Doug Brunk

SAN DIEGO – Children with ADHD were effectively treated on 50% of their optimal stimulant dose by pairing placebo pills with their stimulant medication, Dr. Adrian Sandler reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The technique, known as conditioned placebo dose reduction, could mark a new way to treat attention-deficit hyperactivity disorder (ADHD) and other chronic conditions, said Dr. Sandler, medical director of the Olson Huff Center for Child Development at Mission Children's Hospital, Asheville, N.C.

He and his associates enrolled 137 children with ADHD aged 6–12 years.

The children were divided into 3 groups. Group 1's treatment was decreased from 100% of optimal stimulant dose plus placebo to 50% of stimulant dose plus placebo. Group 2's treatment decreased from 100% of stimulant to 50% of stimulant. Group 3 served as the control, which no reduction in stimulant treatment. Of the 137 children, 70 completed the dose reduction phase. Most children in group 1 remained stable or improved during dose reduction while most in group 2 deteriorated.

The investigators observed no differences in control of ADHD symptoms between groups 1 and 3, and both groups showed improved ADHD control compared with the children in group 2.

Treatment emergent side effects were lowest among children in group 1, while those in group 2 seemed to show an increase in side effects as dose reduction went on.

At the time of this meeting, only 22 children had completed the study's maintenance phase. But so far Dr. Sandler and his associates have detected no differences in ADHD control or in discontinuation rates between groups 1 and 3.

The reduction technique could mark a new way to treat ADHD and other chronic conditions. DR. SANDLER

SAN DIEGO – Children with ADHD were effectively treated on 50% of their optimal stimulant dose by pairing placebo pills with their stimulant medication, Dr. Adrian Sandler reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The technique, known as conditioned placebo dose reduction, could mark a new way to treat attention-deficit hyperactivity disorder (ADHD) and other chronic conditions, said Dr. Sandler, medical director of the Olson Huff Center for Child Development at Mission Children's Hospital, Asheville, N.C.

He and his associates enrolled 137 children with ADHD aged 6–12 years.

The children were divided into 3 groups. Group 1's treatment was decreased from 100% of optimal stimulant dose plus placebo to 50% of stimulant dose plus placebo. Group 2's treatment decreased from 100% of stimulant to 50% of stimulant. Group 3 served as the control, which no reduction in stimulant treatment. Of the 137 children, 70 completed the dose reduction phase. Most children in group 1 remained stable or improved during dose reduction while most in group 2 deteriorated.

The investigators observed no differences in control of ADHD symptoms between groups 1 and 3, and both groups showed improved ADHD control compared with the children in group 2.

Treatment emergent side effects were lowest among children in group 1, while those in group 2 seemed to show an increase in side effects as dose reduction went on.

At the time of this meeting, only 22 children had completed the study's maintenance phase. But so far Dr. Sandler and his associates have detected no differences in ADHD control or in discontinuation rates between groups 1 and 3.

The reduction technique could mark a new way to treat ADHD and other chronic conditions. DR. SANDLER

SAN DIEGO – Children with ADHD were effectively treated on 50% of their optimal stimulant dose by pairing placebo pills with their stimulant medication, Dr. Adrian Sandler reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

The technique, known as conditioned placebo dose reduction, could mark a new way to treat attention-deficit hyperactivity disorder (ADHD) and other chronic conditions, said Dr. Sandler, medical director of the Olson Huff Center for Child Development at Mission Children's Hospital, Asheville, N.C.

He and his associates enrolled 137 children with ADHD aged 6–12 years.

The children were divided into 3 groups. Group 1's treatment was decreased from 100% of optimal stimulant dose plus placebo to 50% of stimulant dose plus placebo. Group 2's treatment decreased from 100% of stimulant to 50% of stimulant. Group 3 served as the control, which no reduction in stimulant treatment. Of the 137 children, 70 completed the dose reduction phase. Most children in group 1 remained stable or improved during dose reduction while most in group 2 deteriorated.

The investigators observed no differences in control of ADHD symptoms between groups 1 and 3, and both groups showed improved ADHD control compared with the children in group 2.

Treatment emergent side effects were lowest among children in group 1, while those in group 2 seemed to show an increase in side effects as dose reduction went on.

At the time of this meeting, only 22 children had completed the study's maintenance phase. But so far Dr. Sandler and his associates have detected no differences in ADHD control or in discontinuation rates between groups 1 and 3.

The reduction technique could mark a new way to treat ADHD and other chronic conditions. DR. SANDLER

By Doug Brunk, San Diego Bureau

Now in his fifth year of dementia, 86-year-old Leonard Winakur doesn't know what day it is. If he's not sleeping when his son, Dr. Jerald Winakur, drops by for a visit (as Dr. Winakur does nearly every day), sometimes he'll engage his son in superficial conversation. Other times he's abrasive and says things like "You ought to come around more often" or "You're not my son."

"As my brother Michael says, he thinks it's always a good visit when he can get my father to laugh," said Dr. Winakur, who practices internal medicine and geriatrics in San Antonio. "We're able to do that on occasion."

Even though Leonard's dementia and physical health continue to worsen, Dr. Winakur and his brother do what they can to keep their father at home with his wife, Frances. That includes sharing the $1,500/month cost of assistance from two home health aides.

"My brother and I are my parents' only real social activity, so we feel we need to go over there frequently, not only to check on them but also to spend time with them," said Dr. Winakur. "My brother does that task on the weekends when I'm off from my doctoring life, and I try to spend time with my wife. During the week, I'll generally go by my parents' house every day, usually after work. My wife helps me a lot. My mother's big outing every week is to go to the beauty shop, something she's done for 50 years, probably. My brother or I will take her in the morning to her appointment, and my wife will pick her up and take her out to lunch."

