dr. Luxenberg said that it is surely higher than the national average of 2% reported by Medicare for the period of July 1, 2006, through Dec. 31, 2006. “It isn't being identified as clearly as it should be,” he asserted.

He recommended being specific about delirium symptoms of risk factors during admission assessments (see sidebar). “On your problem list, identify things explicitly because the people who do the [Minimum Data Set] look for written data from the doctor,” he said. “Anytime a patient is on a lot of medications we should list polypharmacy as one of their problems, even if they need every one of those drugs. Similarly, if the person has delirium, we should write it, not imply it.”

In a study of 2,158 patients with an average age of 84, admitted to a skilled nursing facility from a hospital, 16% had delirium as defined by the Confusion Assessment Method (J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M441–5). In addition, about 13% of patients had two or more symptoms of delirium and about 40% had one symptom of delirium.

Unresolved, delirium can have significant impact on mortality. One study of 393 postacute care patients (with an average age of 84 years) found that functional recovery differed significantly by delirium resolution status (J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:204–8). Specifically, patients who resolved their delirium within 2 weeks without recurrence regained 100% of their prehospital functional level, while those who did not retained less than 50% of their prehospital functional level.

In a more recent study, researchers used the Memorial Delirium Assessment Scale to assess psychomotor activity in 457 newly admitted delirious postacute care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:174–9). The patients were classified as hyperactive, hypoactive, mixed, or normal.

Hypoactive patients were 1.6 times more likely to die during 1 year of follow-up compared with patients who had normal psychomotor activity, a difference that was statistically significant. Patients with the hyperactive and mixed subtypes had an increased risk of dying during 1 year of follow-up compared with patients who had normal psychomotor activity, but the elevations were not statistically significant.

The current data on treatment options for delirium “makes you yearn for more data and better studies,” he said.

A Cochrane review that Dr. Luxenberg helped assemble on the use of antipsychotics for delirium found only three studies suitable for inclusion (Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI:10.1002/14651858.CD005594.pub2.) Meta-analysis was only possible in comparing risperidone vs. haloperidol and olanzapine vs. haloperidol. The results showed no significant difference in overall effect on delirium with olanzapine or risperidone compared with haloperidol.

Data on the use of cholinesterase inhibitors and benzodiazepines for delirium are even more sparse.

One controlled study of haloperidol as a delirium prophylaxis in hip surgery patients found that while there was no effect on the postoperative incidence of acute confusion, patients in the haloperidol arm had earlier improvement of delirium scores and had less severe delirium compared with patients who did not take the drug. The average age of study participants was 79 years (J. Am. Geriatr. Soc. 2005;53:1658–66).

“Somebody should do this study again,” Dr. Luxenberg said. “This is potentially interesting.”

Until more is known about medical interventions for delirium, other approaches are worthy of consideration, including the use of bright or blue light for circadian rhythm disturbances, complementary and alternative medicine, and minimizing the need for restraints by using clysis and by using intramuscular injections instead of intravenous injections, he said.

“Deemphasize the idea that you have to search for an underlying cause of delirium, such as [ordering] a CT scan to look for intra-abdominal abscesses,” he said. “Looking for the common things—the drugs, the [urinary tract infections]—suffices. If the patients aren't coughing, they're not short of breath, and their oxygen saturation is fine, they probably don't need a chest CT to look for occult pneumonia as the cause of their delirium.”

'Deemphasize the idea that you have to search for an underlying cause of delirium.' Look at drugs, UTIs instead. DR. LUXENBURG

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of 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.

Dr. Bruckner 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. She 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,” said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. “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 than 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 their daughter's condition. She has continued to use 5% minoxidil for 6 months with some improvement.

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

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. In many cases, however, recurrence of the lesion is common and all of the treatments have potential adverse effects.

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 decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes. The decision “was controversial, but it was made with the family. It's something that they're comfortable with at this point,” she said.

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 girl 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 after 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, and 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 the ages of 1 and 6 years, 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.

Scaly plaque is shown on the right lower extremity of the boy with linear porokeratosis. After a course of imiquimod, he opted outof therapy, but his condition is still closely monitored.

Papules, plaques are seen on knuckles of the girl with erythropoietic protoporphyria. Photos courtesy Dr. Anna L. Bruckner

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of 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.

Dr. Bruckner 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. She 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,” said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. “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 than 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 their daughter's condition. She has continued to use 5% minoxidil for 6 months with some improvement.

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

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. In many cases, however, recurrence of the lesion is common and all of the treatments have potential adverse effects.

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 decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes. The decision “was controversial, but it was made with the family. It's something that they're comfortable with at this point,” she said.

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 girl 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 after 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, and 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 the ages of 1 and 6 years, 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.

Scaly plaque is shown on the right lower extremity of the boy with linear porokeratosis. After a course of imiquimod, he opted outof therapy, but his condition is still closely monitored.

Papules, plaques are seen on knuckles of the girl with erythropoietic protoporphyria. Photos courtesy Dr. Anna L. Bruckner

CORONADO, CALIF. — Making the correct diagnosis and choosing the best therapy are standard goals of 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.

Dr. Bruckner 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. She 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,” said Dr. Bruckner, also assistant professor of dermatology and pediatrics at Stanford (Calif.) University. “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 than 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 their daughter's condition. She has continued to use 5% minoxidil for 6 months with some improvement.

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

Treatments include the use of topical retinoids, imiquimod, and fluorouracil. Destructive therapies include cryotherapy, electrodesiccation, laser ablation, and excision. In many cases, however, recurrence of the lesion is common and all of the treatments have potential adverse effects.

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 decided that the best therapy was no therapy, but they continue to monitor the lesion for worrisome changes. The decision “was controversial, but it was made with the family. It's something that they're comfortable with at this point,” she said.

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 girl 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 after 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, and 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 the ages of 1 and 6 years, 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.

Scaly plaque is shown on the right lower extremity of the boy with linear porokeratosis. After a course of imiquimod, he opted outof therapy, but his condition is still closely monitored.

Papules, plaques are seen on knuckles of the girl with erythropoietic protoporphyria. Photos courtesy Dr. Anna L. Bruckner

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 when they were retested 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.T. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“It is conceivable that this [result] is due to aggressive treatment of cardiovascular risk factors,” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven, Conn. “These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.”

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 single-photon emission computed tomography myocardial perfusion imaging.

In the current study, known as DIAD-2, Dr. Wackers and his 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. The initial and repeat DIAD studies were read by the same blinded panel of experts and included computer quantification of defect size, said Dr. Wackers, who is also a professor of diagnostic radiology and medicine at Yale.

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.

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

At baseline, this 59-year-old asymptomatic man had a small reversible defect in the anterior wall (arrows). Three years later, the images have normalized. Courtesy Dr. Frans J.T. 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 when they were retested 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.T. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“It is conceivable that this [result] is due to aggressive treatment of cardiovascular risk factors,” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven, Conn. “These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.”

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 single-photon emission computed tomography myocardial perfusion imaging.

In the current study, known as DIAD-2, Dr. Wackers and his 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. The initial and repeat DIAD studies were read by the same blinded panel of experts and included computer quantification of defect size, said Dr. Wackers, who is also a professor of diagnostic radiology and medicine at Yale.

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.

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

At baseline, this 59-year-old asymptomatic man had a small reversible defect in the anterior wall (arrows). Three years later, the images have normalized. Courtesy Dr. Frans J.T. 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 when they were retested 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.T. Wackers said at the annual meeting of the American Society of Nuclear Cardiology.

“It is conceivable that this [result] is due to aggressive treatment of cardiovascular risk factors,” said Dr. Wackers, director of the cardiovascular nuclear imaging and stress laboratories at Yale University, New Haven, Conn. “These results are consistent with the INSPIRE study and the COURAGE trial, which found that aggressive and optimal treatment can reverse myocardial perfusion abnormalities.”

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 single-photon emission computed tomography myocardial perfusion imaging.

In the current study, known as DIAD-2, Dr. Wackers and his 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. The initial and repeat DIAD studies were read by the same blinded panel of experts and included computer quantification of defect size, said Dr. Wackers, who is also a professor of diagnostic radiology and medicine at Yale.

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.

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

At baseline, this 59-year-old asymptomatic man had a small reversible defect in the anterior wall (arrows). Three years later, the images have normalized. Courtesy Dr. Frans J.T. Wackers

SAN DIEGO — Obese patients who underwent laparoscopic gastric bypass surgery had significantly lower rates of bleeding and venous thromboembolic events than those who had open gastric bypass surgery, results from a review of 1,128 patients showed.

“Probably more important than any type of mechanical compression or chemical prophylaxis [in preventing bleeding and venous thromboembolic events] is our emphasis on getting patients out of bed on postoperative day zero,” Dr. Christopher J. Northup said at the annual meeting of the American Society for Bariatric Surgery, where he presented the results of his retrospective, nonrandomized study. “That's probably where a lot of the difference has come from.”

He and his associates at the University of Virginia, Charlottesville, used medical records to identify the rates of bleeding and venous thromboembolic events in patients who underwent laparoscopic and open gastric bypass surgery between 1995 and 2005.

The average age of the 363 patients in the open gastric bypass group was 40, and their average body mass index (BMI) was 55 kg/m

Both groups of patients followed the same weight-based enoxaparin prophylaxis protocol. Patients who weighed less than 300 pounds received 30 mg enoxaparin every 12 hours. Those who weighed 300–400 pounds received 30 mg in the morning and 60 mg in the afternoon, and those who weighed more than 400 pounds received 60 mg every 12 hours.

The first dose of enoxaparin, given while the patient was still in the preoperative holding area, was continued through each patient's hospital stay. Lower extremity compression devices were used intraoperatively and postoperatively in all patients.

The rate of hemorrhage was 4.1% in the open-surgery group (15 patients), compared with 1.4% in the laparoscopic group (11 patients). Deep venous thrombosis occurred in seven patients in the open group (1.9%), compared with two patients in the laparoscopic group (0.3%). Pulmonary embolism (PE) occurred in six patients in the open group (1.7%), compared with two patients in the laparoscopic group (0.3%). All differences were statistically significant.

