Doug Brunk

SAN DIEGO – Obesity-related liver disease may be clinically underrecognized, results from a single-center study showed.

“Our results indicate that a normal liver ultrasound, liver function tests, and gross appearance does not exclude the presence of significant liver disease,” the researchers, led by Dr. Joshua E. Roller, wrote in a poster presented at the annual meeting of the American Society for Bariatric Surgery. “If certain subgroups of morbidly obese patients can be identified that are at increased risk for liver disease progression, then intervention with bariatric surgery may become especially critical, and should be aggressively pursued.”

The researchers, of Duke Weight Loss Surgery Center at Duke University, Durham, N.C., reviewed the demographic, perioperative, and liver biopsy data from 153 patients who underwent Roux-en-Y gastric bypass for morbid obesity from January 2005 to September 2006. The mean age of patients was 41 years, their mean body mass index was 48 kg/m

The researchers reported that preoperatively only 7.8% of patients had abnormal liver function tests, and ultrasound detected fatty liver in 35% of patients.

However, 92% of patients had abnormal liver biopsies: mild steatosis was present in 58.3%, moderate steatosis was found in 21.1%, and 12.6% of patients had severe steatosis. Fibrosis was present in 12.6% of the liver biopsy specimens.

Intraoperatively, the liver appeared normal by surgeon observation in 65% of patients, whereas the rest of the patients appeared to have a fatty and/or enlarged liver. The researchers identified nonalcoholic steatohepatitis in 24.5% of patients with steatosis, of whom 48.6% had mild fibrosis.

Nonalcoholic steatohepatitis was significantly more common in men than in women (45.8% vs. 20.5%, respectively) and in whites compared with African Americans (27.9% vs. 9.7%). Patients aged 50 years and older had higher rates of nonalcoholic steatohepatitis than did their younger counterparts, but the difference was not statistically significant (35% vs. 20.5%).

Liver fibrosis was significantly more common in whites than in African Americans (16.4% vs. 0%, respectively) and in men compared with women (33.3% vs. 8.5%).

No associations were detected between the presence of nonalcoholic steatohepatitis or liver fibrosis and preoperative weight loss, weight gain, or body mass index.

SAN DIEGO – Obesity-related liver disease may be clinically underrecognized, results from a single-center study showed.

“Our results indicate that a normal liver ultrasound, liver function tests, and gross appearance does not exclude the presence of significant liver disease,” the researchers, led by Dr. Joshua E. Roller, wrote in a poster presented at the annual meeting of the American Society for Bariatric Surgery. “If certain subgroups of morbidly obese patients can be identified that are at increased risk for liver disease progression, then intervention with bariatric surgery may become especially critical, and should be aggressively pursued.”

The researchers, of Duke Weight Loss Surgery Center at Duke University, Durham, N.C., reviewed the demographic, perioperative, and liver biopsy data from 153 patients who underwent Roux-en-Y gastric bypass for morbid obesity from January 2005 to September 2006. The mean age of patients was 41 years, their mean body mass index was 48 kg/m

The researchers reported that preoperatively only 7.8% of patients had abnormal liver function tests, and ultrasound detected fatty liver in 35% of patients.

However, 92% of patients had abnormal liver biopsies: mild steatosis was present in 58.3%, moderate steatosis was found in 21.1%, and 12.6% of patients had severe steatosis. Fibrosis was present in 12.6% of the liver biopsy specimens.

Intraoperatively, the liver appeared normal by surgeon observation in 65% of patients, whereas the rest of the patients appeared to have a fatty and/or enlarged liver. The researchers identified nonalcoholic steatohepatitis in 24.5% of patients with steatosis, of whom 48.6% had mild fibrosis.

Nonalcoholic steatohepatitis was significantly more common in men than in women (45.8% vs. 20.5%, respectively) and in whites compared with African Americans (27.9% vs. 9.7%). Patients aged 50 years and older had higher rates of nonalcoholic steatohepatitis than did their younger counterparts, but the difference was not statistically significant (35% vs. 20.5%).

Liver fibrosis was significantly more common in whites than in African Americans (16.4% vs. 0%, respectively) and in men compared with women (33.3% vs. 8.5%).

No associations were detected between the presence of nonalcoholic steatohepatitis or liver fibrosis and preoperative weight loss, weight gain, or body mass index.

SAN DIEGO – Obesity-related liver disease may be clinically underrecognized, results from a single-center study showed.

“Our results indicate that a normal liver ultrasound, liver function tests, and gross appearance does not exclude the presence of significant liver disease,” the researchers, led by Dr. Joshua E. Roller, wrote in a poster presented at the annual meeting of the American Society for Bariatric Surgery. “If certain subgroups of morbidly obese patients can be identified that are at increased risk for liver disease progression, then intervention with bariatric surgery may become especially critical, and should be aggressively pursued.”