To complicate the caregiving situation, Frances has developed severe macular degeneration and is unable to perform some activities of daily living.

"I'm running kind of a mini two-bed nursing home in their house," said Dr. Winakur, who is on the faculty at the Center for Medical Humanities and Ethics at the University of Texas, San Antonio. "I've had many conversations with my mother about maybe moving her into an assisted-living situation where there might be a dementia unit on the same campus. But she won't consider that—at least not now. They're most comfortable in their own home. Even though I as a medical professional know there are 'other levels of care' available for them, keeping them home is what will make them most comfortable now."

The circumstances frustrate him in the sense that "you don't want to watch this [decline] happening to them, but it is happening," he said.

Though he shares caregiving duties with his brother, Dr. Winakur noted that his mother carries the bulk of burden. She lives with Leonard's erratic behavior 24 hours a day, 7 days a week. "Every year we try to get her to go away for a week and visit relatives back east. One of us—usually my brother—will take her, and I will stay with my father. It should be more [often] than that, but she won't go. She knows my father gets agitated when she isn't there. He can't remember that she's gone away for a visit. He thinks something's wrong. It's a trying time for him. My mother knows it is, which is one of the reasons that keeps her from going," he says.

He was quick to note that it takes "great effort" to keep his parents at home. It is expensive, frustrating, and depleting, "but it can be done. We've been doing it for 4 years." Dr. Winakur knows something will disrupt the current balance of care. His father might become acutely ill or break a hip. "That will necessitate a change," he said. "What will happen then is that my father will most likely end up in some sort of long-term-care facility. And my mother will probably need ongoing help if she elects to stay at home. Then I'll have one parent in a long-term-care facility and one parent at home."

For him, the events have underscored the importance of discussing end-of-life issues with parents long before an actual crisis arises. "I read a statistic that 75% of Americans haven't had the kind of in-depth conversation with their siblings and their parents about end-of-life issues," Dr. Winakur noted. "[These discussions] need to be had. As doctors, we need to take the initiative with our elderly parents."

Dr. Robert Kane said his mother's greatest fear was losing her independence. That fear was realized in 1999 when Ruth Kane suffered a stroke at the age of 84 in her Florida condominium. A stepwise decline in health led to her death in a nursing home 3 years later, despite the best efforts of Dr. Kane, an international expert in long-term care, and his sister, Joan C. West, to "get the system to perform the way it should."

First, there was a brief hospitalization in Florida and a move to a rehabilitation hospital near Ms. West in Long Island, N.Y., where Ruth was able to regain her ability to perform most activities of daily living.

Then, Ruth was moved into an assisted living facility, where she was hospitalized several times for heart failure and her overall physical and mental health began to decline. From there, she was moved into another assisted-living facility in the area known for its special dementia care. Nine months later, she entered a nursing home, where she died after a 3-month stay.

"I had a good network of people who could find geriatricians to care for my mother in the various places she was," said Dr. Kane, who holds the endowed chair in long-term care and aging at the University of Minnesota School of Public Health, Minneapolis. "But that didn't make the care good. For example, the geriatrician who was caring for her did not necessarily have admitting privileges in the hospital they would take her to when she fell down in assisted living."

Although Dr. Kane and his sister discussed having Ruth move in with one of them when she completed her rehabilitation, they determined that would not work. "The only reasonable approach would have been to set her up in an apartment and bring in 24-hour care," Dr. Kane said. "She was so hard on people who took care of her that it would have been a constant battle just keeping the roster full."

Dr. Kane and Ms. West cowrote a book about the frustrations they experienced trying to arrange long-term care for Ruth, called "It Shouldn't Be This Way: The Failure of Long-Term Care" (Nashville: Vanderbilt University Press, 2005). Three key lessons he learned from the ordeal were:

▸ Be wary about whom you trust. "Discharge planners are not your advocates," he said. "Their job is to move people out of hospitals. If you're looking for a doctor to take care of your mother, I would probably start with the American Geriatrics Society. If you're looking for an assisted-living facility, I would try and find somebody I trust in the area who can tell me where the good places are."

▸ Choose your battles carefully. It's easy to fall into an unequal negotiating position when arranging for the care of a loved one, even if you know more than the people who are delivering the care. "You can't afford to either antagonize them or to push them to a point where they say, 'We just can't do the job,'" Dr. Kane said.

▸ Assume a leadership role. Dr. Kane said he draws inspiration from the Howard Beale character portrayed by Peter Finch in the 1976 film "Network," who got people to shout, "I'm mad as hell, and I'm not going to take it anymore!" Physicians "ought to be advocates for major reform in the way health care is delivered, to recognize that we live in a world of chronic disease and that the acute care fixation that we have in our current health care system is never going to do the job," he said.

To help bring about such reform, Dr. Kane founded Professionals with Personal Experience in Chronic Care, a group of more than 700 physicians, nurses, and other health care workers whose main purpose is to advocate for improvements in the way long-term care is delivered. (For information, visit www.ppecc.org

Book Selections For Caregivers

"Caregiving at Home," by Dr. William Leahy and the editors of Hartman Publishing (Albuquerque: Hartman Publishing, 2005).

"How to Care for Aging Parents," by Virginia Morris (New York: Workman Publishing, 2004).

"It Shouldn't Be This Way: The Failure of Long-Term Care," by Dr. Robert L. Kane and Joan C. West (Nashville, Tenn.: Vanderbilt University Press, 2005).

"Meeting the Challenges of Chronic Illness," by Dr. Robert L. Kane, Reinhard Priester, J.D., and Annette M. Totten, Ph.D. (Baltimore: The Johns Hopkins University Press, 2005).

"Our Parents, Ourselves: How American Health Care Imperils Middle Age and Beyond," by Judith Steinberg Turiel (Berkeley: University of California Press, 2005).