There was one fatal PE in the laparoscopic group. “All of the thromboembolic and bleeding events occurred during primary procedures,” said Dr. Northup of the surgery department at the University of Virginia. “None of these events happened during reoperation for small bowel obstruction or for other reasons.

“In dealing with the small complication rates of PE and DVT, this still remains a relatively small study population,” he noted. Another limitation was that no routine lower-extremity duplex ultrasound examinations were done, so “we likely missed several deep venous thromboses,” he said.

One meeting attendee asked Dr. Northup to clarify how he and his associates arrived at the enoxaparin dosing used in the study. “I don't think there is any good literature to say what protocol is best,” he replied. “Ours was based upon experience. This is what we use.”

Getting patients out of bed on postoperative day zero is important for prevention of bleeding. DR. NORTHUP

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Obese patients who underwent laparoscopic gastric bypass surgery had significantly lower rates of bleeding and venous thromboembolic events than those who had open gastric bypass surgery, results from a review of 1,128 patients showed.

“Probably more important than any type of mechanical compression or chemical prophylaxis [in preventing bleeding and venous thromboembolic events] is our emphasis on getting patients out of bed on postoperative day zero,” Dr. Christopher J. Northup said at the annual meeting of the American Society for Bariatric Surgery, where he presented the results of his retrospective, nonrandomized study. “That's probably where a lot of the difference has come from.”

He and his associates at the University of Virginia, Charlottesville, used medical records to identify the rates of bleeding and venous thromboembolic events in patients who underwent laparoscopic and open gastric bypass surgery between 1995 and 2005.

The average age of the 363 patients in the open gastric bypass group was 40, and their average body mass index (BMI) was 55 kg/m

Both groups of patients followed the same weight-based enoxaparin prophylaxis protocol. Patients who weighed less than 300 pounds received 30 mg enoxaparin every 12 hours. Those who weighed 300–400 pounds received 30 mg in the morning and 60 mg in the afternoon, and those who weighed more than 400 pounds received 60 mg every 12 hours.

The first dose of enoxaparin, given while the patient was still in the preoperative holding area, was continued through each patient's hospital stay. Lower extremity compression devices were used intraoperatively and postoperatively in all patients.

The rate of hemorrhage was 4.1% in the open-surgery group (15 patients), compared with 1.4% in the laparoscopic group (11 patients). Deep venous thrombosis occurred in seven patients in the open group (1.9%), compared with two patients in the laparoscopic group (0.3%). Pulmonary embolism (PE) occurred in six patients in the open group (1.7%), compared with two patients in the laparoscopic group (0.3%). All differences were statistically significant.

There was one fatal PE in the laparoscopic group. “All of the thromboembolic and bleeding events occurred during primary procedures,” said Dr. Northup of the surgery department at the University of Virginia. “None of these events happened during reoperation for small bowel obstruction or for other reasons.

“In dealing with the small complication rates of PE and DVT, this still remains a relatively small study population,” he noted. Another limitation was that no routine lower-extremity duplex ultrasound examinations were done, so “we likely missed several deep venous thromboses,” he said.

One meeting attendee asked Dr. Northup to clarify how he and his associates arrived at the enoxaparin dosing used in the study. “I don't think there is any good literature to say what protocol is best,” he replied. “Ours was based upon experience. This is what we use.”

Getting patients out of bed on postoperative day zero is important for prevention of bleeding. DR. NORTHUP

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — Obese patients who underwent laparoscopic gastric bypass surgery had significantly lower rates of bleeding and venous thromboembolic events than those who had open gastric bypass surgery, results from a review of 1,128 patients showed.

“Probably more important than any type of mechanical compression or chemical prophylaxis [in preventing bleeding and venous thromboembolic events] is our emphasis on getting patients out of bed on postoperative day zero,” Dr. Christopher J. Northup said at the annual meeting of the American Society for Bariatric Surgery, where he presented the results of his retrospective, nonrandomized study. “That's probably where a lot of the difference has come from.”

He and his associates at the University of Virginia, Charlottesville, used medical records to identify the rates of bleeding and venous thromboembolic events in patients who underwent laparoscopic and open gastric bypass surgery between 1995 and 2005.

The average age of the 363 patients in the open gastric bypass group was 40, and their average body mass index (BMI) was 55 kg/m

Both groups of patients followed the same weight-based enoxaparin prophylaxis protocol. Patients who weighed less than 300 pounds received 30 mg enoxaparin every 12 hours. Those who weighed 300–400 pounds received 30 mg in the morning and 60 mg in the afternoon, and those who weighed more than 400 pounds received 60 mg every 12 hours.

The first dose of enoxaparin, given while the patient was still in the preoperative holding area, was continued through each patient's hospital stay. Lower extremity compression devices were used intraoperatively and postoperatively in all patients.

The rate of hemorrhage was 4.1% in the open-surgery group (15 patients), compared with 1.4% in the laparoscopic group (11 patients). Deep venous thrombosis occurred in seven patients in the open group (1.9%), compared with two patients in the laparoscopic group (0.3%). Pulmonary embolism (PE) occurred in six patients in the open group (1.7%), compared with two patients in the laparoscopic group (0.3%). All differences were statistically significant.

There was one fatal PE in the laparoscopic group. “All of the thromboembolic and bleeding events occurred during primary procedures,” said Dr. Northup of the surgery department at the University of Virginia. “None of these events happened during reoperation for small bowel obstruction or for other reasons.

“In dealing with the small complication rates of PE and DVT, this still remains a relatively small study population,” he noted. Another limitation was that no routine lower-extremity duplex ultrasound examinations were done, so “we likely missed several deep venous thromboses,” he said.

One meeting attendee asked Dr. Northup to clarify how he and his associates arrived at the enoxaparin dosing used in the study. “I don't think there is any good literature to say what protocol is best,” he replied. “Ours was based upon experience. This is what we use.”

Getting patients out of bed on postoperative day zero is important for prevention of bleeding. DR. NORTHUP

ELSEVIER GLOBAL MEDICAL NEWS

Emerging endoluminal techniques and devices intended for weight loss therapy may reduce the risk of morbidity and mortality associated with current bariatric surgery approaches, according to the research findings of Dr. Philip Schauer and his associates.

The use of endoluminal approaches to avoid any type of abdominal incision and, more importantly, any intra-abdominal dissection “may go a long way to further reduce the morbidity of these operations, making them cheaper and safer,” Dr. Schauer said in an interview. “Potentially, they may expand the access for patients. Only 1% of patients with severe obesity are actually getting access to surgery, which is the only known therapy to be effective for a large percentage of patients.”

Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the bariatric and metabolic institute of the Cleveland Clinic, and his associates categorized the current endoluminal methods for weight loss therapy as presurgical endoluminal therapy, postsurgical endoluminal revision procedures, and primary procedures (Surg. Endosc. 2007;21:347-56).

In the presurgical endoluminal therapy arena, Dr. Michel Gagner and his associates pioneered a two-stage operation consisting of a sleeve gastrectomy followed by a Roux-en-Y gastric bypass (RYGB) or a duodenal switch (Obes. Surg. 2003;13:861-4).

“The rationale is that the first-stage operation, sleeve gastrectomy, is comparatively simple (requiring no anastomosis), needs less operative time (1–2 hours), and results in a predictable 40- to 50-kg weight loss,” Dr. Schauer and his associates wrote in their review. “Such weight loss reduces the operative risk for the second-stage procedure, which presumably results in more weight loss and greater durability.”

Dr. Gagner, professor of surgery and chief of bariatric surgery at Cornell University, New York, and his associates were also the first to publish results of an approach using the placement of endoluminal duodenojejunal tube or plastic sleeve to the first part of the duodenum proximal to the ampulla of Vater in pigs as a weight-loss strategy (Obes. Surg. 2006;16:620-6). This study, which demonstrated good weight loss in pigs, was the basis for the first human trial reported by Dr. Leonardo Rodriguez and his associates at the annual meeting of the American Society for Metabolic and Bariatric Surgery (formerly the American Society for Bariatric Surgery) in June 2007.

In the human trial, 12 patients from Chile and Brazil, including four with diabetes, underwent placement of a 61-cm endoluminal duodenojejunal tube or plastic sleeve that was anchored endoscopically in the duodenum and removed after 12 weeks.

All patients achieved an estimated weight loss of at least 10%, and 10 of the 12 patients lost an estimated 24% of their weight. All of the diabetic patients completed the study without the need for hypoglycemic medications.

“By diverting the flow of food from the duodenum and the proximal jejunum, we might be able to change some of the GI hormones that may switch the diabetes to reverse itself,” Dr. Gagner said in an interview. “I think we will see more and more of that technology being developed, and we'll see variants like different materials, different lengths [of sleeves], et cetera.” Dr. Gagner was not affiliated with the study.

In other studies of presurgical endoluminal therapy, the intragastric balloon developed by BioEnterics Corp. has been used successfully as a first-stage procedure to reduce presurgical weight and perioperative risk in superobese patients, but clinical results are limited.

In the arena of postsurgical endoluminal revision procedures, small studies of C.R. Bard Inc.'s EndoCinch suturing system and endoscopic suturing device have demonstrated promising results.

Dr. Christopher C. Thompson and his associates used the EndoCinch suturing system in eight patients who had undergone RYGB but had regained an average of 24 kg from baseline (Surg. Obes. Relat. Dis. 2005;1:223). They placed plications at the rim of the anastomosis, thereby reducing the anastomotic aperture. At 4 months after undergoing the procedure, six of the eight patients had lost an average of 10 kg, and four reported significant improvements in satiety.

In another study, Dr. Michael Schweitzer and his associates used the endoscopic suturing device in four patients who regained weight after RYGB surgery (J. Laparoendosc. Adv. Surg. Tech. A. 2004;14:223-6). The study did not include long-term results, but noted that all four patients reported improvements in early weight loss and satiety.

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons in April 2007, Dr. Roberto Fogel of Caracas, Venezuela, reported that an endoluminal vertical gastroplasty procedure produced an average excess weight loss of 46% in patients 3 months after surgery. In this procedure, an interrupted suture pattern was used in 31 patients with a mean body mass index of 38.1 kg/m

Such suturing procedures hold particular promise, Dr. Schauer said, because “they emulate gastric restriction, a concept that has been proven over several decades in bariatric surgery.”

