Doug Brunk

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The first step in considering Mohs surgery for melanoma is a detailed informed consent, Dr. Kenneth G. Gross advised at a meeting of the American Society for Mohs Surgery.

He uses the consent form "to counsel the patient, tell them about the tumor, and what I expect to do," said Dr. Gross, a dermatologic surgeon practicing in San Diego.

For example, his standard Mohs consent form is modified to include the possibility of taking an additional rim of tissue beyond the ostensibly clear Mohs margin, the possible need for immunohistochemistry, and the inclusion of postoperative therapy with imiquimod.

Dr. Gross photographs the melanoma lesions prior to surgery and also documents cross-measurements from adjacent anatomical areas to localize the melanoma. "I have had patients referred to me for a melanoma, but neither the patient, nor the referring doctor, nor I could find the site," he said. "That's a very embarrassing thing."

At the time of biopsy and/or when the patient is first seen for preoperative evaluation, and again on the day of surgery, the clinical status of the regional nodes should be evaluated and documented. "My note includes a statement such as: 'The regional nodes were negative or bilaterally negative to palpation.'"

He went on to share his clinical approach to Mohs surgery for melanoma:

▸ Outline the melanoma using magnification with and without a Wood's lamp, plus an additional margin of 3–5 mm. Dermoscopy "may be helpful in delineating the margins," he said.

▸ Excise the lesion using standard Mohs technique to below the hair follicles, if possible.

Dr. Gross uses Dr. John A. Zitelli's criteria to determine positive margins, defined as nests of three or more atypical melanocytes, melanocytes above the dermal-epidermal junction, or nonuniform contiguous melanocytic hyperplasia at the dermal-epidermal junction.

Other suspicious findings include confluent atypical melanocytes down the adnexa, increased numbers of melanophages, brisk inflammation, and dermal scarring.

He noted that one recent study found that about 25% of in situ melanomas on biopsy are upstaged to invasive melanoma if step cross-sections were done. "So I think cross-sectioning has to be part of your overall way of doing things," he said. "In our office, after the Mohs margins are assessed using standard Mohs technique, then the blocks are partially thawed and cross-sectioned by frozen section processing. This allows both assessment of invasion and another look at how closely the tumor approaches the 'clear' margins. It influences whether we take an additional rim of tissue—processed by permanent section technique—past our Mohs margin."

▸ Be capable of producing high-quality Mohs slides. "You want 2- to 4-mcm wafers of high quality," said Dr. Gross, who is also with the department of medicine at the University of California, San Diego.

▸ Consider double-reading the slides with a pathologist. "I'm not completely comfortable reading these slides myself," he said. "If you're a dermatopathologist, you may be comfortable reading these slides on your own. But for the rest of us, if you have an association with a dermatopathologist or pathologist, double-reading the slides gives you a tremendous advantage."

Dr. Gross uses hematoxylin and eosin (H&E) staining for his frozen section slides, and every second or third slide is left unstained for immunohistochemistry (IHC) if needed.

▸ When clear margins are achieved, close the wound. Starting on postoperative day 25, Dr. Gross begins imiquimod cream b.i.d. for 6 weeks, titering the effect to produce a brisk immune response.

Dr. Gross said there is now a consensus among leading surgical oncologists that sentinel node biopsy is the standard of care for primary cutaneous melanoma measuring 1.0–3.5 mm thick.

'I have had patients referred to me for a melanoma, but [no one] could find the site.' DR. GROSS

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

SANTA ANA PUEBLO, N.M. — The way Dr. Jerry Feldman sees it, facial anatomy is like a peanut butter and jelly sandwich.

"It's kind of mushed around rather than arranged like layers of bricks that are neatly piled on top of each other," he said at a meeting of the American Society for Mohs Surgery.

Dr. Feldman explained that most of what is known about facial anatomy comes from studies of cadavers, in which tissue often is distorted and shrunken.

"Does this correlate with living anatomy?" he asked. "The science of anatomy is dynamic, evolving, and controversial. You would have thought all these issues would have been worked out in the 19th century, but they haven't been. There are plenty of articles that are still debating where certain nerves and fascial layers are."

There also is wide variability in facial anatomy among patients, and facial anatomy can be asymmetric, emphasized Dr. Feldman, who is director of dermatologic surgery at Cook County Hospital in Chicago.

He offered four questions to keep in mind before and after every dermatologic procedure involving the face:

▸ What is the blood supply to the area?

▸ What motor and sensory nerves are involved?

▸ What layers of tissue will I cut through?

▸ How does my excision and closure affect the function of the immediate and surrounding tissue? "It's not just aesthetics that count, it's function," Dr. Feldman said.

He acknowledged that translating the facial anatomy described in a medical textbook or a scientific article to a patient can be difficult. "Don't be discouraged," he said. "Learning is a lifelong task. It's best to take baby steps."

Good ways to master facial anatomy include studying the original medical literature, taking a relevant course sponsored by the American Society for Dermatologic Surgery or by attending Dr. Hugh Greenway's annual superficial anatomy and cutaneous surgery course in San Diego.

"The best tool is real patients," he said.

Summer Reading Recommendations

Dr. Feldman suggested several anatomy books:

"Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery" (Brooke Seckel, M.D. St. Louis: Quality Medical Publishing, 1994)

"Surgical Anatomy of the Face, Second Edition" (Wayne F. Larrabee Jr., M.D., Kathleen H. Makielski, M.D., and Jenifer L. Henderson, M.D. Philadelphia: Lippincott, Williams & Wilkins, 2003)

"Principles of Nasal Reconstruction" (Shan R. Baker, M.D., Sam Naficy, M.D., and Brian Jewet, M.D. Philadelphia: Mosby, 2002)

"Surgical Anatomy of the Skin" (Stuart J. Salasche, M.D., Gerald Bernstein M.D., and Mickey Senkarik. Norwalk, Conn: Appleton & Lange, 1988)

"The Forehead and Temporal Fossa: Anatomy and Technique" (David M. Knize, M.D. Philadelphia: Lippincott Williams & Wilkins, 2001)

"Surgical Anatomy Around the Orbit: The System of Zones" (Barry M. Zide, M.D., and Glenn W. Jelks, M.D. Philadelphia: Lippincott Williams & Wilkins, 2005)

"Atlas of Aesthetic Face & Neck Surgery" (Gregory LaTrenta, M.D. London: W.B. Saunders Ltd., 2003)

SANTA ANA PUEBLO, N.M. — Evaluation of Mohs specimens sent to the American Society for Mohs Surgery for peer review has offered an opportunity to critique various styles of processing Mohs specimens and of planning second stages.