By Doug Brunk, San Diego Bureau

Now in his fifth year of dementia, 86-year-old Leonard Winakur doesn't know what day it is. If he's not sleeping when his son, Dr. Jerald Winakur, drops by for a visit (as Dr. Winakur does nearly every day), sometimes he'll engage his son in superficial conversation. Other times he's abrasive and says things like "You ought to come around more often" or "You're not my son."

"As my brother Michael says, he thinks it's always a good visit when he can get my father to laugh," said Dr. Winakur, who practices internal medicine and geriatrics in San Antonio. "We're able to do that on occasion."

Even though Leonard's dementia and physical health continue to worsen, Dr. Winakur and his brother do what they can to keep their father at home with his wife, Frances. That includes sharing the $1,500/month cost of assistance from two home health aides.

"My brother and I are my parents' only real social activity, so we feel we need to go over there frequently, not only to check on them but also to spend time with them," said Dr. Winakur. "My brother does that task on the weekends when I'm off from my doctoring life, and I try to spend time with my wife. During the week, I'll generally go by my parents' house every day, usually after work. My wife helps me a lot. My mother's big outing every week is to go to the beauty shop, something she's done for 50 years, probably. My brother or I will take her in the morning to her appointment, and my wife will pick her up and take her out to lunch."

To complicate the caregiving situation, Frances has developed severe macular degeneration and is unable to perform some activities of daily living.

"I'm running kind of a mini two-bed nursing home in their house," said Dr. Winakur, who is on the faculty at the Center for Medical Humanities and Ethics at the University of Texas, San Antonio. "I've had many conversations with my mother about maybe moving her into an assisted-living situation where there might be a dementia unit on the same campus. But she won't consider that—at least not now. They're most comfortable in their own home. Even though I as a medical professional know there are 'other levels of care' available for them, keeping them home is what will make them most comfortable now."

The circumstances frustrate him in the sense that "you don't want to watch this [decline] happening to them, but it is happening," he said.

Though he shares caregiving duties with his brother, Dr. Winakur noted that his mother carries the bulk of burden. She lives with Leonard's erratic behavior 24 hours a day, 7 days a week. "Every year we try to get her to go away for a week and visit relatives back east. One of us—usually my brother—will take her, and I will stay with my father. It should be more [often] than that, but she won't go. She knows my father gets agitated when she isn't there. He can't remember that she's gone away for a visit. He thinks something's wrong. It's a trying time for him. My mother knows it is, which is one of the reasons that keeps her from going," he says.

He was quick to note that it takes "great effort" to keep his parents at home. It is expensive, frustrating, and depleting, "but it can be done. We've been doing it for 4 years." Dr. Winakur knows something will disrupt the current balance of care. His father might become acutely ill or break a hip. "That will necessitate a change," he said. "What will happen then is that my father will most likely end up in some sort of long-term-care facility. And my mother will probably need ongoing help if she elects to stay at home. Then I'll have one parent in a long-term-care facility and one parent at home."

For him, the events have underscored the importance of discussing end-of-life issues with parents long before an actual crisis arises. "I read a statistic that 75% of Americans haven't had the kind of in-depth conversation with their siblings and their parents about end-of-life issues," Dr. Winakur noted. "[These discussions] need to be had. As doctors, we need to take the initiative with our elderly parents."

Dr. Robert Kane said his mother's greatest fear was losing her independence. That fear was realized in 1999 when Ruth Kane suffered a stroke at the age of 84 in her Florida condominium. A stepwise decline in health led to her death in a nursing home 3 years later, despite the best efforts of Dr. Kane, an international expert in long-term care, and his sister, Joan C. West, to "get the system to perform the way it should."

First, there was a brief hospitalization in Florida and a move to a rehabilitation hospital near Ms. West in Long Island, N.Y., where Ruth was able to regain her ability to perform most activities of daily living.

Then, Ruth was moved into an assisted living facility, where she was hospitalized several times for heart failure and her overall physical and mental health began to decline. From there, she was moved into another assisted-living facility in the area known for its special dementia care. Nine months later, she entered a nursing home, where she died after a 3-month stay.

"I had a good network of people who could find geriatricians to care for my mother in the various places she was," said Dr. Kane, who holds the endowed chair in long-term care and aging at the University of Minnesota School of Public Health, Minneapolis. "But that didn't make the care good. For example, the geriatrician who was caring for her did not necessarily have admitting privileges in the hospital they would take her to when she fell down in assisted living."

Although Dr. Kane and his sister discussed having Ruth move in with one of them when she completed her rehabilitation, they determined that would not work. "The only reasonable approach would have been to set her up in an apartment and bring in 24-hour care," Dr. Kane said. "She was so hard on people who took care of her that it would have been a constant battle just keeping the roster full."

Dr. Kane and Ms. West cowrote a book about the frustrations they experienced trying to arrange long-term care for Ruth, called "It Shouldn't Be This Way: The Failure of Long-Term Care" (Nashville: Vanderbilt University Press, 2005). Three key lessons he learned from the ordeal were:

▸ Be wary about whom you trust. "Discharge planners are not your advocates," he said. "Their job is to move people out of hospitals. If you're looking for a doctor to take care of your mother, I would probably start with the American Geriatrics Society. If you're looking for an assisted-living facility, I would try and find somebody I trust in the area who can tell me where the good places are."

▸ Choose your battles carefully. It's easy to fall into an unequal negotiating position when arranging for the care of a loved one, even if you know more than the people who are delivering the care. "You can't afford to either antagonize them or to push them to a point where they say, 'We just can't do the job,'" Dr. Kane said.