Dr. Schauer is one of the clinicians participating in the phase III RESTORe (Randomized Evaluation of Endoscopic Suturing Transorally for Anastomotic Outlet Reduction) trial for patients with inadequate weight loss following RYGB.

The purpose of the trial, which is supported by Bard and Davol Inc., is to evaluate weight loss and other clinical outcomes following application of transoral reduction of a dilated gastrojejunostomy anastomosis in 220 patients who have not achieved adequate weight loss following RYGB. The expected completion date of the trial is July 2008.

The use of endoluminal techniques for the primary treatment of obesity is in its infancy, Dr. Schauer said. One investigational device that has been studied in small trials of patients outside the United States is the transoral gastroplasty (TOGa) system, developed by Satiety Inc. In this procedure, an endoscopic stapling device is inserted through the mouth to the stomach to create a small restrictive pouch.

Dr. Gagner said that he is optimistic about such developments but cautioned that much more study is required before they are embraced by gastrointestinal endoscopic surgeons.

“It's great that we have this research effort going on, that there's a lot of enthusiasm,” he said. “People think it's going to happen overnight. I think it's going to take much longer than what we think.”

Dr. Schauer called the development of endoluminal techniques for obesity “another potential great leap forward in reducing the risk of these procedures. We already know that going from open procedures to laparoscopic procedures was one of the major factors that propelled bariatric surgery from a very low niche field [15,000 cases per year] across the United States, to 200,000 procedures per year. What really drove that was the reduction in complications and recovery.”

Similar success with endoluminal techniques will take time, and will require the ability to overcome technical hurdles and challenges associated with reimbursement. “These procedures will require new CPT codes and applications to insurance carriers to get reimbursed,” he said.

Dr. Schauer disclosed that he is a paid consultant for Bard, Davol, Ethicon Endo-Surgery Inc., Stryker Endoscopy, Baxter International Inc., W.L. Gore & Associates Inc., and Barosense Inc.

Dr. Gagner disclosed that he is a scientific adviser for GI Dynamics Inc. He also has received research grants from Covidien AG, Olympus America Inc., and Bard.

'We might be able to change some of the GI hormones that may switch the diabetes to reverse itself.' DR. GAGNER

Emerging endoluminal techniques and devices intended for weight loss therapy may reduce the risk of morbidity and mortality associated with current bariatric surgery approaches, according to the research findings of Dr. Philip Schauer and his associates.

The use of endoluminal approaches to avoid any type of abdominal incision and, more importantly, any intra-abdominal dissection “may go a long way to further reduce the morbidity of these operations, making them cheaper and safer,” Dr. Schauer said in an interview. “Potentially, they may expand the access for patients. Only 1% of patients with severe obesity are actually getting access to surgery, which is the only known therapy to be effective for a large percentage of patients.”

Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the bariatric and metabolic institute of the Cleveland Clinic, and his associates categorized the current endoluminal methods for weight loss therapy as presurgical endoluminal therapy, postsurgical endoluminal revision procedures, and primary procedures (Surg. Endosc. 2007;21:347-56).

In the presurgical endoluminal therapy arena, Dr. Michel Gagner and his associates pioneered a two-stage operation consisting of a sleeve gastrectomy followed by a Roux-en-Y gastric bypass (RYGB) or a duodenal switch (Obes. Surg. 2003;13:861-4).

“The rationale is that the first-stage operation, sleeve gastrectomy, is comparatively simple (requiring no anastomosis), needs less operative time (1–2 hours), and results in a predictable 40- to 50-kg weight loss,” Dr. Schauer and his associates wrote in their review. “Such weight loss reduces the operative risk for the second-stage procedure, which presumably results in more weight loss and greater durability.”

Dr. Gagner, professor of surgery and chief of bariatric surgery at Cornell University, New York, and his associates were also the first to publish results of an approach using the placement of endoluminal duodenojejunal tube or plastic sleeve to the first part of the duodenum proximal to the ampulla of Vater in pigs as a weight-loss strategy (Obes. Surg. 2006;16:620-6). This study, which demonstrated good weight loss in pigs, was the basis for the first human trial reported by Dr. Leonardo Rodriguez and his associates at the annual meeting of the American Society for Metabolic and Bariatric Surgery (formerly the American Society for Bariatric Surgery) in June 2007.

In the human trial, 12 patients from Chile and Brazil, including four with diabetes, underwent placement of a 61-cm endoluminal duodenojejunal tube or plastic sleeve that was anchored endoscopically in the duodenum and removed after 12 weeks.

All patients achieved an estimated weight loss of at least 10%, and 10 of the 12 patients lost an estimated 24% of their weight. All of the diabetic patients completed the study without the need for hypoglycemic medications.

“By diverting the flow of food from the duodenum and the proximal jejunum, we might be able to change some of the GI hormones that may switch the diabetes to reverse itself,” Dr. Gagner said in an interview. “I think we will see more and more of that technology being developed, and we'll see variants like different materials, different lengths [of sleeves], et cetera.” Dr. Gagner was not affiliated with the study.

In other studies of presurgical endoluminal therapy, the intragastric balloon developed by BioEnterics Corp. has been used successfully as a first-stage procedure to reduce presurgical weight and perioperative risk in superobese patients, but clinical results are limited.

In the arena of postsurgical endoluminal revision procedures, small studies of C.R. Bard Inc.'s EndoCinch suturing system and endoscopic suturing device have demonstrated promising results.

Dr. Christopher C. Thompson and his associates used the EndoCinch suturing system in eight patients who had undergone RYGB but had regained an average of 24 kg from baseline (Surg. Obes. Relat. Dis. 2005;1:223). They placed plications at the rim of the anastomosis, thereby reducing the anastomotic aperture. At 4 months after undergoing the procedure, six of the eight patients had lost an average of 10 kg, and four reported significant improvements in satiety.

In another study, Dr. Michael Schweitzer and his associates used the endoscopic suturing device in four patients who regained weight after RYGB surgery (J. Laparoendosc. Adv. Surg. Tech. A. 2004;14:223-6). The study did not include long-term results, but noted that all four patients reported improvements in early weight loss and satiety.

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons in April 2007, Dr. Roberto Fogel of Caracas, Venezuela, reported that an endoluminal vertical gastroplasty procedure produced an average excess weight loss of 46% in patients 3 months after surgery. In this procedure, an interrupted suture pattern was used in 31 patients with a mean body mass index of 38.1 kg/m

Such suturing procedures hold particular promise, Dr. Schauer said, because “they emulate gastric restriction, a concept that has been proven over several decades in bariatric surgery.”

Dr. Schauer is one of the clinicians participating in the phase III RESTORe (Randomized Evaluation of Endoscopic Suturing Transorally for Anastomotic Outlet Reduction) trial for patients with inadequate weight loss following RYGB.

The purpose of the trial, which is supported by Bard and Davol Inc., is to evaluate weight loss and other clinical outcomes following application of transoral reduction of a dilated gastrojejunostomy anastomosis in 220 patients who have not achieved adequate weight loss following RYGB. The expected completion date of the trial is July 2008.

The use of endoluminal techniques for the primary treatment of obesity is in its infancy, Dr. Schauer said. One investigational device that has been studied in small trials of patients outside the United States is the transoral gastroplasty (TOGa) system, developed by Satiety Inc. In this procedure, an endoscopic stapling device is inserted through the mouth to the stomach to create a small restrictive pouch.

Dr. Gagner said that he is optimistic about such developments but cautioned that much more study is required before they are embraced by gastrointestinal endoscopic surgeons.

“It's great that we have this research effort going on, that there's a lot of enthusiasm,” he said. “People think it's going to happen overnight. I think it's going to take much longer than what we think.”

Dr. Schauer called the development of endoluminal techniques for obesity “another potential great leap forward in reducing the risk of these procedures. We already know that going from open procedures to laparoscopic procedures was one of the major factors that propelled bariatric surgery from a very low niche field [15,000 cases per year] across the United States, to 200,000 procedures per year. What really drove that was the reduction in complications and recovery.”

Similar success with endoluminal techniques will take time, and will require the ability to overcome technical hurdles and challenges associated with reimbursement. “These procedures will require new CPT codes and applications to insurance carriers to get reimbursed,” he said.

Dr. Schauer disclosed that he is a paid consultant for Bard, Davol, Ethicon Endo-Surgery Inc., Stryker Endoscopy, Baxter International Inc., W.L. Gore & Associates Inc., and Barosense Inc.

Dr. Gagner disclosed that he is a scientific adviser for GI Dynamics Inc. He also has received research grants from Covidien AG, Olympus America Inc., and Bard.

'We might be able to change some of the GI hormones that may switch the diabetes to reverse itself.' DR. GAGNER

Emerging endoluminal techniques and devices intended for weight loss therapy may reduce the risk of morbidity and mortality associated with current bariatric surgery approaches, according to the research findings of Dr. Philip Schauer and his associates.

The use of endoluminal approaches to avoid any type of abdominal incision and, more importantly, any intra-abdominal dissection “may go a long way to further reduce the morbidity of these operations, making them cheaper and safer,” Dr. Schauer said in an interview. “Potentially, they may expand the access for patients. Only 1% of patients with severe obesity are actually getting access to surgery, which is the only known therapy to be effective for a large percentage of patients.”

Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the bariatric and metabolic institute of the Cleveland Clinic, and his associates categorized the current endoluminal methods for weight loss therapy as presurgical endoluminal therapy, postsurgical endoluminal revision procedures, and primary procedures (Surg. Endosc. 2007;21:347-56).

In the presurgical endoluminal therapy arena, Dr. Michel Gagner and his associates pioneered a two-stage operation consisting of a sleeve gastrectomy followed by a Roux-en-Y gastric bypass (RYGB) or a duodenal switch (Obes. Surg. 2003;13:861-4).