Some styles fail to comply with the basic principle of Mohs surgery. Undermining-type stage II reexcisions, straight-down cuts through the midline of stage II, and squared-off edges are examples of types of stage II reexcisions "that can turn the Mohs proof of tumor extirpation to pretense," Dr. Sharon F. Tiefenbrunn said at a meeting of the American Society for Mohs Surgery (ASMS).

Mohs surgery "is a proven technique with a 95%–99% cure rate in the published literature," she said, but the rules "used to plan reexcision and to evaluate adequacy of the slides from these reexcisions have not been published."

She discussed her "rules" for Mohs surgery based on patterns that emerged during the analysis. "Most of these rules are fairly obvious and are stated for completeness," said Dr. Tiefenbrunn, a dermatologic surgeon who practices in St. Louis and is the current president of the ASMS.

Rules for stage I include the following:

▸ The complete skin edge must be included on the slides and examined. (The ASMS uses 90% as its standard of completeness.)

▸ The complete deep margin (90%) must be present on the slide.

▸ Make sure tissue remains intact on the wafers, without shredding.

▸ Make sure structural details are visible.

▸ Use adequate stain.

▸ Use visible ink for orientation and to ensure complete examination of sectioned specimens.

▸ Tumor must be identified and mapped accurately.

The rules for stage II include:

▸ If the skin edge is missing on stage I, it must be taken on stage II.

▸ If deep tissue is missing on stage I, it must be taken on stage II. "We see a few cases where these simple mandates slide by," she said.

▸ Stage II must include the tumor in stage I. "Early wafers must be unequivocally clear to call the stage clear if tumor is seen deep in the block," she said.

▸ Respect the Heisenberg uncertainty principle. "We must overlap in all directions from the edge of the tumor and we must connect to the previous layer and confirm with inked margins," said Dr. Tiefenbrunn.

If the connection to the defect left by the previous stage is not examined, a larger overlap will be needed.

She pointed out that taking 20 turns of the cryostat before putting a section on the slide means that approximately 200 micrometers of tissue from the sample are lost. This amounts to 0.2 mm, a space in which tumor can travel undetected. If 95% of all possible angles of spread of the tumor are to be examined, an overlap of about 2.5 mm is needed.

"Failure to follow the above rules can turn proof to pretense," she said.

Common errors in Mohs surgery occur in planning the second stage, particularly inadequate overlap and lack of concern about observing the line of connection of stage II to stage I. "Undermining-type reexcisions in which the dermal rim of tissue is undermined and a vertical or beveled incision is made circumferentially around the defect connecting to this plane, frequently accompanied by vertical incision extending radially from the defect to complete this excision, [are] a common error," she said.

"This section is then processed so that only one of the four planes of the surgical margin is examined. The exclusion of the deep margin and the radially cut ends of the specimen from exam can allow tumor to be left behind. Proper process of an undermining stage II is difficult for the technician. Even if this type of reexcision is processed properly, there is inadequate overlap on the deep margin," she said.

"Straight-down cuts, such as the type made when stage II is reexcising half of the stage I defect, are another source of error," she said. "If a straight-down cut is used and not adequately flattened, this 2.5 mm of necessary overlap doubles the every-0.2 mm of space between the defect and the depth of the reexcision. This needed overlap can easily exceed the size of the defect."

SANTA ANA PUEBLO, N.M. — Evaluation of Mohs specimens sent to the American Society for Mohs Surgery for peer review has offered an opportunity to critique various styles of processing Mohs specimens and of planning second stages.

Some styles fail to comply with the basic principle of Mohs surgery. Undermining-type stage II reexcisions, straight-down cuts through the midline of stage II, and squared-off edges are examples of types of stage II reexcisions "that can turn the Mohs proof of tumor extirpation to pretense," Dr. Sharon F. Tiefenbrunn said at a meeting of the American Society for Mohs Surgery (ASMS).

Mohs surgery "is a proven technique with a 95%–99% cure rate in the published literature," she said, but the rules "used to plan reexcision and to evaluate adequacy of the slides from these reexcisions have not been published."

She discussed her "rules" for Mohs surgery based on patterns that emerged during the analysis. "Most of these rules are fairly obvious and are stated for completeness," said Dr. Tiefenbrunn, a dermatologic surgeon who practices in St. Louis and is the current president of the ASMS.

Rules for stage I include the following:

▸ The complete skin edge must be included on the slides and examined. (The ASMS uses 90% as its standard of completeness.)

▸ The complete deep margin (90%) must be present on the slide.

▸ Make sure tissue remains intact on the wafers, without shredding.

▸ Make sure structural details are visible.

▸ Use adequate stain.

▸ Use visible ink for orientation and to ensure complete examination of sectioned specimens.

▸ Tumor must be identified and mapped accurately.

The rules for stage II include:

▸ If the skin edge is missing on stage I, it must be taken on stage II.

▸ If deep tissue is missing on stage I, it must be taken on stage II. "We see a few cases where these simple mandates slide by," she said.

▸ Stage II must include the tumor in stage I. "Early wafers must be unequivocally clear to call the stage clear if tumor is seen deep in the block," she said.

▸ Respect the Heisenberg uncertainty principle. "We must overlap in all directions from the edge of the tumor and we must connect to the previous layer and confirm with inked margins," said Dr. Tiefenbrunn.

If the connection to the defect left by the previous stage is not examined, a larger overlap will be needed.

She pointed out that taking 20 turns of the cryostat before putting a section on the slide means that approximately 200 micrometers of tissue from the sample are lost. This amounts to 0.2 mm, a space in which tumor can travel undetected. If 95% of all possible angles of spread of the tumor are to be examined, an overlap of about 2.5 mm is needed.

"Failure to follow the above rules can turn proof to pretense," she said.