▸ Assume a leadership role. Dr. Kane said he draws inspiration from the Howard Beale character portrayed by Peter Finch in the 1976 film "Network," who got people to shout, "I'm mad as hell, and I'm not going to take it anymore!" Physicians "ought to be advocates for major reform in the way health care is delivered, to recognize that we live in a world of chronic disease and that the acute care fixation that we have in our current health care system is never going to do the job," he said.

To help bring about such reform, Dr. Kane founded Professionals with Personal Experience in Chronic Care, a group of more than 700 physicians, nurses, and other health care workers whose main purpose is to advocate for improvements in the way long-term care is delivered. (For information, visit www.ppecc.org

Book Selections For Caregivers

"Caregiving at Home," by Dr. William Leahy and the editors of Hartman Publishing (Albuquerque: Hartman Publishing, 2005).

"How to Care for Aging Parents," by Virginia Morris (New York: Workman Publishing, 2004).

"It Shouldn't Be This Way: The Failure of Long-Term Care," by Dr. Robert L. Kane and Joan C. West (Nashville, Tenn.: Vanderbilt University Press, 2005).

"Meeting the Challenges of Chronic Illness," by Dr. Robert L. Kane, Reinhard Priester, J.D., and Annette M. Totten, Ph.D. (Baltimore: The Johns Hopkins University Press, 2005).

"Our Parents, Ourselves: How American Health Care Imperils Middle Age and Beyond," by Judith Steinberg Turiel (Berkeley: University of California Press, 2005).

By Doug Brunk, San Diego Bureau

Now in his fifth year of dementia, 86-year-old Leonard Winakur doesn't know what day it is. If he's not sleeping when his son, Dr. Jerald Winakur, drops by for a visit (as Dr. Winakur does nearly every day), sometimes he'll engage his son in superficial conversation. Other times he's abrasive and says things like "You ought to come around more often" or "You're not my son."

"As my brother Michael says, he thinks it's always a good visit when he can get my father to laugh," said Dr. Winakur, who practices internal medicine and geriatrics in San Antonio. "We're able to do that on occasion."

Even though Leonard's dementia and physical health continue to worsen, Dr. Winakur and his brother do what they can to keep their father at home with his wife, Frances. That includes sharing the $1,500/month cost of assistance from two home health aides.

"My brother and I are my parents' only real social activity, so we feel we need to go over there frequently, not only to check on them but also to spend time with them," said Dr. Winakur. "My brother does that task on the weekends when I'm off from my doctoring life, and I try to spend time with my wife. During the week, I'll generally go by my parents' house every day, usually after work. My wife helps me a lot. My mother's big outing every week is to go to the beauty shop, something she's done for 50 years, probably. My brother or I will take her in the morning to her appointment, and my wife will pick her up and take her out to lunch."

To complicate the caregiving situation, Frances has developed severe macular degeneration and is unable to perform some activities of daily living.

"I'm running kind of a mini two-bed nursing home in their house," said Dr. Winakur, who is on the faculty at the Center for Medical Humanities and Ethics at the University of Texas, San Antonio. "I've had many conversations with my mother about maybe moving her into an assisted-living situation where there might be a dementia unit on the same campus. But she won't consider that—at least not now. They're most comfortable in their own home. Even though I as a medical professional know there are 'other levels of care' available for them, keeping them home is what will make them most comfortable now."

The circumstances frustrate him in the sense that "you don't want to watch this [decline] happening to them, but it is happening," he said.

Though he shares caregiving duties with his brother, Dr. Winakur noted that his mother carries the bulk of burden. She lives with Leonard's erratic behavior 24 hours a day, 7 days a week. "Every year we try to get her to go away for a week and visit relatives back east. One of us—usually my brother—will take her, and I will stay with my father. It should be more [often] than that, but she won't go. She knows my father gets agitated when she isn't there. He can't remember that she's gone away for a visit. He thinks something's wrong. It's a trying time for him. My mother knows it is, which is one of the reasons that keeps her from going," he says.

He was quick to note that it takes "great effort" to keep his parents at home. It is expensive, frustrating, and depleting, "but it can be done. We've been doing it for 4 years." Dr. Winakur knows something will disrupt the current balance of care. His father might become acutely ill or break a hip. "That will necessitate a change," he said. "What will happen then is that my father will most likely end up in some sort of long-term-care facility. And my mother will probably need ongoing help if she elects to stay at home. Then I'll have one parent in a long-term-care facility and one parent at home."

For him, the events have underscored the importance of discussing end-of-life issues with parents long before an actual crisis arises. "I read a statistic that 75% of Americans haven't had the kind of in-depth conversation with their siblings and their parents about end-of-life issues," Dr. Winakur noted. "[These discussions] need to be had. As doctors, we need to take the initiative with our elderly parents."

Dr. Robert Kane said his mother's greatest fear was losing her independence. That fear was realized in 1999 when Ruth Kane suffered a stroke at the age of 84 in her Florida condominium. A stepwise decline in health led to her death in a nursing home 3 years later, despite the best efforts of Dr. Kane, an international expert in long-term care, and his sister, Joan C. West, to "get the system to perform the way it should."

First, there was a brief hospitalization in Florida and a move to a rehabilitation hospital near Ms. West in Long Island, N.Y., where Ruth was able to regain her ability to perform most activities of daily living.

Then, Ruth was moved into an assisted living facility, where she was hospitalized several times for heart failure and her overall physical and mental health began to decline. From there, she was moved into another assisted-living facility in the area known for its special dementia care. Nine months later, she entered a nursing home, where she died after a 3-month stay.

"I had a good network of people who could find geriatricians to care for my mother in the various places she was," said Dr. Kane, who holds the endowed chair in long-term care and aging at the University of Minnesota School of Public Health, Minneapolis. "But that didn't make the care good. For example, the geriatrician who was caring for her did not necessarily have admitting privileges in the hospital they would take her to when she fell down in assisted living."