“The rationale is that the first-stage operation, sleeve gastrectomy, is comparatively simple (requiring no anastomosis), needs less operative time (1–2 hours), and results in a predictable 40- to 50-kg weight loss,” Dr. Schauer and his associates wrote in their review. “Such weight loss reduces the operative risk for the second-stage procedure, which presumably results in more weight loss and greater durability.”

Dr. Gagner, professor of surgery and chief of bariatric surgery at Cornell University, New York, and his associates were also the first to publish results of an approach using the placement of endoluminal duodenojejunal tube or plastic sleeve to the first part of the duodenum proximal to the ampulla of Vater in pigs as a weight-loss strategy (Obes. Surg. 2006;16:620-6). This study, which demonstrated good weight loss in pigs, was the basis for the first human trial reported by Dr. Leonardo Rodriguez and his associates at the annual meeting of the American Society for Metabolic and Bariatric Surgery (formerly the American Society for Bariatric Surgery) in June 2007.

In the human trial, 12 patients from Chile and Brazil, including four with diabetes, underwent placement of a 61-cm endoluminal duodenojejunal tube or plastic sleeve that was anchored endoscopically in the duodenum and removed after 12 weeks.

All patients achieved an estimated weight loss of at least 10%, and 10 of the 12 patients lost an estimated 24% of their weight. All of the diabetic patients completed the study without the need for hypoglycemic medications.

“By diverting the flow of food from the duodenum and the proximal jejunum, we might be able to change some of the GI hormones that may switch the diabetes to reverse itself,” Dr. Gagner said in an interview. “I think we will see more and more of that technology being developed, and we'll see variants like different materials, different lengths [of sleeves], et cetera.” Dr. Gagner was not affiliated with the study.

In other studies of presurgical endoluminal therapy, the intragastric balloon developed by BioEnterics Corp. has been used successfully as a first-stage procedure to reduce presurgical weight and perioperative risk in superobese patients, but clinical results are limited.

In the arena of postsurgical endoluminal revision procedures, small studies of C.R. Bard Inc.'s EndoCinch suturing system and endoscopic suturing device have demonstrated promising results.

Dr. Christopher C. Thompson and his associates used the EndoCinch suturing system in eight patients who had undergone RYGB but had regained an average of 24 kg from baseline (Surg. Obes. Relat. Dis. 2005;1:223). They placed plications at the rim of the anastomosis, thereby reducing the anastomotic aperture. At 4 months after undergoing the procedure, six of the eight patients had lost an average of 10 kg, and four reported significant improvements in satiety.

In another study, Dr. Michael Schweitzer and his associates used the endoscopic suturing device in four patients who regained weight after RYGB surgery (J. Laparoendosc. Adv. Surg. Tech. A. 2004;14:223-6). The study did not include long-term results, but noted that all four patients reported improvements in early weight loss and satiety.

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons in April 2007, Dr. Roberto Fogel of Caracas, Venezuela, reported that an endoluminal vertical gastroplasty procedure produced an average excess weight loss of 46% in patients 3 months after surgery. In this procedure, an interrupted suture pattern was used in 31 patients with a mean body mass index of 38.1 kg/m

Such suturing procedures hold particular promise, Dr. Schauer said, because “they emulate gastric restriction, a concept that has been proven over several decades in bariatric surgery.”

Dr. Schauer is one of the clinicians participating in the phase III RESTORe (Randomized Evaluation of Endoscopic Suturing Transorally for Anastomotic Outlet Reduction) trial for patients with inadequate weight loss following RYGB.

The purpose of the trial, which is supported by Bard and Davol Inc., is to evaluate weight loss and other clinical outcomes following application of transoral reduction of a dilated gastrojejunostomy anastomosis in 220 patients who have not achieved adequate weight loss following RYGB. The expected completion date of the trial is July 2008.

The use of endoluminal techniques for the primary treatment of obesity is in its infancy, Dr. Schauer said. One investigational device that has been studied in small trials of patients outside the United States is the transoral gastroplasty (TOGa) system, developed by Satiety Inc. In this procedure, an endoscopic stapling device is inserted through the mouth to the stomach to create a small restrictive pouch.

Dr. Gagner said that he is optimistic about such developments but cautioned that much more study is required before they are embraced by gastrointestinal endoscopic surgeons.

“It's great that we have this research effort going on, that there's a lot of enthusiasm,” he said. “People think it's going to happen overnight. I think it's going to take much longer than what we think.”

Dr. Schauer called the development of endoluminal techniques for obesity “another potential great leap forward in reducing the risk of these procedures. We already know that going from open procedures to laparoscopic procedures was one of the major factors that propelled bariatric surgery from a very low niche field [15,000 cases per year] across the United States, to 200,000 procedures per year. What really drove that was the reduction in complications and recovery.”

Similar success with endoluminal techniques will take time, and will require the ability to overcome technical hurdles and challenges associated with reimbursement. “These procedures will require new CPT codes and applications to insurance carriers to get reimbursed,” he said.

Dr. Schauer disclosed that he is a paid consultant for Bard, Davol, Ethicon Endo-Surgery Inc., Stryker Endoscopy, Baxter International Inc., W.L. Gore & Associates Inc., and Barosense Inc.

Dr. Gagner disclosed that he is a scientific adviser for GI Dynamics Inc. He also has received research grants from Covidien AG, Olympus America Inc., and Bard.

'We might be able to change some of the GI hormones that may switch the diabetes to reverse itself.' DR. GAGNER

CORONADO, CALIF. — "Some of the most painful and troublesome hemangiomas I've taken care of are those in the genital area," Dr. Sheila Fallon Friedlander said at the annual meeting of the Pacific Dermatologic Association. "They are extremely painful and often require intervention."

Other worrisome hemangiomas include those which cause visual obstruction, airway obstruction, deformation, and friction, said Dr. Friedlander, section chief of dermatology at Rady Children's Hospital-San Diego.

She added that segmental or patterned hemangiomas are likely to become problematic, and that multiple lesions raise the issue of possible visceral involvement.

Other worrisome hemangiomas include those which appear in the lumbosacral area. "That could indicate tethered spinal cord and spinal dysraphism, so I worry about that," Dr. Friedlander said. "There have also been several articles describing pelvis or sacral syndrome: anomalies of the pelvic or genitourinary organs if you have a hemangioma that's plaquelike and large in the anogenital area."

The prevalence of infantile hemangiomas is not clear, but it appears that 1%–2% of newborns will have such a lesion. When children are followed out to 1 year of age, the prevalence is 10%–12%. "Fortunately for them and for us, most of these lesions never cause a problem," said Dr. Friedlander.

About one-third of hemangiomas are present at birth but most develop during the first few months of life. Sometimes the first sign is a white vasoconstricted area of skin. "But over time the area will become red and then become protuberant," she said. "If you watch it long enough it will grow for the first 6–12 months of life, it will stop growing, and it will eventually improve. Fortunately, that's good news. So remember: You can be consulted about a lesion in an infant that just looks like a vasoconstricted or white area, but it may be an early hemangioma."

Dr. Friedlander noted that traditionally experts have stated "30% of hemangiomas fade away by age 3, 70% by age 7, and 90% by age 9." When the affected child reaches age 4 or 5, "we get a sense of those lesions which are going to go and those which are going to stay," she said. "The standard in our office is to tell families to definitely return around 4 years of age before [the child starts] kindergarten to see what it looks like."

Research on the etiology of hemangiomas continues to evolve. To date, high-risk patients include those with large facial plaquelike hemangiomas, preemies, twins, and infants born to mothers with abnormalities in the placenta.

Large plaquelike lesions, particularly of the face, warrant a careful physical exam, eye exam, an echocardiogram, and often an MRI/magnetic resonance angiography of the head.

The goal of treatment is to prevent function-threatening events such as disfigurement and to minimize psychosocial distress, "but you don't want to do something very aggressive early on that's going to lead to scarring which was unnecessary," Dr. Friedlander said.

Systemic prednisone at a dose of 2–5 mg/kg per day is indicated for patients with symptomatic troublesome lesions. Dr. Friedlander said that flavored agents "taste a lot better than regular generics." She uses Orapred syrup (prednisolone sodium phosphate) which comes in a concentration of 15 mg/5 mL. She usually starts with a dose of 2 mg/kg per day as one early morning dose with food.

Patients usually require months rather than weeks of therapy. Approximately 30% of lesions will shrink, another 40% will stop growing but may not shrink, and the remaining 30% may not respond, even if the steroid dose is increased. "It is important to monitor blood pressure and growth during treatment," she said. "At our center, we treat these children with H2 blockers to prevent gastric irritation, and make certain that they are aware of the risks of severe varicella infection if they are exposed to this virus. If that occurs, they should receive oral acyclovir."

Other treatment options include topical class 1 steroids such as clobetasol for thin lesions, and intralesional corticosteroids such as triamcinolone acetonide. "These can be very useful for discreet lesions but you need to be careful around the eyes," she emphasized. "There have been some reports of central retinal or ophthalmic artery occlusion and blindness. For that reason I refer to ophthalmology if periorbital injection is required."

Laser treatment of infantile hemangiomas is controversial, but she said that it makes a "tremendous difference" in children who develop ulcerated lesions in the groin area. "These kids are in horrendous pain," she said. "For many of them, one or two laser treatments will expedite healing such that they are no longer in pain."

Dr. Friedlander said she had no conflicts of interest regarding products mentioned in her presentation.

Children who develop ulcerated lesions, such as this one in the perianal region, may be in great pain.

Large, plaquelike lesions of the face warrant an echocardiogram and possibly MRI/MR angiography. PHOTOS COURTESY DR. SHEILA FALLON FRIEDLANDER & CHILDREN'S PEDIATRIC DERM SPECIALISTS, SAN DIEGO

CORONADO, CALIF. — "Some of the most painful and troublesome hemangiomas I've taken care of are those in the genital area," Dr. Sheila Fallon Friedlander said at the annual meeting of the Pacific Dermatologic Association. "They are extremely painful and often require intervention."

Other worrisome hemangiomas include those which cause visual obstruction, airway obstruction, deformation, and friction, said Dr. Friedlander, section chief of dermatology at Rady Children's Hospital-San Diego.

She added that segmental or patterned hemangiomas are likely to become problematic, and that multiple lesions raise the issue of possible visceral involvement.