Common errors in Mohs surgery occur in planning the second stage, particularly inadequate overlap and lack of concern about observing the line of connection of stage II to stage I. "Undermining-type reexcisions in which the dermal rim of tissue is undermined and a vertical or beveled incision is made circumferentially around the defect connecting to this plane, frequently accompanied by vertical incision extending radially from the defect to complete this excision, [are] a common error," she said.

"This section is then processed so that only one of the four planes of the surgical margin is examined. The exclusion of the deep margin and the radially cut ends of the specimen from exam can allow tumor to be left behind. Proper process of an undermining stage II is difficult for the technician. Even if this type of reexcision is processed properly, there is inadequate overlap on the deep margin," she said.

"Straight-down cuts, such as the type made when stage II is reexcising half of the stage I defect, are another source of error," she said. "If a straight-down cut is used and not adequately flattened, this 2.5 mm of necessary overlap doubles the every-0.2 mm of space between the defect and the depth of the reexcision. This needed overlap can easily exceed the size of the defect."

SANTA ANA PUEBLO, N.M. — Evaluation of Mohs specimens sent to the American Society for Mohs Surgery for peer review has offered an opportunity to critique various styles of processing Mohs specimens and of planning second stages.

Some styles fail to comply with the basic principle of Mohs surgery. Undermining-type stage II reexcisions, straight-down cuts through the midline of stage II, and squared-off edges are examples of types of stage II reexcisions "that can turn the Mohs proof of tumor extirpation to pretense," Dr. Sharon F. Tiefenbrunn said at a meeting of the American Society for Mohs Surgery (ASMS).

Mohs surgery "is a proven technique with a 95%–99% cure rate in the published literature," she said, but the rules "used to plan reexcision and to evaluate adequacy of the slides from these reexcisions have not been published."

She discussed her "rules" for Mohs surgery based on patterns that emerged during the analysis. "Most of these rules are fairly obvious and are stated for completeness," said Dr. Tiefenbrunn, a dermatologic surgeon who practices in St. Louis and is the current president of the ASMS.

Rules for stage I include the following:

▸ The complete skin edge must be included on the slides and examined. (The ASMS uses 90% as its standard of completeness.)

▸ The complete deep margin (90%) must be present on the slide.

▸ Make sure tissue remains intact on the wafers, without shredding.

▸ Make sure structural details are visible.

▸ Use adequate stain.

▸ Use visible ink for orientation and to ensure complete examination of sectioned specimens.

▸ Tumor must be identified and mapped accurately.

The rules for stage II include:

▸ If the skin edge is missing on stage I, it must be taken on stage II.

▸ If deep tissue is missing on stage I, it must be taken on stage II. "We see a few cases where these simple mandates slide by," she said.

▸ Stage II must include the tumor in stage I. "Early wafers must be unequivocally clear to call the stage clear if tumor is seen deep in the block," she said.

▸ Respect the Heisenberg uncertainty principle. "We must overlap in all directions from the edge of the tumor and we must connect to the previous layer and confirm with inked margins," said Dr. Tiefenbrunn.

If the connection to the defect left by the previous stage is not examined, a larger overlap will be needed.

She pointed out that taking 20 turns of the cryostat before putting a section on the slide means that approximately 200 micrometers of tissue from the sample are lost. This amounts to 0.2 mm, a space in which tumor can travel undetected. If 95% of all possible angles of spread of the tumor are to be examined, an overlap of about 2.5 mm is needed.

"Failure to follow the above rules can turn proof to pretense," she said.

Common errors in Mohs surgery occur in planning the second stage, particularly inadequate overlap and lack of concern about observing the line of connection of stage II to stage I. "Undermining-type reexcisions in which the dermal rim of tissue is undermined and a vertical or beveled incision is made circumferentially around the defect connecting to this plane, frequently accompanied by vertical incision extending radially from the defect to complete this excision, [are] a common error," she said.

"This section is then processed so that only one of the four planes of the surgical margin is examined. The exclusion of the deep margin and the radially cut ends of the specimen from exam can allow tumor to be left behind. Proper process of an undermining stage II is difficult for the technician. Even if this type of reexcision is processed properly, there is inadequate overlap on the deep margin," she said.

"Straight-down cuts, such as the type made when stage II is reexcising half of the stage I defect, are another source of error," she said. "If a straight-down cut is used and not adequately flattened, this 2.5 mm of necessary overlap doubles the every-0.2 mm of space between the defect and the depth of the reexcision. This needed overlap can easily exceed the size of the defect."

SANTA ANA PUEBLO, N.M. — The reducing opposed multilobed flap repair offers significant advantages over traditional closure methods for medium-size skin cancer defects below the knee, especially with respect to flap necrosis and overall complications, Dr. Anthony J. Dixon said at a meeting of the American Society for Mohs Surgery.

The reducing opposed multilobed (ROM) technique, which Dr. Dixon developed and first described a few years ago, uses a random-pattern skin flap for defects below the knee that are 10–45 mm in diameter (Dermatol. Surg. 2004;30:1406–11). The pattern consists of semicircular lobes that extend both cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

"The next semicircle is two-thirds the diameter of the first semicircle and so on," said Dr. Dixon, a dermatologic surgeon who practices in Belmont, Australia. "You keep making semicircles until you have semicircles 5–8 mm in diameter; then you stop."

The number of semicircles depends on the depth of the primary lesion. "It's quite common to have three semicircles on each side [of the defect]," he said.

The technique involves transposing each semicircular lobe with standard sutures, starting from the lobes most distant from the defect and working inward.

"Throughout the technique you know that tension is being accumulated along the way," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia. "Rather than tension being in the central defect, tension is being accumulated at the periphery. Therefore, it should result in less wound tension and breakdown centrally."

Postoperatively, Dr. Dixon advises his patients to minimize walking for 24 hours and then slowly increase the amount of walking. "We ask them when they are seated to elevate their leg when they can for the first 4 days," he added.

He takes every alternate suture out in 2 weeks and the rest at 3 weeks. At 6 months, scarring from the procedure "is invariably difficult to find," he said.

In an unpublished analysis, Dr. Dixon and his associates compared 212 patients who underwent ROM flap repairs with 83 patients who underwent repair with ellipse or with other random flap patterns. The diameter of the defect size in all patients ranged from 11 to 45 mm.