Although Dr. Kane and his sister discussed having Ruth move in with one of them when she completed her rehabilitation, they determined that would not work. "The only reasonable approach would have been to set her up in an apartment and bring in 24-hour care," Dr. Kane said. "She was so hard on people who took care of her that it would have been a constant battle just keeping the roster full."

Dr. Kane and Ms. West cowrote a book about the frustrations they experienced trying to arrange long-term care for Ruth, called "It Shouldn't Be This Way: The Failure of Long-Term Care" (Nashville: Vanderbilt University Press, 2005). Three key lessons he learned from the ordeal were:

▸ Be wary about whom you trust. "Discharge planners are not your advocates," he said. "Their job is to move people out of hospitals. If you're looking for a doctor to take care of your mother, I would probably start with the American Geriatrics Society. If you're looking for an assisted-living facility, I would try and find somebody I trust in the area who can tell me where the good places are."

▸ Choose your battles carefully. It's easy to fall into an unequal negotiating position when arranging for the care of a loved one, even if you know more than the people who are delivering the care. "You can't afford to either antagonize them or to push them to a point where they say, 'We just can't do the job,'" Dr. Kane said.

▸ Assume a leadership role. Dr. Kane said he draws inspiration from the Howard Beale character portrayed by Peter Finch in the 1976 film "Network," who got people to shout, "I'm mad as hell, and I'm not going to take it anymore!" Physicians "ought to be advocates for major reform in the way health care is delivered, to recognize that we live in a world of chronic disease and that the acute care fixation that we have in our current health care system is never going to do the job," he said.

To help bring about such reform, Dr. Kane founded Professionals with Personal Experience in Chronic Care, a group of more than 700 physicians, nurses, and other health care workers whose main purpose is to advocate for improvements in the way long-term care is delivered. (For information, visit www.ppecc.org

Book Selections For Caregivers

"Caregiving at Home," by Dr. William Leahy and the editors of Hartman Publishing (Albuquerque: Hartman Publishing, 2005).

"How to Care for Aging Parents," by Virginia Morris (New York: Workman Publishing, 2004).

"It Shouldn't Be This Way: The Failure of Long-Term Care," by Dr. Robert L. Kane and Joan C. West (Nashville, Tenn.: Vanderbilt University Press, 2005).

"Meeting the Challenges of Chronic Illness," by Dr. Robert L. Kane, Reinhard Priester, J.D., and Annette M. Totten, Ph.D. (Baltimore: The Johns Hopkins University Press, 2005).

"Our Parents, Ourselves: How American Health Care Imperils Middle Age and Beyond," by Judith Steinberg Turiel (Berkeley: University of California Press, 2005).

SAN DIEGO — High-resolution MRI is a useful tool to assess ligaments and membranes in the upper cervical spine and classify structural abnormalities in grades of severity, results from a controlled study of 92 whiplash injury patients have demonstrated.

The finding is important because the structural basis of whiplash injury is unknown, Jostein Krakenes, Ph.D., said at the annual meeting of the Cervical Spine Research Society.

“Structural changes can be graded with reasonable reliability [using MRI],” he said.

For the prospective study, 92 patients with whiplash injuries sustained after frontal or rear-end automobile collisions 2–9 years previously and 30 uninjured controls underwent high-resolution MRI of the craniovertebral junction in three orthogonal planes, said Dr. Krakenes of Haukeland University Hospital, Bergen, Norway. The investigators included only patients with persistent neck pain, tenderness in neck muscles and other soft tissues by palpation, and decreased range of neck motion 3 months after the whiplash injury.

Three radiologists blinded to the clinical information interpreted the images twice at 3-month intervals.

He explained that on MRI normal alar ligaments and membranes show low signal intensity and appear dark. Increased signal intensity within ligaments, meanwhile, is regarded as injury.

A high signal in one-third or less of the cross-section was defined as grade 1, a high signal in one-third to two-thirds of the cross-section was grade 2, and a high signal in two-thirds or more of the cross-section was grade 3.

Of the 394 ligaments and membranes evaluated, 117 (30%) were grade 2 or 3 lesions in the whiplash group. Among the 140 ligaments and membranes evaluated in the control group, only 7 (5%) had grade 2 lesions and none had grade 3 lesions.

Most of the damage in the whiplash group patients with grade 2 or 3 lesions was localized to the alar ligaments, said Dr. Krakenes. Most of the high grade changes seen in controls were localized to the transverse ligaments.

When the investigators assessed inter- and intraobserver agreement, highest reliability was found for the atlanto-occipital membrane and lowest for the transverse ligament.

He concluded that increasing neck disability index with increased MRI grading “indicates that craniovertebral ligament lesions may explain some of the impairment of the whiplash associated disorder.”

Increased signal intensity on MRI, as pictured above, suggests damage to the alar ligaments in whiplash injury patients, according to Dr. Jostein Krakenes. Photos courtesy Dr. Jostein Krakenes

SAN DIEGO — High-resolution MRI is a useful tool to assess ligaments and membranes in the upper cervical spine and classify structural abnormalities in grades of severity, results from a controlled study of 92 whiplash injury patients have demonstrated.

The finding is important because the structural basis of whiplash injury is unknown, Jostein Krakenes, Ph.D., said at the annual meeting of the Cervical Spine Research Society.

“Structural changes can be graded with reasonable reliability [using MRI],” he said.

For the prospective study, 92 patients with whiplash injuries sustained after frontal or rear-end automobile collisions 2–9 years previously and 30 uninjured controls underwent high-resolution MRI of the craniovertebral junction in three orthogonal planes, said Dr. Krakenes of Haukeland University Hospital, Bergen, Norway. The investigators included only patients with persistent neck pain, tenderness in neck muscles and other soft tissues by palpation, and decreased range of neck motion 3 months after the whiplash injury.