The researchers, of Duke Weight Loss Surgery Center at Duke University, Durham, N.C., reviewed the demographic, perioperative, and liver biopsy data from 153 patients who underwent Roux-en-Y gastric bypass for morbid obesity from January 2005 to September 2006. The mean age of patients was 41 years, their mean body mass index was 48 kg/m

The researchers reported that preoperatively only 7.8% of patients had abnormal liver function tests, and ultrasound detected fatty liver in 35% of patients.

However, 92% of patients had abnormal liver biopsies: mild steatosis was present in 58.3%, moderate steatosis was found in 21.1%, and 12.6% of patients had severe steatosis. Fibrosis was present in 12.6% of the liver biopsy specimens.

Intraoperatively, the liver appeared normal by surgeon observation in 65% of patients, whereas the rest of the patients appeared to have a fatty and/or enlarged liver. The researchers identified nonalcoholic steatohepatitis in 24.5% of patients with steatosis, of whom 48.6% had mild fibrosis.

Nonalcoholic steatohepatitis was significantly more common in men than in women (45.8% vs. 20.5%, respectively) and in whites compared with African Americans (27.9% vs. 9.7%). Patients aged 50 years and older had higher rates of nonalcoholic steatohepatitis than did their younger counterparts, but the difference was not statistically significant (35% vs. 20.5%).

Liver fibrosis was significantly more common in whites than in African Americans (16.4% vs. 0%, respectively) and in men compared with women (33.3% vs. 8.5%).

No associations were detected between the presence of nonalcoholic steatohepatitis or liver fibrosis and preoperative weight loss, weight gain, or body mass index.

SAN DIEGO – Asthma may be overdiagnosed in many obese African American women who present with dyspnea, results from a small pilot study suggest.

The finding is important because the incidence rates of asthma and obesity have increased over the last 20 years, especially among African American women, Dr. Daniel Waggoner reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

“If somebody gives you a very good history of asthma symptoms, sometimes it's a little bit easier to make the diagnosis,” Dr. Waggoner, of the division of allergy and immunology at Creighton University, Omaha, Neb., said in an interview.

“But if somebody comes in with rather nebulous symptoms, it's very important to get some objective testing to make a diagnosis [of asthma], because many medications [for it] have side effects, and they're expensive,” Dr. Waggoner continued.

He and his associates evaluated 18 African American women aged 19-50 years who live in or near Omaha and who had a physician diagnosis of asthma for at least 3 months. All had a body mass index (kg/m

Over the course of three office visits, the researchers performed the following measurements in each patient to verify the asthma diagnosis: spirometry with postbronchodilator values, exhaled nitric oxide (eNO), methacholine challenges, and full-body plethysmography. Each of the four tests was considered a positive criterion for the diagnosis of asthma.

Dr. Waggoner reported that of the 18 patients, only 8 (44%) had a positive methacholine challenge, 1 (6%) had demonstrated airway reversibility on spirometry, 10 (56%) had elevated eNO, and 6 (33%) had airflow obstruction as measured by plethysmography.

No patient met all four criteria for the diagnosis of asthma, and only 39% met two or more of the criteria.

“Only one patient did not have an albuterol prescription,” Dr. Waggoner added during the interview. “I was really surprised that we didn't have at least a handful more [who] demonstrated reversibility with albuterol or a bronchodilator.”

In their poster, the researchers concluded that in African American women who present with dyspnea, “an eNO and methacholine challenge should be considered to confirm or refute the diagnosis of asthma. Full-body plethysmography may provide clues to etiologies of dyspnea other than asthma, [such as physiologic air trapping] associated with obesity.”

The study was funded by the State of Nebraska Tobacco Settlement.

'If somebody comes in with rather nebulous symptoms, it's very important to get some objective testing.' DR. WAGGONER

SAN DIEGO – Asthma may be overdiagnosed in many obese African American women who present with dyspnea, results from a small pilot study suggest.

The finding is important because the incidence rates of asthma and obesity have increased over the last 20 years, especially among African American women, Dr. Daniel Waggoner reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

“If somebody gives you a very good history of asthma symptoms, sometimes it's a little bit easier to make the diagnosis,” Dr. Waggoner, of the division of allergy and immunology at Creighton University, Omaha, Neb., said in an interview.

“But if somebody comes in with rather nebulous symptoms, it's very important to get some objective testing to make a diagnosis [of asthma], because many medications [for it] have side effects, and they're expensive,” Dr. Waggoner continued.