The rate of partial flap necrosis was 0.9% in the ROM flap group, compared with 7.2% in the non-ROM flap group, a difference that was statistically significant. The overall rate of complications was 12.7% in the ROM flap group, compared with 28.9% in the non-ROM flap group, a difference that also was statistically significant, he reported.

There were no statistically significant differences between the two groups in terms of the rates of postoperative infections and wound dehiscence, although the rates were smaller in the ROM flap group than in the non-ROM flap group.

The patients "generally liked" the ROM flap procedure. "They liked being able to get up and walk around," Dr. Dixon said.

The study had several limitations: It was not randomized, it was a consecutive series of patients, and all the procedures were performed by Dr. Dixon. "A prospective, randomized controlled trial would be valuable to confirm the findings of this retrospective study," he said.

The reducing opposed multilobed (ROM) flap repair is used for defects below the knee.

Semicircular lobes extend cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

Each of the lobes is transposed with standard sutures, starting from the lobes most distant from the defect and from working inward.

Suturing is finished. Every alternate suture will be taken out in 2 weeks, and the rest at 3 weeks. Photos courtesy Dr. Anthony J. Dixon

SANTA ANA PUEBLO, N.M. — The reducing opposed multilobed flap repair offers significant advantages over traditional closure methods for medium-size skin cancer defects below the knee, especially with respect to flap necrosis and overall complications, Dr. Anthony J. Dixon said at a meeting of the American Society for Mohs Surgery.

The reducing opposed multilobed (ROM) technique, which Dr. Dixon developed and first described a few years ago, uses a random-pattern skin flap for defects below the knee that are 10–45 mm in diameter (Dermatol. Surg. 2004;30:1406–11). The pattern consists of semicircular lobes that extend both cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

"The next semicircle is two-thirds the diameter of the first semicircle and so on," said Dr. Dixon, a dermatologic surgeon who practices in Belmont, Australia. "You keep making semicircles until you have semicircles 5–8 mm in diameter; then you stop."

The number of semicircles depends on the depth of the primary lesion. "It's quite common to have three semicircles on each side [of the defect]," he said.

The technique involves transposing each semicircular lobe with standard sutures, starting from the lobes most distant from the defect and working inward.

"Throughout the technique you know that tension is being accumulated along the way," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia. "Rather than tension being in the central defect, tension is being accumulated at the periphery. Therefore, it should result in less wound tension and breakdown centrally."

Postoperatively, Dr. Dixon advises his patients to minimize walking for 24 hours and then slowly increase the amount of walking. "We ask them when they are seated to elevate their leg when they can for the first 4 days," he added.

He takes every alternate suture out in 2 weeks and the rest at 3 weeks. At 6 months, scarring from the procedure "is invariably difficult to find," he said.

In an unpublished analysis, Dr. Dixon and his associates compared 212 patients who underwent ROM flap repairs with 83 patients who underwent repair with ellipse or with other random flap patterns. The diameter of the defect size in all patients ranged from 11 to 45 mm.

The rate of partial flap necrosis was 0.9% in the ROM flap group, compared with 7.2% in the non-ROM flap group, a difference that was statistically significant. The overall rate of complications was 12.7% in the ROM flap group, compared with 28.9% in the non-ROM flap group, a difference that also was statistically significant, he reported.

There were no statistically significant differences between the two groups in terms of the rates of postoperative infections and wound dehiscence, although the rates were smaller in the ROM flap group than in the non-ROM flap group.

The patients "generally liked" the ROM flap procedure. "They liked being able to get up and walk around," Dr. Dixon said.

The study had several limitations: It was not randomized, it was a consecutive series of patients, and all the procedures were performed by Dr. Dixon. "A prospective, randomized controlled trial would be valuable to confirm the findings of this retrospective study," he said.

The reducing opposed multilobed (ROM) flap repair is used for defects below the knee.

Semicircular lobes extend cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

Each of the lobes is transposed with standard sutures, starting from the lobes most distant from the defect and from working inward.

Suturing is finished. Every alternate suture will be taken out in 2 weeks, and the rest at 3 weeks. Photos courtesy Dr. Anthony J. Dixon

SANTA ANA PUEBLO, N.M. — The reducing opposed multilobed flap repair offers significant advantages over traditional closure methods for medium-size skin cancer defects below the knee, especially with respect to flap necrosis and overall complications, Dr. Anthony J. Dixon said at a meeting of the American Society for Mohs Surgery.

The reducing opposed multilobed (ROM) technique, which Dr. Dixon developed and first described a few years ago, uses a random-pattern skin flap for defects below the knee that are 10–45 mm in diameter (Dermatol. Surg. 2004;30:1406–11). The pattern consists of semicircular lobes that extend both cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

"The next semicircle is two-thirds the diameter of the first semicircle and so on," said Dr. Dixon, a dermatologic surgeon who practices in Belmont, Australia. "You keep making semicircles until you have semicircles 5–8 mm in diameter; then you stop."

The number of semicircles depends on the depth of the primary lesion. "It's quite common to have three semicircles on each side [of the defect]," he said.

The technique involves transposing each semicircular lobe with standard sutures, starting from the lobes most distant from the defect and working inward.

"Throughout the technique you know that tension is being accumulated along the way," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia. "Rather than tension being in the central defect, tension is being accumulated at the periphery. Therefore, it should result in less wound tension and breakdown centrally."

Postoperatively, Dr. Dixon advises his patients to minimize walking for 24 hours and then slowly increase the amount of walking. "We ask them when they are seated to elevate their leg when they can for the first 4 days," he added.

He takes every alternate suture out in 2 weeks and the rest at 3 weeks. At 6 months, scarring from the procedure "is invariably difficult to find," he said.

In an unpublished analysis, Dr. Dixon and his associates compared 212 patients who underwent ROM flap repairs with 83 patients who underwent repair with ellipse or with other random flap patterns. The diameter of the defect size in all patients ranged from 11 to 45 mm.

The rate of partial flap necrosis was 0.9% in the ROM flap group, compared with 7.2% in the non-ROM flap group, a difference that was statistically significant. The overall rate of complications was 12.7% in the ROM flap group, compared with 28.9% in the non-ROM flap group, a difference that also was statistically significant, he reported.

There were no statistically significant differences between the two groups in terms of the rates of postoperative infections and wound dehiscence, although the rates were smaller in the ROM flap group than in the non-ROM flap group.