Other worrisome hemangiomas include those which appear in the lumbosacral area. "That could indicate tethered spinal cord and spinal dysraphism, so I worry about that," Dr. Friedlander said. "There have also been several articles describing pelvis or sacral syndrome: anomalies of the pelvic or genitourinary organs if you have a hemangioma that's plaquelike and large in the anogenital area."

The prevalence of infantile hemangiomas is not clear, but it appears that 1%–2% of newborns will have such a lesion. When children are followed out to 1 year of age, the prevalence is 10%–12%. "Fortunately for them and for us, most of these lesions never cause a problem," said Dr. Friedlander.

About one-third of hemangiomas are present at birth but most develop during the first few months of life. Sometimes the first sign is a white vasoconstricted area of skin. "But over time the area will become red and then become protuberant," she said. "If you watch it long enough it will grow for the first 6–12 months of life, it will stop growing, and it will eventually improve. Fortunately, that's good news. So remember: You can be consulted about a lesion in an infant that just looks like a vasoconstricted or white area, but it may be an early hemangioma."

Dr. Friedlander noted that traditionally experts have stated "30% of hemangiomas fade away by age 3, 70% by age 7, and 90% by age 9." When the affected child reaches age 4 or 5, "we get a sense of those lesions which are going to go and those which are going to stay," she said. "The standard in our office is to tell families to definitely return around 4 years of age before [the child starts] kindergarten to see what it looks like."

Research on the etiology of hemangiomas continues to evolve. To date, high-risk patients include those with large facial plaquelike hemangiomas, preemies, twins, and infants born to mothers with abnormalities in the placenta.

Large plaquelike lesions, particularly of the face, warrant a careful physical exam, eye exam, an echocardiogram, and often an MRI/magnetic resonance angiography of the head.

The goal of treatment is to prevent function-threatening events such as disfigurement and to minimize psychosocial distress, "but you don't want to do something very aggressive early on that's going to lead to scarring which was unnecessary," Dr. Friedlander said.

Systemic prednisone at a dose of 2–5 mg/kg per day is indicated for patients with symptomatic troublesome lesions. Dr. Friedlander said that flavored agents "taste a lot better than regular generics." She uses Orapred syrup (prednisolone sodium phosphate) which comes in a concentration of 15 mg/5 mL. She usually starts with a dose of 2 mg/kg per day as one early morning dose with food.

Patients usually require months rather than weeks of therapy. Approximately 30% of lesions will shrink, another 40% will stop growing but may not shrink, and the remaining 30% may not respond, even if the steroid dose is increased. "It is important to monitor blood pressure and growth during treatment," she said. "At our center, we treat these children with H2 blockers to prevent gastric irritation, and make certain that they are aware of the risks of severe varicella infection if they are exposed to this virus. If that occurs, they should receive oral acyclovir."

Other treatment options include topical class 1 steroids such as clobetasol for thin lesions, and intralesional corticosteroids such as triamcinolone acetonide. "These can be very useful for discreet lesions but you need to be careful around the eyes," she emphasized. "There have been some reports of central retinal or ophthalmic artery occlusion and blindness. For that reason I refer to ophthalmology if periorbital injection is required."

Laser treatment of infantile hemangiomas is controversial, but she said that it makes a "tremendous difference" in children who develop ulcerated lesions in the groin area. "These kids are in horrendous pain," she said. "For many of them, one or two laser treatments will expedite healing such that they are no longer in pain."

Dr. Friedlander said she had no conflicts of interest regarding products mentioned in her presentation.

Children who develop ulcerated lesions, such as this one in the perianal region, may be in great pain.

Large, plaquelike lesions of the face warrant an echocardiogram and possibly MRI/MR angiography. PHOTOS COURTESY DR. SHEILA FALLON FRIEDLANDER & CHILDREN'S PEDIATRIC DERM SPECIALISTS, SAN DIEGO

CORONADO, CALIF. — "Some of the most painful and troublesome hemangiomas I've taken care of are those in the genital area," Dr. Sheila Fallon Friedlander said at the annual meeting of the Pacific Dermatologic Association. "They are extremely painful and often require intervention."

Other worrisome hemangiomas include those which cause visual obstruction, airway obstruction, deformation, and friction, said Dr. Friedlander, section chief of dermatology at Rady Children's Hospital-San Diego.

She added that segmental or patterned hemangiomas are likely to become problematic, and that multiple lesions raise the issue of possible visceral involvement.

Other worrisome hemangiomas include those which appear in the lumbosacral area. "That could indicate tethered spinal cord and spinal dysraphism, so I worry about that," Dr. Friedlander said. "There have also been several articles describing pelvis or sacral syndrome: anomalies of the pelvic or genitourinary organs if you have a hemangioma that's plaquelike and large in the anogenital area."

The prevalence of infantile hemangiomas is not clear, but it appears that 1%–2% of newborns will have such a lesion. When children are followed out to 1 year of age, the prevalence is 10%–12%. "Fortunately for them and for us, most of these lesions never cause a problem," said Dr. Friedlander.

About one-third of hemangiomas are present at birth but most develop during the first few months of life. Sometimes the first sign is a white vasoconstricted area of skin. "But over time the area will become red and then become protuberant," she said. "If you watch it long enough it will grow for the first 6–12 months of life, it will stop growing, and it will eventually improve. Fortunately, that's good news. So remember: You can be consulted about a lesion in an infant that just looks like a vasoconstricted or white area, but it may be an early hemangioma."

Dr. Friedlander noted that traditionally experts have stated "30% of hemangiomas fade away by age 3, 70% by age 7, and 90% by age 9." When the affected child reaches age 4 or 5, "we get a sense of those lesions which are going to go and those which are going to stay," she said. "The standard in our office is to tell families to definitely return around 4 years of age before [the child starts] kindergarten to see what it looks like."

Research on the etiology of hemangiomas continues to evolve. To date, high-risk patients include those with large facial plaquelike hemangiomas, preemies, twins, and infants born to mothers with abnormalities in the placenta.

Large plaquelike lesions, particularly of the face, warrant a careful physical exam, eye exam, an echocardiogram, and often an MRI/magnetic resonance angiography of the head.

The goal of treatment is to prevent function-threatening events such as disfigurement and to minimize psychosocial distress, "but you don't want to do something very aggressive early on that's going to lead to scarring which was unnecessary," Dr. Friedlander said.

Systemic prednisone at a dose of 2–5 mg/kg per day is indicated for patients with symptomatic troublesome lesions. Dr. Friedlander said that flavored agents "taste a lot better than regular generics." She uses Orapred syrup (prednisolone sodium phosphate) which comes in a concentration of 15 mg/5 mL. She usually starts with a dose of 2 mg/kg per day as one early morning dose with food.

Patients usually require months rather than weeks of therapy. Approximately 30% of lesions will shrink, another 40% will stop growing but may not shrink, and the remaining 30% may not respond, even if the steroid dose is increased. "It is important to monitor blood pressure and growth during treatment," she said. "At our center, we treat these children with H2 blockers to prevent gastric irritation, and make certain that they are aware of the risks of severe varicella infection if they are exposed to this virus. If that occurs, they should receive oral acyclovir."

Other treatment options include topical class 1 steroids such as clobetasol for thin lesions, and intralesional corticosteroids such as triamcinolone acetonide. "These can be very useful for discreet lesions but you need to be careful around the eyes," she emphasized. "There have been some reports of central retinal or ophthalmic artery occlusion and blindness. For that reason I refer to ophthalmology if periorbital injection is required."

Laser treatment of infantile hemangiomas is controversial, but she said that it makes a "tremendous difference" in children who develop ulcerated lesions in the groin area. "These kids are in horrendous pain," she said. "For many of them, one or two laser treatments will expedite healing such that they are no longer in pain."

Dr. Friedlander said she had no conflicts of interest regarding products mentioned in her presentation.

Children who develop ulcerated lesions, such as this one in the perianal region, may be in great pain.

Large, plaquelike lesions of the face warrant an echocardiogram and possibly MRI/MR angiography. PHOTOS COURTESY DR. SHEILA FALLON FRIEDLANDER & CHILDREN'S PEDIATRIC DERM SPECIALISTS, SAN DIEGO

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

"It's clear that 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 on 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 the use of 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.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind 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.

"There's this great shortage and it's hard to get an appointment," he said. "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 injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

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

"It's clear that 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 on 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 the use of 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.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind 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.

"There's this great shortage and it's hard to get an appointment," he said. "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 injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

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

"It's clear that 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 on 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 the use of 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.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind 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.

"There's this great shortage and it's hard to get an appointment," he said. "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 injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

CORONADO, CALIF. — The side effects associated with epidermal growth factor receptor inhibitors can be so awful that several cancer patients have told Dr. Jonathan Cotliar that they would rather die than continue taking them.

"That's significant when you hear that from many people," Dr. Cotliar said at the annual meeting of the Pacific Dermatologic Association.

One side effect that occurs in 60%–80% of cancer patients who take epidermal growth factor receptor inhibitors (EGFRIs) is skin toxicity, mostly in the form of papulopustular lesions. Paronychia, fissures, xerosis, alopecia, eyelash trichomegaly, telangiectasias, and photosensitivity also can occur.

"I think the companies that developed these drugs underestimated the significance of cutaneous toxicity," said Dr. Cotliar, director of inpatient dermatology services in the division of dermatology at the University of California, Los Angeles.

The incidence of skin toxicity among patients who take the monoclonal antibodies cetuximab (Erbitux) or panitumumab (Vectibix) is somewhat higher compared with those who take the tyrosine kinase inhibitors erlotinib (Tarceva) or gefitinib (Iressa). All of the agents cause apoptosis of keratinocytes. "That's probably the major event that allows for what we see clinically in these patients," he said.

"We also know that there is early initiation of keratinocyte differentiation. In theory, that allows the stratum corneum to become impaired, which leads to many of these toxicities. We also know that inhibition of epidermal growth factor leads to epithelial cell production of proinflammatory mediators. That allows for the adaptive immune response to take hold," he explained.

Papulopustular lesions commonly occur on the face, chest, back, and scalp. The palms and soles are spared.