He and his associates evaluated 18 African American women aged 19-50 years who live in or near Omaha and who had a physician diagnosis of asthma for at least 3 months. All had a body mass index (kg/m

Over the course of three office visits, the researchers performed the following measurements in each patient to verify the asthma diagnosis: spirometry with postbronchodilator values, exhaled nitric oxide (eNO), methacholine challenges, and full-body plethysmography. Each of the four tests was considered a positive criterion for the diagnosis of asthma.

Dr. Waggoner reported that of the 18 patients, only 8 (44%) had a positive methacholine challenge, 1 (6%) had demonstrated airway reversibility on spirometry, 10 (56%) had elevated eNO, and 6 (33%) had airflow obstruction as measured by plethysmography.

No patient met all four criteria for the diagnosis of asthma, and only 39% met two or more of the criteria.

“Only one patient did not have an albuterol prescription,” Dr. Waggoner added during the interview. “I was really surprised that we didn't have at least a handful more [who] demonstrated reversibility with albuterol or a bronchodilator.”

In their poster, the researchers concluded that in African American women who present with dyspnea, “an eNO and methacholine challenge should be considered to confirm or refute the diagnosis of asthma. Full-body plethysmography may provide clues to etiologies of dyspnea other than asthma, [such as physiologic air trapping] associated with obesity.”

The study was funded by the State of Nebraska Tobacco Settlement.

'If somebody comes in with rather nebulous symptoms, it's very important to get some objective testing.' DR. WAGGONER

SAN DIEGO – Asthma may be overdiagnosed in many obese African American women who present with dyspnea, results from a small pilot study suggest.

The finding is important because the incidence rates of asthma and obesity have increased over the last 20 years, especially among African American women, Dr. Daniel Waggoner reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

“If somebody gives you a very good history of asthma symptoms, sometimes it's a little bit easier to make the diagnosis,” Dr. Waggoner, of the division of allergy and immunology at Creighton University, Omaha, Neb., said in an interview.

“But if somebody comes in with rather nebulous symptoms, it's very important to get some objective testing to make a diagnosis [of asthma], because many medications [for it] have side effects, and they're expensive,” Dr. Waggoner continued.

He and his associates evaluated 18 African American women aged 19-50 years who live in or near Omaha and who had a physician diagnosis of asthma for at least 3 months. All had a body mass index (kg/m

Over the course of three office visits, the researchers performed the following measurements in each patient to verify the asthma diagnosis: spirometry with postbronchodilator values, exhaled nitric oxide (eNO), methacholine challenges, and full-body plethysmography. Each of the four tests was considered a positive criterion for the diagnosis of asthma.

Dr. Waggoner reported that of the 18 patients, only 8 (44%) had a positive methacholine challenge, 1 (6%) had demonstrated airway reversibility on spirometry, 10 (56%) had elevated eNO, and 6 (33%) had airflow obstruction as measured by plethysmography.

No patient met all four criteria for the diagnosis of asthma, and only 39% met two or more of the criteria.

“Only one patient did not have an albuterol prescription,” Dr. Waggoner added during the interview. “I was really surprised that we didn't have at least a handful more [who] demonstrated reversibility with albuterol or a bronchodilator.”

In their poster, the researchers concluded that in African American women who present with dyspnea, “an eNO and methacholine challenge should be considered to confirm or refute the diagnosis of asthma. Full-body plethysmography may provide clues to etiologies of dyspnea other than asthma, [such as physiologic air trapping] associated with obesity.”

The study was funded by the State of Nebraska Tobacco Settlement.

'If somebody comes in with rather nebulous symptoms, it's very important to get some objective testing.' DR. WAGGONER

SAN DIEGO — Thirteen percent of patients who underwent laparoscopic adjustable gastric banding required a major reoperation, results from a long-term, single-center study showed.

“We see complications, even many years after surgery,” Dr. Vincenzo Bacci said at the annual meeting of the American Society for Bariatric Surgery. “This information should really be conveyed to our surgical candidates. Lifelong management and surveillance are necessary for these patients.”

He and his associates studied the rate and causes of reoperation in 448 patients who underwent laparoscopic adjustable gastric banding at La Sapienza University in Rome, between 1996 and 2006. In 2002 the perigastric technique was replaced by the pars flaccida approach. Of the 448 patients, 83% were women; their average body mass index was 43 kg/m

Dr. Bacci reported that 59 patients (13%) required a major reoperation for band repositioning/removal or revision, and 29 patients (6%) required a minor reoperation for port complications. The rate of major reoperation was 4.1 per 100 person-years, while the rate of minor reoperation was 2.1 per 100 person-years.