The patients "generally liked" the ROM flap procedure. "They liked being able to get up and walk around," Dr. Dixon said.

The study had several limitations: It was not randomized, it was a consecutive series of patients, and all the procedures were performed by Dr. Dixon. "A prospective, randomized controlled trial would be valuable to confirm the findings of this retrospective study," he said.

The reducing opposed multilobed (ROM) flap repair is used for defects below the knee.

Semicircular lobes extend cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.

Each of the lobes is transposed with standard sutures, starting from the lobes most distant from the defect and from working inward.

Suturing is finished. Every alternate suture will be taken out in 2 weeks, and the rest at 3 weeks. Photos courtesy Dr. Anthony J. Dixon

LAS VEGAS — Both young and old patients had significant improvements in preoperative cardiovascular comorbidities after laparoscopic Roux-en-Y gastric bypass surgery, results from a large, single-center study showed.

However, the improvements were less pronounced in patients aged 50 years and older, compared with younger patients, Eric Ketchum said at a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“People over age 50 did pretty well,” Mr. Ketchum, a fourth-year medical student at Stanford (Calif.) University, said in an interview. “For example, 75% of them did not have to take medicines for diabetes [after surgery], but they did a little bit worse than younger people did.”

He and his associates in the department of surgery at Stanford University Medical Center reviewed the records of 273 patients who underwent laparoscopic Roux-en-Y gastric bypass during January 2003-December 2005. They compared the resolution of comorbidities, cardiovascular risk factors, and weight loss 1 year after surgery in patients aged 50 and older with those in patients younger than age 50.

One year postoperatively, the mean body mass index was similar between the older and younger groups (31 kg/m

The older patients showed less postoperative reductions than did the younger patients in levels of total cholesterol (8% vs. 16%, respectively), LDL cholesterol (17% vs. 26%), triglycerides (31% vs. 42%), and HDL cholesterol (15% vs. 19%).

Patients in the older group also required more medicines postoperatively, compared with those in the younger group, for preoperative comorbid conditions including hypertension (65% vs. 78%, respectively), hyperlipidemia (73% vs. 78%), and diabetes (75% vs. 94%).

Patients in the older group also showed less improvement than the younger group in terms of C-reactive protein (55% vs. 81%) and lipoprotein (a) (11% vs. 26%).

However, patients in the older group demonstrated greater improvement than the younger group in terms of hemoglobin A_1c levels (15% vs. 12%) and homocysteine levels (26% vs. 17%).

In their poster, the researchers noted that the “12-month postoperative lipid parameters did not show a statistically significant difference between the two cohorts” probably because “a significantly higher proportion of the senior cohort was medicated for hyperlipidemia” preoperatively.

LAS VEGAS — Both young and old patients had significant improvements in preoperative cardiovascular comorbidities after laparoscopic Roux-en-Y gastric bypass surgery, results from a large, single-center study showed.

However, the improvements were less pronounced in patients aged 50 years and older, compared with younger patients, Eric Ketchum said at a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“People over age 50 did pretty well,” Mr. Ketchum, a fourth-year medical student at Stanford (Calif.) University, said in an interview. “For example, 75% of them did not have to take medicines for diabetes [after surgery], but they did a little bit worse than younger people did.”

He and his associates in the department of surgery at Stanford University Medical Center reviewed the records of 273 patients who underwent laparoscopic Roux-en-Y gastric bypass during January 2003-December 2005. They compared the resolution of comorbidities, cardiovascular risk factors, and weight loss 1 year after surgery in patients aged 50 and older with those in patients younger than age 50.

One year postoperatively, the mean body mass index was similar between the older and younger groups (31 kg/m

The older patients showed less postoperative reductions than did the younger patients in levels of total cholesterol (8% vs. 16%, respectively), LDL cholesterol (17% vs. 26%), triglycerides (31% vs. 42%), and HDL cholesterol (15% vs. 19%).

Patients in the older group also required more medicines postoperatively, compared with those in the younger group, for preoperative comorbid conditions including hypertension (65% vs. 78%, respectively), hyperlipidemia (73% vs. 78%), and diabetes (75% vs. 94%).

Patients in the older group also showed less improvement than the younger group in terms of C-reactive protein (55% vs. 81%) and lipoprotein (a) (11% vs. 26%).

However, patients in the older group demonstrated greater improvement than the younger group in terms of hemoglobin A_1c levels (15% vs. 12%) and homocysteine levels (26% vs. 17%).

In their poster, the researchers noted that the “12-month postoperative lipid parameters did not show a statistically significant difference between the two cohorts” probably because “a significantly higher proportion of the senior cohort was medicated for hyperlipidemia” preoperatively.

LAS VEGAS — Both young and old patients had significant improvements in preoperative cardiovascular comorbidities after laparoscopic Roux-en-Y gastric bypass surgery, results from a large, single-center study showed.

However, the improvements were less pronounced in patients aged 50 years and older, compared with younger patients, Eric Ketchum said at a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“People over age 50 did pretty well,” Mr. Ketchum, a fourth-year medical student at Stanford (Calif.) University, said in an interview. “For example, 75% of them did not have to take medicines for diabetes [after surgery], but they did a little bit worse than younger people did.”

He and his associates in the department of surgery at Stanford University Medical Center reviewed the records of 273 patients who underwent laparoscopic Roux-en-Y gastric bypass during January 2003-December 2005. They compared the resolution of comorbidities, cardiovascular risk factors, and weight loss 1 year after surgery in patients aged 50 and older with those in patients younger than age 50.

One year postoperatively, the mean body mass index was similar between the older and younger groups (31 kg/m

The older patients showed less postoperative reductions than did the younger patients in levels of total cholesterol (8% vs. 16%, respectively), LDL cholesterol (17% vs. 26%), triglycerides (31% vs. 42%), and HDL cholesterol (15% vs. 19%).

Patients in the older group also required more medicines postoperatively, compared with those in the younger group, for preoperative comorbid conditions including hypertension (65% vs. 78%, respectively), hyperlipidemia (73% vs. 78%), and diabetes (75% vs. 94%).

Patients in the older group also showed less improvement than the younger group in terms of C-reactive protein (55% vs. 81%) and lipoprotein (a) (11% vs. 26%).