Histology reveals a thinned stratum corneum, dilated follicular infundibula, necrotic keratinocytes, and mixed inflammation in the upper dermis. "In addition, you may see acantholysis of the follicular epithelium," Dr. Cotliar said.

Ironically, skin toxicity—specifically the papulopustular lesions—is a surrogate marker for treatment efficacy of EGFRIs. "We know that this eruption is more severe and incidence is greater in responders to these medications than in those who don't respond," said Dr. Cotliar, who disclosed that he is a consultant for Amgen Inc., which manufactures panitumumab, and has received honoraria from the company.

"We also know that there is a nice correlation between survival, both overall and progression free, [and] severity of the rash. We don't know if this is an epiphenomenon or if there's something about the cutaneous toxicity that's allowing the immune response to percolate and fight the underlying cancer," he noted.

The severity of papulopustular lesions seems to be linked to the EGFRI dose. "We also know that patients typically develop these lesions 1–3 weeks after their first infusion or their first pills," he said. "The maximal toxicity occurs by weeks 3–5."

Once patients stop taking the EGFRI, the cutaneous side effects usually resolve within a couple of weeks.

There is no current standard for treating skin toxicity associated with EGFRI use. A proposed treatment algorithm was recently published (Oncologist 2007;12:610–21), but "everything we know about treating these patients is based on case reports," Dr. Cotliar said.

A first approach might involve modifying the dose of the EGFRI by following package insert instructions. Most patients referred to Dr. Cotliar and his associates are started on 1% or 2% hydrocortisone or sometimes tetracycline or doxycycline.

"A lot of times I will start patients on doxycycline 100 mg b.i.d.," he said. "I also typically start—for the first week or two—with a mid- to high-potency topical corticosteroid."

One "black hole" among possible treatment options is isotretinoin. "Nobody's sure what effect it has on tumor biology," he said. "We're also not sure of its effect on EGFRIs. We need to know more about that. We do know from case reports that 20–30 mg/day is successful in helping resolve some of these lesions."

Other potential treatments for papulopustular lesions include colloidal oatmeal lotion, topical erythromycin, clindamycin, metronidazole, and topical retinoids.

Potential treatments for xerosis and pruritus triggered by the use of EGFRIs include bland emollients and antihistamines.

Potential treatments for paronychia and fissures include aluminum acetate soaks, 4% thymol, emollients, topical corticosteroids, intralesional steroids, systemic antibiotics, electrodesiccation, cryosurgery, surgical debridement, and nail plate avulsion, Dr. Cotliar said.

Lastly, pulsed dye lasers can be used to treat telangiectasias.

Papulopustular lesions are commonly seen in patients who are taking epidermal growth factor inhibitors. Courtesy Dr. Jonathan Cotliar

CORONADO, CALIF. — The side effects associated with epidermal growth factor receptor inhibitors can be so awful that several cancer patients have told Dr. Jonathan Cotliar that they would rather die than continue taking them.

"That's significant when you hear that from many people," Dr. Cotliar said at the annual meeting of the Pacific Dermatologic Association.

One side effect that occurs in 60%–80% of cancer patients who take epidermal growth factor receptor inhibitors (EGFRIs) is skin toxicity, mostly in the form of papulopustular lesions. Paronychia, fissures, xerosis, alopecia, eyelash trichomegaly, telangiectasias, and photosensitivity also can occur.

"I think the companies that developed these drugs underestimated the significance of cutaneous toxicity," said Dr. Cotliar, director of inpatient dermatology services in the division of dermatology at the University of California, Los Angeles.

The incidence of skin toxicity among patients who take the monoclonal antibodies cetuximab (Erbitux) or panitumumab (Vectibix) is somewhat higher compared with those who take the tyrosine kinase inhibitors erlotinib (Tarceva) or gefitinib (Iressa). All of the agents cause apoptosis of keratinocytes. "That's probably the major event that allows for what we see clinically in these patients," he said.

"We also know that there is early initiation of keratinocyte differentiation. In theory, that allows the stratum corneum to become impaired, which leads to many of these toxicities. We also know that inhibition of epidermal growth factor leads to epithelial cell production of proinflammatory mediators. That allows for the adaptive immune response to take hold," he explained.

Papulopustular lesions commonly occur on the face, chest, back, and scalp. The palms and soles are spared.

Histology reveals a thinned stratum corneum, dilated follicular infundibula, necrotic keratinocytes, and mixed inflammation in the upper dermis. "In addition, you may see acantholysis of the follicular epithelium," Dr. Cotliar said.

Ironically, skin toxicity—specifically the papulopustular lesions—is a surrogate marker for treatment efficacy of EGFRIs. "We know that this eruption is more severe and incidence is greater in responders to these medications than in those who don't respond," said Dr. Cotliar, who disclosed that he is a consultant for Amgen Inc., which manufactures panitumumab, and has received honoraria from the company.

"We also know that there is a nice correlation between survival, both overall and progression free, [and] severity of the rash. We don't know if this is an epiphenomenon or if there's something about the cutaneous toxicity that's allowing the immune response to percolate and fight the underlying cancer," he noted.

The severity of papulopustular lesions seems to be linked to the EGFRI dose. "We also know that patients typically develop these lesions 1–3 weeks after their first infusion or their first pills," he said. "The maximal toxicity occurs by weeks 3–5."

Once patients stop taking the EGFRI, the cutaneous side effects usually resolve within a couple of weeks.

There is no current standard for treating skin toxicity associated with EGFRI use. A proposed treatment algorithm was recently published (Oncologist 2007;12:610–21), but "everything we know about treating these patients is based on case reports," Dr. Cotliar said.

A first approach might involve modifying the dose of the EGFRI by following package insert instructions. Most patients referred to Dr. Cotliar and his associates are started on 1% or 2% hydrocortisone or sometimes tetracycline or doxycycline.

"A lot of times I will start patients on doxycycline 100 mg b.i.d.," he said. "I also typically start—for the first week or two—with a mid- to high-potency topical corticosteroid."

One "black hole" among possible treatment options is isotretinoin. "Nobody's sure what effect it has on tumor biology," he said. "We're also not sure of its effect on EGFRIs. We need to know more about that. We do know from case reports that 20–30 mg/day is successful in helping resolve some of these lesions."

Other potential treatments for papulopustular lesions include colloidal oatmeal lotion, topical erythromycin, clindamycin, metronidazole, and topical retinoids.

Potential treatments for xerosis and pruritus triggered by the use of EGFRIs include bland emollients and antihistamines.

Potential treatments for paronychia and fissures include aluminum acetate soaks, 4% thymol, emollients, topical corticosteroids, intralesional steroids, systemic antibiotics, electrodesiccation, cryosurgery, surgical debridement, and nail plate avulsion, Dr. Cotliar said.

Lastly, pulsed dye lasers can be used to treat telangiectasias.

Papulopustular lesions are commonly seen in patients who are taking epidermal growth factor inhibitors. Courtesy Dr. Jonathan Cotliar

CORONADO, CALIF. — The side effects associated with epidermal growth factor receptor inhibitors can be so awful that several cancer patients have told Dr. Jonathan Cotliar that they would rather die than continue taking them.

"That's significant when you hear that from many people," Dr. Cotliar said at the annual meeting of the Pacific Dermatologic Association.

One side effect that occurs in 60%–80% of cancer patients who take epidermal growth factor receptor inhibitors (EGFRIs) is skin toxicity, mostly in the form of papulopustular lesions. Paronychia, fissures, xerosis, alopecia, eyelash trichomegaly, telangiectasias, and photosensitivity also can occur.

"I think the companies that developed these drugs underestimated the significance of cutaneous toxicity," said Dr. Cotliar, director of inpatient dermatology services in the division of dermatology at the University of California, Los Angeles.

The incidence of skin toxicity among patients who take the monoclonal antibodies cetuximab (Erbitux) or panitumumab (Vectibix) is somewhat higher compared with those who take the tyrosine kinase inhibitors erlotinib (Tarceva) or gefitinib (Iressa). All of the agents cause apoptosis of keratinocytes. "That's probably the major event that allows for what we see clinically in these patients," he said.

"We also know that there is early initiation of keratinocyte differentiation. In theory, that allows the stratum corneum to become impaired, which leads to many of these toxicities. We also know that inhibition of epidermal growth factor leads to epithelial cell production of proinflammatory mediators. That allows for the adaptive immune response to take hold," he explained.

Papulopustular lesions commonly occur on the face, chest, back, and scalp. The palms and soles are spared.

Histology reveals a thinned stratum corneum, dilated follicular infundibula, necrotic keratinocytes, and mixed inflammation in the upper dermis. "In addition, you may see acantholysis of the follicular epithelium," Dr. Cotliar said.

Ironically, skin toxicity—specifically the papulopustular lesions—is a surrogate marker for treatment efficacy of EGFRIs. "We know that this eruption is more severe and incidence is greater in responders to these medications than in those who don't respond," said Dr. Cotliar, who disclosed that he is a consultant for Amgen Inc., which manufactures panitumumab, and has received honoraria from the company.

"We also know that there is a nice correlation between survival, both overall and progression free, [and] severity of the rash. We don't know if this is an epiphenomenon or if there's something about the cutaneous toxicity that's allowing the immune response to percolate and fight the underlying cancer," he noted.

The severity of papulopustular lesions seems to be linked to the EGFRI dose. "We also know that patients typically develop these lesions 1–3 weeks after their first infusion or their first pills," he said. "The maximal toxicity occurs by weeks 3–5."

Once patients stop taking the EGFRI, the cutaneous side effects usually resolve within a couple of weeks.

There is no current standard for treating skin toxicity associated with EGFRI use. A proposed treatment algorithm was recently published (Oncologist 2007;12:610–21), but "everything we know about treating these patients is based on case reports," Dr. Cotliar said.

A first approach might involve modifying the dose of the EGFRI by following package insert instructions. Most patients referred to Dr. Cotliar and his associates are started on 1% or 2% hydrocortisone or sometimes tetracycline or doxycycline.