Patients with a BMI of greater than 50 kg/m

SAN DIEGO — Thirteen percent of patients who underwent laparoscopic adjustable gastric banding required a major reoperation, results from a long-term, single-center study showed.

“We see complications, even many years after surgery,” Dr. Vincenzo Bacci said at the annual meeting of the American Society for Bariatric Surgery. “This information should really be conveyed to our surgical candidates. Lifelong management and surveillance are necessary for these patients.”

He and his associates studied the rate and causes of reoperation in 448 patients who underwent laparoscopic adjustable gastric banding at La Sapienza University in Rome, between 1996 and 2006. In 2002 the perigastric technique was replaced by the pars flaccida approach. Of the 448 patients, 83% were women; their average body mass index was 43 kg/m

Dr. Bacci reported that 59 patients (13%) required a major reoperation for band repositioning/removal or revision, and 29 patients (6%) required a minor reoperation for port complications. The rate of major reoperation was 4.1 per 100 person-years, while the rate of minor reoperation was 2.1 per 100 person-years.

Patients with a BMI of greater than 50 kg/m

SAN DIEGO — Thirteen percent of patients who underwent laparoscopic adjustable gastric banding required a major reoperation, results from a long-term, single-center study showed.

“We see complications, even many years after surgery,” Dr. Vincenzo Bacci said at the annual meeting of the American Society for Bariatric Surgery. “This information should really be conveyed to our surgical candidates. Lifelong management and surveillance are necessary for these patients.”

He and his associates studied the rate and causes of reoperation in 448 patients who underwent laparoscopic adjustable gastric banding at La Sapienza University in Rome, between 1996 and 2006. In 2002 the perigastric technique was replaced by the pars flaccida approach. Of the 448 patients, 83% were women; their average body mass index was 43 kg/m

Dr. Bacci reported that 59 patients (13%) required a major reoperation for band repositioning/removal or revision, and 29 patients (6%) required a minor reoperation for port complications. The rate of major reoperation was 4.1 per 100 person-years, while the rate of minor reoperation was 2.1 per 100 person-years.

Patients with a BMI of greater than 50 kg/m

SAN DIEGO — Nearly one-third of patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity were admitted to the emergency department, results from a 3-year, single-center study showed.

Abdominal pain and vomiting were the most common symptoms, Dr. Raul J. Rosenthal said at the annual meeting of the American Society for Bariatric Surgery.

Most patients who required emergency department (ED) admission (87%) were treated medically, but 12% required further surgery, said Dr. Rosenthal, a bariatric surgeon with Cleveland Clinic in Weston, Fla. It “is important to know that 12% of patients that come to the emergency room in the first year may end up in the operating room,” he said.

He and his associates studied the medical records of 733 people who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity between 2001 and 2004. The mean age of patients was 45 years, and their mean body mass index was 50 kg/m

Of the 733 patients studied over the 3-year period at the Cleveland Clinic in Weston, 228 (31%) had a history of ED admission. Patients who experienced postoperative complications within 6 days of surgery had a higher rate of ED admissions than did those who experienced postoperative complications on or after 7 days (61% vs. 30%, respectively).

Operation time was significantly longer for patients in the ED admission group (a mean of 91 minutes vs. 87 minutes among those who did not require admission to the emergency department).

Abdominal pain was the most common presenting symptom, followed by vomiting and both nausea and vomiting.

The most common diagnosis was dehydration, followed by obstruction of an anastomosis and stomal ulcer.

Dr. Rosenthal noted that 82% of the emergency department admissions occurred in postoperative year 1. Of these patients, 25% were admitted to the hospital and 12% required surgical treatment.

Of the 733 patients studied over the 3-year period, 228 (31%) had a history of ED admission. DR. ROSENTHAL

SAN DIEGO — Nearly one-third of patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity were admitted to the emergency department, results from a 3-year, single-center study showed.

Abdominal pain and vomiting were the most common symptoms, Dr. Raul J. Rosenthal said at the annual meeting of the American Society for Bariatric Surgery.

Most patients who required emergency department (ED) admission (87%) were treated medically, but 12% required further surgery, said Dr. Rosenthal, a bariatric surgeon with Cleveland Clinic in Weston, Fla. It “is important to know that 12% of patients that come to the emergency room in the first year may end up in the operating room,” he said.

He and his associates studied the medical records of 733 people who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity between 2001 and 2004. The mean age of patients was 45 years, and their mean body mass index was 50 kg/m

Of the 733 patients studied over the 3-year period at the Cleveland Clinic in Weston, 228 (31%) had a history of ED admission. Patients who experienced postoperative complications within 6 days of surgery had a higher rate of ED admissions than did those who experienced postoperative complications on or after 7 days (61% vs. 30%, respectively).