However, patients in the older group demonstrated greater improvement than the younger group in terms of hemoglobin A_1c levels (15% vs. 12%) and homocysteine levels (26% vs. 17%).

In their poster, the researchers noted that the “12-month postoperative lipid parameters did not show a statistically significant difference between the two cohorts” probably because “a significantly higher proportion of the senior cohort was medicated for hyperlipidemia” preoperatively.

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcers/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). None of the patients died.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (odds ratio [OR] 2.1) and having a preoperative hemoglobin A_1c level that was higher than the normal HbA_1c level (OR 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

Patients 'might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcer/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). There were no mortalities.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (OR of 2.1) and having a preoperative hemoglobin A_1c level that was higher than normal (OR of 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

'[Patients] might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcer/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). There were no mortalities.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (OR of 2.1) and having a preoperative hemoglobin A_1c level that was higher than normal (OR of 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

'[Patients] might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

LAS VEGAS — Being male and having a higher than normal preoperative hemoglobin A_1c level were significantly associated with having a major complication following Roux-en-Y gastric bypass surgery, results from an ongoing single-center study showed.

However, the rate of overall complications at 1 year was 15%, which is lower than the 20%–25% that has been reported in the medical literature, Dr. D. Brandon Williams said during a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

“In centers where we have a high volume—we do over 400 of these operations a year—the complication rate is very low, especially the rate of major complications,” said Dr. Williams, of the department of surgery at Stanford (Calif.) University.

Between June 5, 2000, and December 5, 2006, 613 patients with a mean age of 43 years and a mean body mass index of 47 kg/m

Major complications were defined as anastomotic leak, bleeding, deep vein thrombosis (DVT)/pulmonary embolism (PE), bowel obstruction, myocardial infarction (MI), cerebrovascular accident (CVA), intra-abdominal abscess, and pneumonia. Minor complications were defined as micronutrient deficiency, arrhythmia, wound infection/dehiscence/hernia, and ulcers/strictures.

Dr. Williams reported that 92 patients (15%) experienced 133 complications. Of those, 60 patients had minor complications, and 32 had major complications.

The most common complications included bleeding (28), ulcer/strictures (23), vitamin/nutrient deficiency (15), anastomotic leak (12), bowel obstruction (12), wound infection (11), pneumonia (10), DVT/PE (9), abscess (5), MI (3), arrhythmia (3), and CVA (2). There were no mortalities.

Univariate analysis revealed that patients with minor complications were generally older than those with major complications (a mean of 47 vs. 41 years, respectively).

Multivariate analysis revealed that significant predictors of having a major versus a minor complication were being male (OR of 2.1) and having a preoperative hemoglobin A_1c level that was higher than normal (OR of 0.8).

“We actually expected more [factors] would be predictors of complications,” Dr. Williams said. “But there are a couple of things that you can use to counsel your patients preoperatively: They might be more likely to have problems if they have uncontrolled diabetes and if they're male.”

The researchers also observed a strong association between the rate of major complications and surgeon experience. For example, 16 major complications were attributed to surgeons who had performed up to 200 gastric bypass operations. That rate dropped to 6 for those who had performed more than 401 procedures.

However, the rate of minor complications remained about the same, regardless of surgeon experience. “This would suggest that there are patient-dependent [risk factors for complications] that you're not going to be able to predict no matter how good [a surgeon] you are,” he said.

'[Patients] might be more likely to have problems if they have uncontrolled diabetes and if they're male.' DR. WILLIAMS

SAN DIEGO — An increasing number of allergy tests are available on the Internet, and many are of unproven value, Dr. Helen Smith reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Smith, professor and chair of primary care at Brighton and Sussex (England) Medical School, and her associates used the search engines Google and Ask (formerly known as AskJeeves) and entered the following phrase: “allergy AND tests AND (home OR self).” The search identified 38 tests that were offered by 26 suppliers, with 61 different test/supplier combinations.

The most common categories of tests were for allergen-specific IgE (11 examples) and other (11), followed by allergy-specific IgG (4), unspecified dust allergens (4), celiac disease antibodies (4), mold from dust (3), and total IgE (1).

The most common sample requirement was blood from a finger stick (17 examples), followed by drawn blood (11), dust (7), and saliva (1). Two other tests did not require a sample, only answers to a questionnaire. The results for 14 tests required self-interpretation; 8 tests reported the results on a Web site, 5 were mailed to the patient's physician, and 3 were mailed to the patient. For two tests, the method of notification was not clear.

Twenty-four tests offered advice on an information sheet; 11 offered advice from a nutritionist, and 7 provided a telephone help line. In 24 of the 61 test-supplier combinations, no advice was offered. Costs ranged from free questionnaires to $1,290 for a screen of more than 200 allergens.

“Home allergy tests may have an adverse impact on health by giving false reassurance [without] a structured allergy history and inappropriately linking symptoms to a nonexistent allergy,” they wrote.

The tests may adversely impact health by giving false reassurance without a structured allergy history. DR. SMITH

SAN DIEGO — An increasing number of allergy tests are available on the Internet, and many are of unproven value, Dr. Helen Smith reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Smith, professor and chair of primary care at Brighton and Sussex (England) Medical School, and her associates used the search engines Google and Ask (formerly known as AskJeeves) and entered the following phrase: “allergy AND tests AND (home OR self).” The search identified 38 tests that were offered by 26 suppliers, with 61 different test/supplier combinations.

The most common categories of tests were for allergen-specific IgE (11 examples) and other (11), followed by allergy-specific IgG (4), unspecified dust allergens (4), celiac disease antibodies (4), mold from dust (3), and total IgE (1).

The most common sample requirement was blood from a finger stick (17 examples), followed by drawn blood (11), dust (7), and saliva (1). Two other tests did not require a sample, only answers to a questionnaire. The results for 14 tests required self-interpretation; 8 tests reported the results on a Web site, 5 were mailed to the patient's physician, and 3 were mailed to the patient. For two tests, the method of notification was not clear.

Twenty-four tests offered advice on an information sheet; 11 offered advice from a nutritionist, and 7 provided a telephone help line. In 24 of the 61 test-supplier combinations, no advice was offered. Costs ranged from free questionnaires to $1,290 for a screen of more than 200 allergens.

“Home allergy tests may have an adverse impact on health by giving false reassurance [without] a structured allergy history and inappropriately linking symptoms to a nonexistent allergy,” they wrote.