Three radiologists blinded to the clinical information interpreted the images twice at 3-month intervals.

He explained that on MRI normal alar ligaments and membranes show low signal intensity and appear dark. Increased signal intensity within ligaments, meanwhile, is regarded as injury.

A high signal in one-third or less of the cross-section was defined as grade 1, a high signal in one-third to two-thirds of the cross-section was grade 2, and a high signal in two-thirds or more of the cross-section was grade 3.

Of the 394 ligaments and membranes evaluated, 117 (30%) were grade 2 or 3 lesions in the whiplash group. Among the 140 ligaments and membranes evaluated in the control group, only 7 (5%) had grade 2 lesions and none had grade 3 lesions.

Most of the damage in the whiplash group patients with grade 2 or 3 lesions was localized to the alar ligaments, said Dr. Krakenes. Most of the high grade changes seen in controls were localized to the transverse ligaments.

When the investigators assessed inter- and intraobserver agreement, highest reliability was found for the atlanto-occipital membrane and lowest for the transverse ligament.

He concluded that increasing neck disability index with increased MRI grading “indicates that craniovertebral ligament lesions may explain some of the impairment of the whiplash associated disorder.”

Increased signal intensity on MRI, as pictured above, suggests damage to the alar ligaments in whiplash injury patients, according to Dr. Jostein Krakenes. Photos courtesy Dr. Jostein Krakenes

SAN DIEGO — High-resolution MRI is a useful tool to assess ligaments and membranes in the upper cervical spine and classify structural abnormalities in grades of severity, results from a controlled study of 92 whiplash injury patients have demonstrated.

The finding is important because the structural basis of whiplash injury is unknown, Jostein Krakenes, Ph.D., said at the annual meeting of the Cervical Spine Research Society.

“Structural changes can be graded with reasonable reliability [using MRI],” he said.

For the prospective study, 92 patients with whiplash injuries sustained after frontal or rear-end automobile collisions 2–9 years previously and 30 uninjured controls underwent high-resolution MRI of the craniovertebral junction in three orthogonal planes, said Dr. Krakenes of Haukeland University Hospital, Bergen, Norway. The investigators included only patients with persistent neck pain, tenderness in neck muscles and other soft tissues by palpation, and decreased range of neck motion 3 months after the whiplash injury.

Three radiologists blinded to the clinical information interpreted the images twice at 3-month intervals.

He explained that on MRI normal alar ligaments and membranes show low signal intensity and appear dark. Increased signal intensity within ligaments, meanwhile, is regarded as injury.

A high signal in one-third or less of the cross-section was defined as grade 1, a high signal in one-third to two-thirds of the cross-section was grade 2, and a high signal in two-thirds or more of the cross-section was grade 3.

Of the 394 ligaments and membranes evaluated, 117 (30%) were grade 2 or 3 lesions in the whiplash group. Among the 140 ligaments and membranes evaluated in the control group, only 7 (5%) had grade 2 lesions and none had grade 3 lesions.

Most of the damage in the whiplash group patients with grade 2 or 3 lesions was localized to the alar ligaments, said Dr. Krakenes. Most of the high grade changes seen in controls were localized to the transverse ligaments.

When the investigators assessed inter- and intraobserver agreement, highest reliability was found for the atlanto-occipital membrane and lowest for the transverse ligament.

He concluded that increasing neck disability index with increased MRI grading “indicates that craniovertebral ligament lesions may explain some of the impairment of the whiplash associated disorder.”

Increased signal intensity on MRI, as pictured above, suggests damage to the alar ligaments in whiplash injury patients, according to Dr. Jostein Krakenes. Photos courtesy Dr. Jostein Krakenes

LAS VEGAS — Oral contraceptives can be effective for the treatment of acne in women, but should be used as an adjunct to an existing therapy regimen instead of first-line or stand-alone therapy, Dr. Julie C. Harper said at the Fall Clinical Dermatology Conference.

“I never start with these,” said Dr. Harper, of the University of Alabama at Birmingham. “I start with a topical retinoid and add systemic or topical antibiotics, or an antimicrobial like benzoyl peroxide. If the patient does not respond, I don't stop those and then add a birth control pill. I add the birth control pill into the mix.”

Dr. Harper said that 12% of women aged 25–44 have acne, while only 5% of women still have the condition after age 45.

All combination ethinyl estradiol/progestin oral contraceptives (OCs) have the potential to improve acne because their antiandrogenic properties decrease circulating free testosterone by increasing sex hormone-binding globulin.

It's important to weigh the benefit of OCs against the documented risks, which include:

▸ Venous thromboembolism. The risk is tripled in current users of oral contraceptives, and that risk increases with higher doses of ethinyl estradiol. The mortality rates double for OC users aged 35–45.

▸ Stroke. Women aged 20–24 who use OCs face a 2.5-fold higher risk of ischemic stroke, compared with their peers who do not use them. The risk is directly proportional to the estrogen dose used and increases with age.

“These risks are probably not as significant now as they were several years ago when all of the birth control pills contained ethinyl estradiol doses near 50 micrograms,” Dr. Harper noted. “Now we're seeing [ethinyl estradiol dosages] at 25, 30, and 35 micrograms. Hypertension, cigarette smoking, and migraine headaches also substantially increase this [stroke] risk.”

▸ Myocardial infarction. Eighty percent of heart attacks that occur in women who are on an OC can be attributed to cigarette smoking. “The remainder occurs in people who are taking birth control pills who have other known risks, like hypertension or diabetes,” she said, adding that she does not prescribe OCs to smokers.