Operation time was significantly longer for patients in the ED admission group (a mean of 91 minutes vs. 87 minutes among those who did not require admission to the emergency department).

Abdominal pain was the most common presenting symptom, followed by vomiting and both nausea and vomiting.

The most common diagnosis was dehydration, followed by obstruction of an anastomosis and stomal ulcer.

Dr. Rosenthal noted that 82% of the emergency department admissions occurred in postoperative year 1. Of these patients, 25% were admitted to the hospital and 12% required surgical treatment.

Of the 733 patients studied over the 3-year period, 228 (31%) had a history of ED admission. DR. ROSENTHAL

SAN DIEGO — Nearly one-third of patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity were admitted to the emergency department, results from a 3-year, single-center study showed.

Abdominal pain and vomiting were the most common symptoms, Dr. Raul J. Rosenthal said at the annual meeting of the American Society for Bariatric Surgery.

Most patients who required emergency department (ED) admission (87%) were treated medically, but 12% required further surgery, said Dr. Rosenthal, a bariatric surgeon with Cleveland Clinic in Weston, Fla. It “is important to know that 12% of patients that come to the emergency room in the first year may end up in the operating room,” he said.

He and his associates studied the medical records of 733 people who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity between 2001 and 2004. The mean age of patients was 45 years, and their mean body mass index was 50 kg/m

Of the 733 patients studied over the 3-year period at the Cleveland Clinic in Weston, 228 (31%) had a history of ED admission. Patients who experienced postoperative complications within 6 days of surgery had a higher rate of ED admissions than did those who experienced postoperative complications on or after 7 days (61% vs. 30%, respectively).

Operation time was significantly longer for patients in the ED admission group (a mean of 91 minutes vs. 87 minutes among those who did not require admission to the emergency department).

Abdominal pain was the most common presenting symptom, followed by vomiting and both nausea and vomiting.

The most common diagnosis was dehydration, followed by obstruction of an anastomosis and stomal ulcer.

Dr. Rosenthal noted that 82% of the emergency department admissions occurred in postoperative year 1. Of these patients, 25% were admitted to the hospital and 12% required surgical treatment.

Of the 733 patients studied over the 3-year period, 228 (31%) had a history of ED admission. DR. ROSENTHAL

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

SAN DIEGO — Morbidly obese patients who underwent gastric banding had a 60% lower risk of death at 5 years than a group of morbidly obese patients who did not undergo any obesity surgery, results from a large Italian study demonstrated.

Dr. Luca Busetto and his associates studied 821 consecutive patients with a body mass index of greater than 40 kg/m

The mean age of patients was 25 years, Dr. Busetto reported at the annual meeting of the American Society for Bariatric Surgery. The mean follow-up was 5.6 years in the gastric banding group and 7.2 years in the nonsurgical group. Vital status upon study entry was available for 91% of patients in the gastric banding group and in 97% of patients in the nonsurgical group.

Eight deaths occurred in the gastric banding group, compared with 36 deaths in the nonsurgical group, for a total mortality of about 1% and 4%, respectively.

The rate of revisional surgery in the gastric banding group was 13%. The percent of weight loss in this group peaked at 42% in the second year of follow-up and remained stable up to 6 years after surgery.

Multivariate analysis revealed that gastric banding conferred a 60% reduced risk of death, compared with patients in the nonsurgical group. “The reduction in mortality by [gastric] banding seems to be more pronounced in women than in men, in middle-aged than in younger patients, and in superobese than in morbidly obese patients,” Dr. Busetto commented. “However, the number of events observed in the two groups was generally low. Therefore, the results of this subgroup analysis should be interpreted very cautiously.”

He acknowledged that the differences in mortality between the two groups of patients “may be due to some difference in baseline clinical status that remains undetected in our study, in particular the difference in comorbidities.”

Dr. Busetto disclosed that he is a consultant for Allergan and Medtronic. He also is a speaker for Abbott Laboratories.

The number of events observed was generally low. Therefore, the results should be interpreted 'very cautiously.' DR. BUSETTO

SAN DIEGO — Morbidly obese patients who underwent gastric banding had a 60% lower risk of death at 5 years than a group of morbidly obese patients who did not undergo any obesity surgery, results from a large Italian study demonstrated.

Dr. Luca Busetto and his associates studied 821 consecutive patients with a body mass index of greater than 40 kg/m

The mean age of patients was 25 years, Dr. Busetto reported at the annual meeting of the American Society for Bariatric Surgery. The mean follow-up was 5.6 years in the gastric banding group and 7.2 years in the nonsurgical group. Vital status upon study entry was available for 91% of patients in the gastric banding group and in 97% of patients in the nonsurgical group.