The tests may adversely impact health by giving false reassurance without a structured allergy history. DR. SMITH

SAN DIEGO — An increasing number of allergy tests are available on the Internet, and many are of unproven value, Dr. Helen Smith reported during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

Dr. Smith, professor and chair of primary care at Brighton and Sussex (England) Medical School, and her associates used the search engines Google and Ask (formerly known as AskJeeves) and entered the following phrase: “allergy AND tests AND (home OR self).” The search identified 38 tests that were offered by 26 suppliers, with 61 different test/supplier combinations.

The most common categories of tests were for allergen-specific IgE (11 examples) and other (11), followed by allergy-specific IgG (4), unspecified dust allergens (4), celiac disease antibodies (4), mold from dust (3), and total IgE (1).

The most common sample requirement was blood from a finger stick (17 examples), followed by drawn blood (11), dust (7), and saliva (1). Two other tests did not require a sample, only answers to a questionnaire. The results for 14 tests required self-interpretation; 8 tests reported the results on a Web site, 5 were mailed to the patient's physician, and 3 were mailed to the patient. For two tests, the method of notification was not clear.

Twenty-four tests offered advice on an information sheet; 11 offered advice from a nutritionist, and 7 provided a telephone help line. In 24 of the 61 test-supplier combinations, no advice was offered. Costs ranged from free questionnaires to $1,290 for a screen of more than 200 allergens.

“Home allergy tests may have an adverse impact on health by giving false reassurance [without] a structured allergy history and inappropriately linking symptoms to a nonexistent allergy,” they wrote.

The tests may adversely impact health by giving false reassurance without a structured allergy history. DR. SMITH

SAN DIEGO — People with allergic rhinitis report more sleep problems during winter, compared with the general population, Dr. Eli Meltzer said in a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The finding underscores the importance of asking patients with allergic rhinitis how their symptoms are affecting their sleep quantity and quality.

“[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired,” Dr. Meltzer, an allergist who practices in San Diego, said in an interview.

Dr. Meltzer and his associates mailed a 27-item survey to 6,476 people nationwide between December 2005 and February 2006 who had completed a screening questionnaire during May and June of 2004 to target people with symptoms of allergic rhinitis. The purpose of the follow-up survey was to provide a longitudinal assessment of disease and to capture seasonal variation in disease burden.

Respondents used the Medical Outcomes Study Sleep Scale to rate their sleep. It measures sleep quality and quantity on two scales, a sleep adequacy scale and a sleep problems index scale, ranging from 0 to 100: Higher adequacy scale scores correspond to more adequate amounts of sleep; higher problems scale scores correspond to poorer sleep quality. The scales' mean general population norms are 60.5 and 26.9, respectively.

Complete data were available on 5,371 of the respondents. Of these, 1,788 (33%) reported symptoms consistent with seasonal or perennial allergic rhinitis during the previous 4 weeks that were not related to a cold or to the flu, such as runny nose/sniffling, sneezing, itchy nose, congested nose, and postnasal drainage.

The allergic rhinitis sufferers' mean scores on the sleep adequacy and sleep problems index scales were 51.1 and 35.3, respectively. More than 65% of the allergic rhinitis sufferers reported problems falling asleep or falling back to sleep after awakening, and fewer than half indicated they get enough sleep or feel rested upon awakening.

GlaxoSmithKline funded the study. Dr. Meltzer disclosed he has received research grants and honoraria from the company.

'[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired.' DR. MELTZER

SAN DIEGO — People with allergic rhinitis report more sleep problems during winter, compared with the general population, Dr. Eli Meltzer said in a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The finding underscores the importance of asking patients with allergic rhinitis how their symptoms are affecting their sleep quantity and quality.

“[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired,” Dr. Meltzer, an allergist who practices in San Diego, said in an interview.

Dr. Meltzer and his associates mailed a 27-item survey to 6,476 people nationwide between December 2005 and February 2006 who had completed a screening questionnaire during May and June of 2004 to target people with symptoms of allergic rhinitis. The purpose of the follow-up survey was to provide a longitudinal assessment of disease and to capture seasonal variation in disease burden.

Respondents used the Medical Outcomes Study Sleep Scale to rate their sleep. It measures sleep quality and quantity on two scales, a sleep adequacy scale and a sleep problems index scale, ranging from 0 to 100: Higher adequacy scale scores correspond to more adequate amounts of sleep; higher problems scale scores correspond to poorer sleep quality. The scales' mean general population norms are 60.5 and 26.9, respectively.

Complete data were available on 5,371 of the respondents. Of these, 1,788 (33%) reported symptoms consistent with seasonal or perennial allergic rhinitis during the previous 4 weeks that were not related to a cold or to the flu, such as runny nose/sniffling, sneezing, itchy nose, congested nose, and postnasal drainage.

The allergic rhinitis sufferers' mean scores on the sleep adequacy and sleep problems index scales were 51.1 and 35.3, respectively. More than 65% of the allergic rhinitis sufferers reported problems falling asleep or falling back to sleep after awakening, and fewer than half indicated they get enough sleep or feel rested upon awakening.

GlaxoSmithKline funded the study. Dr. Meltzer disclosed he has received research grants and honoraria from the company.

'[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired.' DR. MELTZER

SAN DIEGO — People with allergic rhinitis report more sleep problems during winter, compared with the general population, Dr. Eli Meltzer said in a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The finding underscores the importance of asking patients with allergic rhinitis how their symptoms are affecting their sleep quantity and quality.

“[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired,” Dr. Meltzer, an allergist who practices in San Diego, said in an interview.

Dr. Meltzer and his associates mailed a 27-item survey to 6,476 people nationwide between December 2005 and February 2006 who had completed a screening questionnaire during May and June of 2004 to target people with symptoms of allergic rhinitis. The purpose of the follow-up survey was to provide a longitudinal assessment of disease and to capture seasonal variation in disease burden.

Respondents used the Medical Outcomes Study Sleep Scale to rate their sleep. It measures sleep quality and quantity on two scales, a sleep adequacy scale and a sleep problems index scale, ranging from 0 to 100: Higher adequacy scale scores correspond to more adequate amounts of sleep; higher problems scale scores correspond to poorer sleep quality. The scales' mean general population norms are 60.5 and 26.9, respectively.