Nor does Dr. Harper, a dermatologist, feel comfortable prescribing OCs to women over the age of 35. Instead, she says she encourages these women to see an ob.gyn. or their primary care provider and to get the birth control pill prescription from them.

▸ Breast cancer. According to a World Health Organization metaanalysis, the relative risk of breast cancer for current oral contraceptive users is 1.24, while the relative risk of cancer that has spread vs. remained localized is 0.88. That means that the disease was found earlier in women who were on an OC than in those who were not.

“The message to me there is, we need to be sure that women who are getting birth control pills are getting well-woman exams,” Dr. Harper said at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc. “I start somebody on a birth control pill and I give them a 6-month supply. I tell them, 'If this is working, you need to get your second 6-month supply from someone who can do that well-woman exam.'”

Another option for acne treatment that Dr. Harper uses in older women is spironolactone, an aldosterone antagonist that binds to the androgen receptor and inhibits androgen biosynthesis in the gonads and adrenal glands. She starts with a dosage of 50–100 mg/day.

“If the woman is able to bear children, I think this needs to be coadministered with a birth control pill,” she said. “If the woman becomes pregnant while on spironolactone, there is risk of feminization of the male fetus.”

Spironolactone can also cause menstrual irregularities. “That's another reason to coadminister with a birth control pill,” she said.

LAS VEGAS — Oral contraceptives can be effective for the treatment of acne in women, but should be used as an adjunct to an existing therapy regimen instead of first-line or stand-alone therapy, Dr. Julie C. Harper said at the Fall Clinical Dermatology Conference.

“I never start with these,” said Dr. Harper, of the University of Alabama at Birmingham. “I start with a topical retinoid and add systemic or topical antibiotics, or an antimicrobial like benzoyl peroxide. If the patient does not respond, I don't stop those and then add a birth control pill. I add the birth control pill into the mix.”

Dr. Harper said that 12% of women aged 25–44 have acne, while only 5% of women still have the condition after age 45.

All combination ethinyl estradiol/progestin oral contraceptives (OCs) have the potential to improve acne because their antiandrogenic properties decrease circulating free testosterone by increasing sex hormone-binding globulin.

It's important to weigh the benefit of OCs against the documented risks, which include:

▸ Venous thromboembolism. The risk is tripled in current users of oral contraceptives, and that risk increases with higher doses of ethinyl estradiol. The mortality rates double for OC users aged 35–45.

▸ Stroke. Women aged 20–24 who use OCs face a 2.5-fold higher risk of ischemic stroke, compared with their peers who do not use them. The risk is directly proportional to the estrogen dose used and increases with age.

“These risks are probably not as significant now as they were several years ago when all of the birth control pills contained ethinyl estradiol doses near 50 micrograms,” Dr. Harper noted. “Now we're seeing [ethinyl estradiol dosages] at 25, 30, and 35 micrograms. Hypertension, cigarette smoking, and migraine headaches also substantially increase this [stroke] risk.”

▸ Myocardial infarction. Eighty percent of heart attacks that occur in women who are on an OC can be attributed to cigarette smoking. “The remainder occurs in people who are taking birth control pills who have other known risks, like hypertension or diabetes,” she said, adding that she does not prescribe OCs to smokers.

Nor does Dr. Harper, a dermatologist, feel comfortable prescribing OCs to women over the age of 35. Instead, she says she encourages these women to see an ob.gyn. or their primary care provider and to get the birth control pill prescription from them.

▸ Breast cancer. According to a World Health Organization metaanalysis, the relative risk of breast cancer for current oral contraceptive users is 1.24, while the relative risk of cancer that has spread vs. remained localized is 0.88. That means that the disease was found earlier in women who were on an OC than in those who were not.

“The message to me there is, we need to be sure that women who are getting birth control pills are getting well-woman exams,” Dr. Harper said at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc. “I start somebody on a birth control pill and I give them a 6-month supply. I tell them, 'If this is working, you need to get your second 6-month supply from someone who can do that well-woman exam.'”

Another option for acne treatment that Dr. Harper uses in older women is spironolactone, an aldosterone antagonist that binds to the androgen receptor and inhibits androgen biosynthesis in the gonads and adrenal glands. She starts with a dosage of 50–100 mg/day.

“If the woman is able to bear children, I think this needs to be coadministered with a birth control pill,” she said. “If the woman becomes pregnant while on spironolactone, there is risk of feminization of the male fetus.”

Spironolactone can also cause menstrual irregularities. “That's another reason to coadminister with a birth control pill,” she said.

LAS VEGAS — Oral contraceptives can be effective for the treatment of acne in women, but should be used as an adjunct to an existing therapy regimen instead of first-line or stand-alone therapy, Dr. Julie C. Harper said at the Fall Clinical Dermatology Conference.

“I never start with these,” said Dr. Harper, of the University of Alabama at Birmingham. “I start with a topical retinoid and add systemic or topical antibiotics, or an antimicrobial like benzoyl peroxide. If the patient does not respond, I don't stop those and then add a birth control pill. I add the birth control pill into the mix.”

Dr. Harper said that 12% of women aged 25–44 have acne, while only 5% of women still have the condition after age 45.

All combination ethinyl estradiol/progestin oral contraceptives (OCs) have the potential to improve acne because their antiandrogenic properties decrease circulating free testosterone by increasing sex hormone-binding globulin.

It's important to weigh the benefit of OCs against the documented risks, which include:

▸ Venous thromboembolism. The risk is tripled in current users of oral contraceptives, and that risk increases with higher doses of ethinyl estradiol. The mortality rates double for OC users aged 35–45.

▸ Stroke. Women aged 20–24 who use OCs face a 2.5-fold higher risk of ischemic stroke, compared with their peers who do not use them. The risk is directly proportional to the estrogen dose used and increases with age.