Eight deaths occurred in the gastric banding group, compared with 36 deaths in the nonsurgical group, for a total mortality of about 1% and 4%, respectively.

The rate of revisional surgery in the gastric banding group was 13%. The percent of weight loss in this group peaked at 42% in the second year of follow-up and remained stable up to 6 years after surgery.

Multivariate analysis revealed that gastric banding conferred a 60% reduced risk of death, compared with patients in the nonsurgical group. “The reduction in mortality by [gastric] banding seems to be more pronounced in women than in men, in middle-aged than in younger patients, and in superobese than in morbidly obese patients,” Dr. Busetto commented. “However, the number of events observed in the two groups was generally low. Therefore, the results of this subgroup analysis should be interpreted very cautiously.”

He acknowledged that the differences in mortality between the two groups of patients “may be due to some difference in baseline clinical status that remains undetected in our study, in particular the difference in comorbidities.”

Dr. Busetto disclosed that he is a consultant for Allergan and Medtronic. He also is a speaker for Abbott Laboratories.

The number of events observed was generally low. Therefore, the results should be interpreted 'very cautiously.' DR. BUSETTO

SAN DIEGO — Morbidly obese patients who underwent gastric banding had a 60% lower risk of death at 5 years than a group of morbidly obese patients who did not undergo any obesity surgery, results from a large Italian study demonstrated.

Dr. Luca Busetto and his associates studied 821 consecutive patients with a body mass index of greater than 40 kg/m

The mean age of patients was 25 years, Dr. Busetto reported at the annual meeting of the American Society for Bariatric Surgery. The mean follow-up was 5.6 years in the gastric banding group and 7.2 years in the nonsurgical group. Vital status upon study entry was available for 91% of patients in the gastric banding group and in 97% of patients in the nonsurgical group.

Eight deaths occurred in the gastric banding group, compared with 36 deaths in the nonsurgical group, for a total mortality of about 1% and 4%, respectively.

The rate of revisional surgery in the gastric banding group was 13%. The percent of weight loss in this group peaked at 42% in the second year of follow-up and remained stable up to 6 years after surgery.

Multivariate analysis revealed that gastric banding conferred a 60% reduced risk of death, compared with patients in the nonsurgical group. “The reduction in mortality by [gastric] banding seems to be more pronounced in women than in men, in middle-aged than in younger patients, and in superobese than in morbidly obese patients,” Dr. Busetto commented. “However, the number of events observed in the two groups was generally low. Therefore, the results of this subgroup analysis should be interpreted very cautiously.”

He acknowledged that the differences in mortality between the two groups of patients “may be due to some difference in baseline clinical status that remains undetected in our study, in particular the difference in comorbidities.”

Dr. Busetto disclosed that he is a consultant for Allergan and Medtronic. He also is a speaker for Abbott Laboratories.

The number of events observed was generally low. Therefore, the results should be interpreted 'very cautiously.' DR. BUSETTO

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT

CARMEL, CALIF. – If preliminary results from an ongoing study are accurate, low baseline total serum testosterone levels could be a marker for obstructive sleep apnea in older men, Yao Schmidt reported at the Western regional meeting of the American Federation for Medical Research.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism, said Ms. Schmidt, who is a second-year medical student at the University of Colorado Health Sciences Center, Denver.

As part of a larger, ongoing study on the effects of exercise on the elderly, she and her associates at the university's Center on Aging evaluated 28 men aged 60–80 years. They recorded each man's apnea-hypopnea index (AHI), baseline total serum testosterone level, age, body mass index (BMI), neck size, and LDL cholesterol level.

The mean age of the men in both groups was 67 years, mean BMI was 29 kg/m

A total of 180 men are expected to enroll in the study through the end of 2009.

The issue is important because 20%–60% of men aged 60–80 years have borderline hypogonadism. MS. SCHMIDT

CARMEL, CALIF. – The evidence for using cholinesterase inhibitors in patients diagnosed with Alzheimer's disease “is pretty darned poor,” Dr. Laura Mosqueda said at the Western regional meeting of the American Federation for Medical Research.

She based her remarks on two recent meta-analyses of the topic. The first was a systematic review of randomized clinical trials of the cholinesterase inhibitors donepezil, rivastigmine, and galantamine.

In a search of the Medline, Embase, and Cochrane databases, researchers led by Dr. Hanna Kaduszkiewicz of Hamburg, Germany, evaluated 412 references published between 1989 and 2004 (BMJ 2005;331:321–7). Of these, 22 were included in the study.