Complete data were available on 5,371 of the respondents. Of these, 1,788 (33%) reported symptoms consistent with seasonal or perennial allergic rhinitis during the previous 4 weeks that were not related to a cold or to the flu, such as runny nose/sniffling, sneezing, itchy nose, congested nose, and postnasal drainage.

The allergic rhinitis sufferers' mean scores on the sleep adequacy and sleep problems index scales were 51.1 and 35.3, respectively. More than 65% of the allergic rhinitis sufferers reported problems falling asleep or falling back to sleep after awakening, and fewer than half indicated they get enough sleep or feel rested upon awakening.

GlaxoSmithKline funded the study. Dr. Meltzer disclosed he has received research grants and honoraria from the company.

'[People who] don't get adequate sleep are cognitively impaired and often psychosocially impaired.' DR. MELTZER

An abnormal white blood cell count is not a useful marker for predicting concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection, results from a large single-center study demonstrated.

The finding is important because although there is a guideline for treating infants and young children with fever without a source (Pediatrics 1993;92:1–12), there is no guideline that addresses the treatment of febrile infants and young children with clinical evidence of viral infection, Dr. Kevin Purcell and Dr. Jaime Fergie said.

The researchers studied the medical records of 1,920 infants and young children admitted to Driscoll Children's Hospital in Corpus Christi, Tex., with respiratory syncytial virus (RSV) lower respiratory tract infections between July 1, 2000, and June 30, 2005 (Pediatr. Infect. Dis. J. 2007;26:311–5).

They defined fever as having a temperature of 100.4° F or higher before admission. The WBC count was considered abnormal if it was lower than 5,000/mcL of blood or it reached or exceeded 15,000/mcL of blood. The median age of the 1,920 patients was 142 days, and 672 had a complete WBC count and bacterial culture.

Overall, only 34 of the 672 patients (5.1%) had a positive bacterial culture. The probability of a WBC less than 5,000/mcL and a level between 15,000 and 29,999/mcL being associated with a concurrent serious bacterial infection ranged from 0% to 5.7%. This was no different from the rate of a normal WBC in febrile and afebrile patients, which ranged from 3.9% to 4.7%. However, patients with a WBC of 30,000/mcL or greater were about six times more likely to have a concurrent serious bacterial infection than those who had lower levels.

“Applying the guideline for treatment of infants and young children with fever without a source to patients with RSV lower respiratory tract infection is of no use in predicting the presence of a concurrent serious bacterial infection. However, we believe [one should] obtain blood cultures in infants with RSV lower respiratory tract infection that have a WBC count of 30,000 per mcL or greater or are toxic-appearing,” they wrote.

An abnormal white blood cell count is not a useful marker for predicting concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection, results from a large single-center study demonstrated.

The finding is important because although there is a guideline for treating infants and young children with fever without a source (Pediatrics 1993;92:1–12), there is no guideline that addresses the treatment of febrile infants and young children with clinical evidence of viral infection, Dr. Kevin Purcell and Dr. Jaime Fergie said.

The researchers studied the medical records of 1,920 infants and young children admitted to Driscoll Children's Hospital in Corpus Christi, Tex., with respiratory syncytial virus (RSV) lower respiratory tract infections between July 1, 2000, and June 30, 2005 (Pediatr. Infect. Dis. J. 2007;26:311–5).

They defined fever as having a temperature of 100.4° F or higher before admission. The WBC count was considered abnormal if it was lower than 5,000/mcL of blood or it reached or exceeded 15,000/mcL of blood. The median age of the 1,920 patients was 142 days, and 672 had a complete WBC count and bacterial culture.

Overall, only 34 of the 672 patients (5.1%) had a positive bacterial culture. The probability of a WBC less than 5,000/mcL and a level between 15,000 and 29,999/mcL being associated with a concurrent serious bacterial infection ranged from 0% to 5.7%. This was no different from the rate of a normal WBC in febrile and afebrile patients, which ranged from 3.9% to 4.7%. However, patients with a WBC of 30,000/mcL or greater were about six times more likely to have a concurrent serious bacterial infection than those who had lower levels.

“Applying the guideline for treatment of infants and young children with fever without a source to patients with RSV lower respiratory tract infection is of no use in predicting the presence of a concurrent serious bacterial infection. However, we believe [one should] obtain blood cultures in infants with RSV lower respiratory tract infection that have a WBC count of 30,000 per mcL or greater or are toxic-appearing,” they wrote.

An abnormal white blood cell count is not a useful marker for predicting concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection, results from a large single-center study demonstrated.

The finding is important because although there is a guideline for treating infants and young children with fever without a source (Pediatrics 1993;92:1–12), there is no guideline that addresses the treatment of febrile infants and young children with clinical evidence of viral infection, Dr. Kevin Purcell and Dr. Jaime Fergie said.

The researchers studied the medical records of 1,920 infants and young children admitted to Driscoll Children's Hospital in Corpus Christi, Tex., with respiratory syncytial virus (RSV) lower respiratory tract infections between July 1, 2000, and June 30, 2005 (Pediatr. Infect. Dis. J. 2007;26:311–5).

They defined fever as having a temperature of 100.4° F or higher before admission. The WBC count was considered abnormal if it was lower than 5,000/mcL of blood or it reached or exceeded 15,000/mcL of blood. The median age of the 1,920 patients was 142 days, and 672 had a complete WBC count and bacterial culture.

Overall, only 34 of the 672 patients (5.1%) had a positive bacterial culture. The probability of a WBC less than 5,000/mcL and a level between 15,000 and 29,999/mcL being associated with a concurrent serious bacterial infection ranged from 0% to 5.7%. This was no different from the rate of a normal WBC in febrile and afebrile patients, which ranged from 3.9% to 4.7%. However, patients with a WBC of 30,000/mcL or greater were about six times more likely to have a concurrent serious bacterial infection than those who had lower levels.

“Applying the guideline for treatment of infants and young children with fever without a source to patients with RSV lower respiratory tract infection is of no use in predicting the presence of a concurrent serious bacterial infection. However, we believe [one should] obtain blood cultures in infants with RSV lower respiratory tract infection that have a WBC count of 30,000 per mcL or greater or are toxic-appearing,” they wrote.