"A lot of times I will start patients on doxycycline 100 mg b.i.d.," he said. "I also typically start—for the first week or two—with a mid- to high-potency topical corticosteroid."

One "black hole" among possible treatment options is isotretinoin. "Nobody's sure what effect it has on tumor biology," he said. "We're also not sure of its effect on EGFRIs. We need to know more about that. We do know from case reports that 20–30 mg/day is successful in helping resolve some of these lesions."

Other potential treatments for papulopustular lesions include colloidal oatmeal lotion, topical erythromycin, clindamycin, metronidazole, and topical retinoids.

Potential treatments for xerosis and pruritus triggered by the use of EGFRIs include bland emollients and antihistamines.

Potential treatments for paronychia and fissures include aluminum acetate soaks, 4% thymol, emollients, topical corticosteroids, intralesional steroids, systemic antibiotics, electrodesiccation, cryosurgery, surgical debridement, and nail plate avulsion, Dr. Cotliar said.

Lastly, pulsed dye lasers can be used to treat telangiectasias.

Papulopustular lesions are commonly seen in patients who are taking epidermal growth factor inhibitors. Courtesy Dr. Jonathan Cotliar

CORONADO, CALIF. — Topical red wine, green tea, and caffeine polyphenols may play a role as chemopreventive agents for actinic keratoses and photodamaged skin, results from a small pilot study suggest.

The first part of the study was designed to assess the safety and efficacy of the individual polyphenols. The second part of the study was designed to assess the efficacy of combination therapy (green tea polyphenols plus vitamin C or red wine polyphenols plus caffeine), Dr. Karen F. Han said at the annual meeting of the Pacific Dermatologic Association.

Patients were eligible for the study if they had at least three actinic keratoses on each forearm, each dorsal hand, or the face/scalp/neck area, and were otherwise in good health.

In a double-blind, left-to-right placebo-controlled trial, the subjects were randomly assigned to one of the tested gels and a placebo gel. Patients were instructed to apply the gels twice a day for 12 weeks.

Before and after clinical photographs were taken, shave or 2-mm punch biopsies were obtained, and the patients were followed monthly for a total of four visits.

At each monthly follow-up visit, Dr. Han, a dermatologist in group practice in Palo Alto, Calif., mapped and counted actinic keratoses, took clinical photographs, and reviewed each patient's self-assessment form. The main outcome measure was the total number of residual actinic keratoses; the secondary outcome measure was an assessment of signs of photodamage, including dyschromia, wrinkling, texture, and telangiectasia.

In part 1 of the study, Dr. Han saw a statistically significant difference between the treatment sides and placebo sides in 11 of 14 patients. Of those 14 patients, 7 (50%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 60% to 100% clearance.

In part 2 of the study, Dr. Han observed a statistically significant difference between the treatment sides and the placebo sides in eight of nine patients who completed this component of the trial. Of those nine patients, seven (78%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 50% to 85% clearance.

Shantel Medical Supply Corp. supplied the gels used for the trial, but Dr. Han did not receive any financial support from the company.

Seven of nine patients had significantlyfewer actinic keratoses on the combination therapy side. DR. HAN

CORONADO, CALIF. — Topical red wine, green tea, and caffeine polyphenols may play a role as chemopreventive agents for actinic keratoses and photodamaged skin, results from a small pilot study suggest.

The first part of the study was designed to assess the safety and efficacy of the individual polyphenols. The second part of the study was designed to assess the efficacy of combination therapy (green tea polyphenols plus vitamin C or red wine polyphenols plus caffeine), Dr. Karen F. Han said at the annual meeting of the Pacific Dermatologic Association.

Patients were eligible for the study if they had at least three actinic keratoses on each forearm, each dorsal hand, or the face/scalp/neck area, and were otherwise in good health.

In a double-blind, left-to-right placebo-controlled trial, the subjects were randomly assigned to one of the tested gels and a placebo gel. Patients were instructed to apply the gels twice a day for 12 weeks.

Before and after clinical photographs were taken, shave or 2-mm punch biopsies were obtained, and the patients were followed monthly for a total of four visits.

At each monthly follow-up visit, Dr. Han, a dermatologist in group practice in Palo Alto, Calif., mapped and counted actinic keratoses, took clinical photographs, and reviewed each patient's self-assessment form. The main outcome measure was the total number of residual actinic keratoses; the secondary outcome measure was an assessment of signs of photodamage, including dyschromia, wrinkling, texture, and telangiectasia.

In part 1 of the study, Dr. Han saw a statistically significant difference between the treatment sides and placebo sides in 11 of 14 patients. Of those 14 patients, 7 (50%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 60% to 100% clearance.

In part 2 of the study, Dr. Han observed a statistically significant difference between the treatment sides and the placebo sides in eight of nine patients who completed this component of the trial. Of those nine patients, seven (78%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 50% to 85% clearance.

Shantel Medical Supply Corp. supplied the gels used for the trial, but Dr. Han did not receive any financial support from the company.

Seven of nine patients had significantlyfewer actinic keratoses on the combination therapy side. DR. HAN

CORONADO, CALIF. — Topical red wine, green tea, and caffeine polyphenols may play a role as chemopreventive agents for actinic keratoses and photodamaged skin, results from a small pilot study suggest.

The first part of the study was designed to assess the safety and efficacy of the individual polyphenols. The second part of the study was designed to assess the efficacy of combination therapy (green tea polyphenols plus vitamin C or red wine polyphenols plus caffeine), Dr. Karen F. Han said at the annual meeting of the Pacific Dermatologic Association.

Patients were eligible for the study if they had at least three actinic keratoses on each forearm, each dorsal hand, or the face/scalp/neck area, and were otherwise in good health.

In a double-blind, left-to-right placebo-controlled trial, the subjects were randomly assigned to one of the tested gels and a placebo gel. Patients were instructed to apply the gels twice a day for 12 weeks.

Before and after clinical photographs were taken, shave or 2-mm punch biopsies were obtained, and the patients were followed monthly for a total of four visits.

At each monthly follow-up visit, Dr. Han, a dermatologist in group practice in Palo Alto, Calif., mapped and counted actinic keratoses, took clinical photographs, and reviewed each patient's self-assessment form. The main outcome measure was the total number of residual actinic keratoses; the secondary outcome measure was an assessment of signs of photodamage, including dyschromia, wrinkling, texture, and telangiectasia.

In part 1 of the study, Dr. Han saw a statistically significant difference between the treatment sides and placebo sides in 11 of 14 patients. Of those 14 patients, 7 (50%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 60% to 100% clearance.

In part 2 of the study, Dr. Han observed a statistically significant difference between the treatment sides and the placebo sides in eight of nine patients who completed this component of the trial. Of those nine patients, seven (78%) had reduced numbers of actinic keratoses that favored the treatment side. The reduction ranged from 50% to 85% clearance.

Shantel Medical Supply Corp. supplied the gels used for the trial, but Dr. Han did not receive any financial support from the company.

Seven of nine patients had significantlyfewer actinic keratoses on the combination therapy side. DR. HAN

Death is not often discussed among physicians, but after Dr. Pauline W. Chen's critically acclaimed book, “Final Exam: A Surgeon's Reflections on Mortality,” (New York: Knopf, 2007) hit bookstores, many physicians approached her, eager to share their own stories about caring for patients at the end of life.

Many said they felt the same way, commented Dr. Chen, a transplant surgeon who lives near Boston.

The book chronicles her transformation from a student taught to depersonalize death to a transplant surgeon who must be emotionally present for patients and their families during the end of life. “I'm not an end-of-life care expert, but I hope that being open about my experience helps.”

In one chapter, she recalls the challenges of her Aunt Grace's kidney failure. She knew what to expect and was the person relatives turned to with questions. But she became preoccupied with her aunt's physical status and transplant candidacy and forgot about her as a person.

Three weeks before Aunt Grace died, she called her niece on the phone. Part of the conversation involved Dr. Chen's request to include her aunt's story in an article she was writing. Aunt Grace granted permission but insisted the article mention the care and support that Dr. Chen's uncle and cousin had provided her. “They have been here for me always,” Aunt Grace told her. “I owe everything to them.”

That brief conversation reminded Dr. Chen of the importance of caring for the person beyond the symptoms and illness.

Despite the growing popularity of palliative medicine and hospice care, Dr. Chen said that some physicians equate patients' deaths with failure. “The metaphor for a surgeon is that you've actually got your hand in there affecting the cure. When those deaths occur, it can be devastating … because you form relationships with your patients [and] you feel like you failed them and [your] profession.”

That sense of responsibility “can hamper our future ability to care for people and for ourselves,” she said. “We worsen the situation by not doing the little bit that we can, which is discussing [end-of-life care] with our patients and among ourselves. By talking about it—by being present for our patients—we can fulfill the ideals that brought us to medicine in the first place.”

Overwhelmed by Gratitude

When San Diego-area physicians feel isolated after a patient's death, many speak with Dr. Charles F. von Gunten, a consultant in hospice and palliative medicine.

“For most doctors, caring for a dying patient is very lonely, because all the other consultants go away,” said Dr. von Gunten, medical director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “If I agree they have done everything that can be done and are doing a good job, [it] helps them cope.”

Such support marks one benefit of expanding palliative care and hospice programs, but medicine has yet to devote adequate training to coping with death, said Dr. von Gunten, who also is editor in chief of the Journal of Palliative Medicine. “The message from the medical culture is, 'You should have no feelings about death.' [Medical training] teaches that doctors are not supposed to be upset by this.”

As an oncology fellow, Dr. von Gunten was rattled when his first patient died. He remembered what he'd learned: Send a sympathy note and attend the funeral of patients with whom you are close.

When Dr. von Gunten arrived at the funeral of one of his patients, the man's family expressed unexpected gratitude. “I couldn't make sense of how grateful the family was. With more maturity, I realized they were expressing gratitude for the sense that I had cared as a doctor, even though he didn't recover; and cared enough to stick with him and go to the funeral.”

Recently, a retired physician Dr. von Gunten had been caring for died. He sent a note to the man's daughters, who asked him to be a pallbearer. “It was their way of saying, 'You were important to him. You're an important part of our family in the doctor role.' It reaffirmed why I wanted to be a doctor. It was a very special day,” he said.