In the 14 trials that used the Alzheimer's disease assessment scale-cognitive subscale, the mean difference between treatment and placebo groups ranged from 1.5 points to 3.9 points, which is a modest effect at best, said Dr. Mosqueda, director of geriatrics and a professor of family medicine at the University of California, Irvine.

In the 12 trials that used the Clinician's Interview-Based Impression of Change scale with caregiver input, the mean differences ranged from 0.26 to 0.54, “which is below what you're even allowed to score on the test,” she said, explaining that the rater is allowed to use only whole integers.

The incidence of adverse effects from the medications was 20% among those in the treatment group and 7% among those who took placebo. The most common adverse events were nausea, vomiting, diarrhea, and weight loss.

“How many times have we had somebody who comes in with Alzheimer's disease, they're losing weight and going through a major work-up, only to realize that they're on donepezil, and that this may be the cause of the weight loss?” Dr. Mosqueda asked.

She also highlighted a more recent Cochrane Review that was led by Dr. Jacqueline Birks of the University of Oxford (England). It was a meta-analysis of studies that also involved the cholinesterase inhibitors donepezil, rivastigmine, and galantamine (Cochrane Database Syst. Rev. 2006; DOI: 10.1002/14651858.CD005593).

It concluded that although these three cholinesterase inhibitors are modestly efficacious for mild to moderate Alzheimer's disease, there are no differences among them in terms of efficacy, even though the three drugs work in slightly different ways.

Despite the paucity of data showing efficacy, one factor that motivates physicians to prescribe cholinesterase inhibitors for Alzheimer's patients is the sense that they “really want to do something” for patients and their families, Dr. Mosqueda said.

“It's much faster to write that prescription than to sit down, review the evidence, and go over the pros and cons with the patient and family. That takes time to do, but I think it's so important for people to understand, so that they can make an informed decision.”

Medication cost is a downside for some patients who have to pay out of pocket for cholinesterase inhibitors. Dr. Mosqueda noted that for families faced with making a financial decision between paying for a cholinesterase inhibitor prescription and enrolling their loved one in an adult day care program, “that adult day care program is much more efficacious. Other, more important issues may not be addressed [with the medication alone]. Sometimes you can spend your time prescribing medicines instead of talking about other issues related to Alzheimer's disease.”

She concluded by saying that cholinesterase inhibitors “are nice, but all of us need comfort, identity, joy, and a big dose of love. That goes a long way when we're caring for people who have Alzheimer's disease and their families. Cholinesterase inhibitors may or may not be an adjunct to that.”

Sometimes you can spend your time prescribing instead of talking about issues related to AD. DR. MOSQUEDA

CARMEL, CALIF. – The evidence for using cholinesterase inhibitors in patients diagnosed with Alzheimer's disease “is pretty darned poor,” Dr. Laura Mosqueda said at the Western regional meeting of the American Federation for Medical Research.

She based her remarks on two recent meta-analyses of the topic. The first was a systematic review of randomized clinical trials of the cholinesterase inhibitors donepezil, rivastigmine, and galantamine.

In a search of the Medline, Embase, and Cochrane databases, researchers led by Dr. Hanna Kaduszkiewicz of Hamburg, Germany, evaluated 412 references published between 1989 and 2004 (BMJ 2005;331:321–7). Of these, 22 were included in the study.

In the 14 trials that used the Alzheimer's disease assessment scale-cognitive subscale, the mean difference between treatment and placebo groups ranged from 1.5 points to 3.9 points, which is a modest effect at best, said Dr. Mosqueda, director of geriatrics and a professor of family medicine at the University of California, Irvine.

In the 12 trials that used the Clinician's Interview-Based Impression of Change scale with caregiver input, the mean differences ranged from 0.26 to 0.54, “which is below what you're even allowed to score on the test,” she said, explaining that the rater is allowed to use only whole integers.

The incidence of adverse effects from the medications was 20% among those in the treatment group and 7% among those who took placebo. The most common adverse events were nausea, vomiting, diarrhea, and weight loss.

“How many times have we had somebody who comes in with Alzheimer's disease, they're losing weight and going through a major work-up, only to realize that they're on donepezil, and that this may be the cause of the weight loss?” Dr. Mosqueda asked.

She also highlighted a more recent Cochrane Review that was led by Dr. Jacqueline Birks of the University of Oxford (England). It was a meta-analysis of studies that also involved the cholinesterase inhibitors donepezil, rivastigmine, and galantamine (Cochrane Database Syst. Rev. 2006; DOI: 10.1002/14651858.CD005593).