No One Is Immune

When two patients of Dr. Robert S. McKelvey committed suicide during his psychiatry residency in the 1970s, he was so devastated he considered leaving the field.

“I took it that I wasn't doing a good enough job or that I wasn't cut out to be a psychiatrist,” recalled Dr. McKelvey, now director of the division of child and adolescent psychiatry at Oregon Health and Science University, Portland.

Physicians' reactions to death vary, said Dr. McKelvey, author of “When a Child Dies: How Pediatric Physicians and Nurses Cope” (Seattle: University of Washington Press, 2007). Patient deaths tend to affect residents and early-career physicians the most, but no physician is immune.

“No matter how experienced you are, there are going to be situations that really affect you,” said Dr. McKelvey, who interviewed about 35 pediatricians, pediatric residents, and pediatric nurses for his book.

He discovered that many coped with a dying child by focusing their energies on keeping the child comfortable, explaining the circumstances to the family, and being emotionally present for them.

One strategy is to share your feelings with someone. “Physicians usually find either someone within their own field to talk to, or a professional listener like a psychiatrist or psychologist, or their spouse. [It helps] to continue to do the job. You realize you have only a limited amount of control over what happens to patients.”

Death is not often discussed among physicians, but after Dr. Pauline W. Chen's critically acclaimed book, “Final Exam: A Surgeon's Reflections on Mortality,” (New York: Knopf, 2007) hit bookstores, many physicians approached her, eager to share their own stories about caring for patients at the end of life.

Many said they felt the same way, commented Dr. Chen, a transplant surgeon who lives near Boston.

The book chronicles her transformation from a student taught to depersonalize death to a transplant surgeon who must be emotionally present for patients and their families during the end of life. “I'm not an end-of-life care expert, but I hope that being open about my experience helps.”

In one chapter, she recalls the challenges of her Aunt Grace's kidney failure. She knew what to expect and was the person relatives turned to with questions. But she became preoccupied with her aunt's physical status and transplant candidacy and forgot about her as a person.

Three weeks before Aunt Grace died, she called her niece on the phone. Part of the conversation involved Dr. Chen's request to include her aunt's story in an article she was writing. Aunt Grace granted permission but insisted the article mention the care and support that Dr. Chen's uncle and cousin had provided her. “They have been here for me always,” Aunt Grace told her. “I owe everything to them.”

That brief conversation reminded Dr. Chen of the importance of caring for the person beyond the symptoms and illness.

Despite the growing popularity of palliative medicine and hospice care, Dr. Chen said that some physicians equate patients' deaths with failure. “The metaphor for a surgeon is that you've actually got your hand in there affecting the cure. When those deaths occur, it can be devastating … because you form relationships with your patients [and] you feel like you failed them and [your] profession.”

That sense of responsibility “can hamper our future ability to care for people and for ourselves,” she said. “We worsen the situation by not doing the little bit that we can, which is discussing [end-of-life care] with our patients and among ourselves. By talking about it—by being present for our patients—we can fulfill the ideals that brought us to medicine in the first place.”

Overwhelmed by Gratitude

When San Diego-area physicians feel isolated after a patient's death, many speak with Dr. Charles F. von Gunten, a consultant in hospice and palliative medicine.

“For most doctors, caring for a dying patient is very lonely, because all the other consultants go away,” said Dr. von Gunten, medical director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “If I agree they have done everything that can be done and are doing a good job, [it] helps them cope.”

Such support marks one benefit of expanding palliative care and hospice programs, but medicine has yet to devote adequate training to coping with death, said Dr. von Gunten, who also is editor in chief of the Journal of Palliative Medicine. “The message from the medical culture is, 'You should have no feelings about death.' [Medical training] teaches that doctors are not supposed to be upset by this.”

As an oncology fellow, Dr. von Gunten was rattled when his first patient died. He remembered what he'd learned: Send a sympathy note and attend the funeral of patients with whom you are close.

When Dr. von Gunten arrived at the funeral of one of his patients, the man's family expressed unexpected gratitude. “I couldn't make sense of how grateful the family was. With more maturity, I realized they were expressing gratitude for the sense that I had cared as a doctor, even though he didn't recover; and cared enough to stick with him and go to the funeral.”

Recently, a retired physician Dr. von Gunten had been caring for died. He sent a note to the man's daughters, who asked him to be a pallbearer. “It was their way of saying, 'You were important to him. You're an important part of our family in the doctor role.' It reaffirmed why I wanted to be a doctor. It was a very special day,” he said.

No One Is Immune

When two patients of Dr. Robert S. McKelvey committed suicide during his psychiatry residency in the 1970s, he was so devastated he considered leaving the field.

“I took it that I wasn't doing a good enough job or that I wasn't cut out to be a psychiatrist,” recalled Dr. McKelvey, now director of the division of child and adolescent psychiatry at Oregon Health and Science University, Portland.

Physicians' reactions to death vary, said Dr. McKelvey, author of “When a Child Dies: How Pediatric Physicians and Nurses Cope” (Seattle: University of Washington Press, 2007). Patient deaths tend to affect residents and early-career physicians the most, but no physician is immune.

“No matter how experienced you are, there are going to be situations that really affect you,” said Dr. McKelvey, who interviewed about 35 pediatricians, pediatric residents, and pediatric nurses for his book.

He discovered that many coped with a dying child by focusing their energies on keeping the child comfortable, explaining the circumstances to the family, and being emotionally present for them.

One strategy is to share your feelings with someone. “Physicians usually find either someone within their own field to talk to, or a professional listener like a psychiatrist or psychologist, or their spouse. [It helps] to continue to do the job. You realize you have only a limited amount of control over what happens to patients.”

Death is not often discussed among physicians, but after Dr. Pauline W. Chen's critically acclaimed book, “Final Exam: A Surgeon's Reflections on Mortality,” (New York: Knopf, 2007) hit bookstores, many physicians approached her, eager to share their own stories about caring for patients at the end of life.

Many said they felt the same way, commented Dr. Chen, a transplant surgeon who lives near Boston.

The book chronicles her transformation from a student taught to depersonalize death to a transplant surgeon who must be emotionally present for patients and their families during the end of life. “I'm not an end-of-life care expert, but I hope that being open about my experience helps.”

In one chapter, she recalls the challenges of her Aunt Grace's kidney failure. She knew what to expect and was the person relatives turned to with questions. But she became preoccupied with her aunt's physical status and transplant candidacy and forgot about her as a person.

Three weeks before Aunt Grace died, she called her niece on the phone. Part of the conversation involved Dr. Chen's request to include her aunt's story in an article she was writing. Aunt Grace granted permission but insisted the article mention the care and support that Dr. Chen's uncle and cousin had provided her. “They have been here for me always,” Aunt Grace told her. “I owe everything to them.”

That brief conversation reminded Dr. Chen of the importance of caring for the person beyond the symptoms and illness.

Despite the growing popularity of palliative medicine and hospice care, Dr. Chen said that some physicians equate patients' deaths with failure. “The metaphor for a surgeon is that you've actually got your hand in there affecting the cure. When those deaths occur, it can be devastating … because you form relationships with your patients [and] you feel like you failed them and [your] profession.”

That sense of responsibility “can hamper our future ability to care for people and for ourselves,” she said. “We worsen the situation by not doing the little bit that we can, which is discussing [end-of-life care] with our patients and among ourselves. By talking about it—by being present for our patients—we can fulfill the ideals that brought us to medicine in the first place.”

Overwhelmed by Gratitude

When San Diego-area physicians feel isolated after a patient's death, many speak with Dr. Charles F. von Gunten, a consultant in hospice and palliative medicine.

“For most doctors, caring for a dying patient is very lonely, because all the other consultants go away,” said Dr. von Gunten, medical director of the Center for Palliative Studies at San Diego Hospice and Palliative Care. “If I agree they have done everything that can be done and are doing a good job, [it] helps them cope.”

Such support marks one benefit of expanding palliative care and hospice programs, but medicine has yet to devote adequate training to coping with death, said Dr. von Gunten, who also is editor in chief of the Journal of Palliative Medicine. “The message from the medical culture is, 'You should have no feelings about death.' [Medical training] teaches that doctors are not supposed to be upset by this.”

As an oncology fellow, Dr. von Gunten was rattled when his first patient died. He remembered what he'd learned: Send a sympathy note and attend the funeral of patients with whom you are close.

When Dr. von Gunten arrived at the funeral of one of his patients, the man's family expressed unexpected gratitude. “I couldn't make sense of how grateful the family was. With more maturity, I realized they were expressing gratitude for the sense that I had cared as a doctor, even though he didn't recover; and cared enough to stick with him and go to the funeral.”

Recently, a retired physician Dr. von Gunten had been caring for died. He sent a note to the man's daughters, who asked him to be a pallbearer. “It was their way of saying, 'You were important to him. You're an important part of our family in the doctor role.' It reaffirmed why I wanted to be a doctor. It was a very special day,” he said.

No One Is Immune

When two patients of Dr. Robert S. McKelvey committed suicide during his psychiatry residency in the 1970s, he was so devastated he considered leaving the field.

“I took it that I wasn't doing a good enough job or that I wasn't cut out to be a psychiatrist,” recalled Dr. McKelvey, now director of the division of child and adolescent psychiatry at Oregon Health and Science University, Portland.

Physicians' reactions to death vary, said Dr. McKelvey, author of “When a Child Dies: How Pediatric Physicians and Nurses Cope” (Seattle: University of Washington Press, 2007). Patient deaths tend to affect residents and early-career physicians the most, but no physician is immune.

“No matter how experienced you are, there are going to be situations that really affect you,” said Dr. McKelvey, who interviewed about 35 pediatricians, pediatric residents, and pediatric nurses for his book.

He discovered that many coped with a dying child by focusing their energies on keeping the child comfortable, explaining the circumstances to the family, and being emotionally present for them.

One strategy is to share your feelings with someone. “Physicians usually find either someone within their own field to talk to, or a professional listener like a psychiatrist or psychologist, or their spouse. [It helps] to continue to do the job. You realize you have only a limited amount of control over what happens to patients.”