It concluded that although these three cholinesterase inhibitors are modestly efficacious for mild to moderate Alzheimer's disease, there are no differences among them in terms of efficacy, even though the three drugs work in slightly different ways.

Despite the paucity of data showing efficacy, one factor that motivates physicians to prescribe cholinesterase inhibitors for Alzheimer's patients is the sense that they “really want to do something” for patients and their families, Dr. Mosqueda said.

“It's much faster to write that prescription than to sit down, review the evidence, and go over the pros and cons with the patient and family. That takes time to do, but I think it's so important for people to understand, so that they can make an informed decision.”

Medication cost is a downside for some patients who have to pay out of pocket for cholinesterase inhibitors. Dr. Mosqueda noted that for families faced with making a financial decision between paying for a cholinesterase inhibitor prescription and enrolling their loved one in an adult day care program, “that adult day care program is much more efficacious. Other, more important issues may not be addressed [with the medication alone]. Sometimes you can spend your time prescribing medicines instead of talking about other issues related to Alzheimer's disease.”

She concluded by saying that cholinesterase inhibitors “are nice, but all of us need comfort, identity, joy, and a big dose of love. That goes a long way when we're caring for people who have Alzheimer's disease and their families. Cholinesterase inhibitors may or may not be an adjunct to that.”

Sometimes you can spend your time prescribing instead of talking about issues related to AD. DR. MOSQUEDA

CARMEL, CALIF. – The evidence for using cholinesterase inhibitors in patients diagnosed with Alzheimer's disease “is pretty darned poor,” Dr. Laura Mosqueda said at the Western regional meeting of the American Federation for Medical Research.

She based her remarks on two recent meta-analyses of the topic. The first was a systematic review of randomized clinical trials of the cholinesterase inhibitors donepezil, rivastigmine, and galantamine.

In a search of the Medline, Embase, and Cochrane databases, researchers led by Dr. Hanna Kaduszkiewicz of Hamburg, Germany, evaluated 412 references published between 1989 and 2004 (BMJ 2005;331:321–7). Of these, 22 were included in the study.

In the 14 trials that used the Alzheimer's disease assessment scale-cognitive subscale, the mean difference between treatment and placebo groups ranged from 1.5 points to 3.9 points, which is a modest effect at best, said Dr. Mosqueda, director of geriatrics and a professor of family medicine at the University of California, Irvine.

In the 12 trials that used the Clinician's Interview-Based Impression of Change scale with caregiver input, the mean differences ranged from 0.26 to 0.54, “which is below what you're even allowed to score on the test,” she said, explaining that the rater is allowed to use only whole integers.

The incidence of adverse effects from the medications was 20% among those in the treatment group and 7% among those who took placebo. The most common adverse events were nausea, vomiting, diarrhea, and weight loss.

“How many times have we had somebody who comes in with Alzheimer's disease, they're losing weight and going through a major work-up, only to realize that they're on donepezil, and that this may be the cause of the weight loss?” Dr. Mosqueda asked.

She also highlighted a more recent Cochrane Review that was led by Dr. Jacqueline Birks of the University of Oxford (England). It was a meta-analysis of studies that also involved the cholinesterase inhibitors donepezil, rivastigmine, and galantamine (Cochrane Database Syst. Rev. 2006; DOI: 10.1002/14651858.CD005593).

It concluded that although these three cholinesterase inhibitors are modestly efficacious for mild to moderate Alzheimer's disease, there are no differences among them in terms of efficacy, even though the three drugs work in slightly different ways.

Despite the paucity of data showing efficacy, one factor that motivates physicians to prescribe cholinesterase inhibitors for Alzheimer's patients is the sense that they “really want to do something” for patients and their families, Dr. Mosqueda said.

“It's much faster to write that prescription than to sit down, review the evidence, and go over the pros and cons with the patient and family. That takes time to do, but I think it's so important for people to understand, so that they can make an informed decision.”

Medication cost is a downside for some patients who have to pay out of pocket for cholinesterase inhibitors. Dr. Mosqueda noted that for families faced with making a financial decision between paying for a cholinesterase inhibitor prescription and enrolling their loved one in an adult day care program, “that adult day care program is much more efficacious. Other, more important issues may not be addressed [with the medication alone]. Sometimes you can spend your time prescribing medicines instead of talking about other issues related to Alzheimer's disease.”

She concluded by saying that cholinesterase inhibitors “are nice, but all of us need comfort, identity, joy, and a big dose of love. That goes a long way when we're caring for people who have Alzheimer's disease and their families. Cholinesterase inhibitors may or may not be an adjunct to that.”

Sometimes you can spend your time prescribing instead of talking about issues related to AD. DR. MOSQUEDA