“These risks are probably not as significant now as they were several years ago when all of the birth control pills contained ethinyl estradiol doses near 50 micrograms,” Dr. Harper noted. “Now we're seeing [ethinyl estradiol dosages] at 25, 30, and 35 micrograms. Hypertension, cigarette smoking, and migraine headaches also substantially increase this [stroke] risk.”

▸ Myocardial infarction. Eighty percent of heart attacks that occur in women who are on an OC can be attributed to cigarette smoking. “The remainder occurs in people who are taking birth control pills who have other known risks, like hypertension or diabetes,” she said, adding that she does not prescribe OCs to smokers.

Nor does Dr. Harper, a dermatologist, feel comfortable prescribing OCs to women over the age of 35. Instead, she says she encourages these women to see an ob.gyn. or their primary care provider and to get the birth control pill prescription from them.

▸ Breast cancer. According to a World Health Organization metaanalysis, the relative risk of breast cancer for current oral contraceptive users is 1.24, while the relative risk of cancer that has spread vs. remained localized is 0.88. That means that the disease was found earlier in women who were on an OC than in those who were not.

“The message to me there is, we need to be sure that women who are getting birth control pills are getting well-woman exams,” Dr. Harper said at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc. “I start somebody on a birth control pill and I give them a 6-month supply. I tell them, 'If this is working, you need to get your second 6-month supply from someone who can do that well-woman exam.'”

Another option for acne treatment that Dr. Harper uses in older women is spironolactone, an aldosterone antagonist that binds to the androgen receptor and inhibits androgen biosynthesis in the gonads and adrenal glands. She starts with a dosage of 50–100 mg/day.

“If the woman is able to bear children, I think this needs to be coadministered with a birth control pill,” she said. “If the woman becomes pregnant while on spironolactone, there is risk of feminization of the male fetus.”

Spironolactone can also cause menstrual irregularities. “That's another reason to coadminister with a birth control pill,” she said.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in mid-winter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures— which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus. “So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring; chest wall retractions; tachypnea with apneic episodes; expiratory wheezing; prolonged expiration; rales and rhonchi; croupy cough; and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5).

“If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trail of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in whom] I would use corticosteroids.”

She also would use them in a baby with RSV and heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” she said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promoting breast-feeding.

One strategy to prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children older than 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in mid-winter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures— which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus. “So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring; chest wall retractions; tachypnea with apneic episodes; expiratory wheezing; prolonged expiration; rales and rhonchi; croupy cough; and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5).

“If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trail of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in whom] I would use corticosteroids.”

She also would use them in a baby with RSV and heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” she said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promoting breast-feeding.

One strategy to prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children older than 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

LAS VEGAS — Respiratory syncytial virus infection is a clinical diagnosis based on patient history, physical exam, and the season of the year, Dr. Veda L. Ackerman said at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“So if you try to tell me that you have a baby who is RSV positive on July 4th in your practice, I'm going to tell you that your RSV test has cross-reacted with another virus,” said Dr. Ackerman, of the section of pulmonology and critical care in the department of pediatrics at the James Whitcomb Riley Hospital for Children, Indianapolis. “We do not see RSV in the summer in the United States. It peaks in mid-winter and early spring.”

You can use RSV rapid tests to make a diagnosis, but these “have both a high degree of false-negatives and a high degree of false-positives,” she said. “You have to take that into consideration.”

Even with viral cultures— which are traditionally the preferred method—there is a high false-negative rate due to the lability of the virus. “So you can't take RSV positive or negative as a very good guideline for what you do,” she explained. “As therapy is largely supportive, proving that the baby has RSV really shouldn't matter to you, except for potential infection control.”

By age 2 years, 99% of children have been infected with RSV at least once and 36% have had a least 2 infections. This makes RSV “as contagious as varicella, and it has significant impact on missed days of school and missed days of work.”

Factors that increase one's risk of acquiring RSV infection include maternal education of grade 12 or less, day care attendance, school-age siblings, lack of breast-feeding, two or more people sharing a bedroom, multiple births, passive smoke exposure, and birth within 6 months before onset of RSV infection.

“Obviously you're much better delivering your baby in March or April than you are in December,” Dr. Ackerman said. “You're less likely to have that baby acquire RSV.”

Clinical features of RSV infection include nasal flaring; chest wall retractions; tachypnea with apneic episodes; expiratory wheezing; prolonged expiration; rales and rhonchi; croupy cough; and hypoxemia and cyanosis. Tiny babies infected with RSV may present only with apnea.

In a study of 213 infants younger than 13 months who had bronchiolitis, the best predictor of more severe disease was an oxygen saturation level of less than 95% oximetry (Am. J. Dis. Child. 1991;145:151–5).

“If you happen to not have [pulse] oximetry in your office, I urge you that it is one of the things that will help you tremendously, both in figuring out what to do with the child with asthma and what to do with the child with bronchiolitis,” Dr. Ackerman said.

Treatment for RSV infection is mainly supportive and includes supplemental humidified oxygen, IV hydration if needed, proper nutrition, and ventilatory assistance for respiratory failure.

A trail of bronchodilators is appropriate, “but to continue them if there's no response is not appropriate,” she warned.

Corticosteroids are not currently indicated for RSV infection but Dr. Ackerman said she would use them in a 9-month-old infant with a second or third episode of wheezing who happens to have RSV. “That's an asthmatic and that's a baby [in whom] I would use corticosteroids.”

She also would use them in a baby with RSV and heart failure.

Efforts to delay RSV spread include limiting contact with infected people, enrolling your child in a day care facility with few children, and washing hands frequently.

The James Whitcomb Riley Hospital for Children is in the midst of a handwashing campaign. Parents are given a brochure on admission which urges them to ask, “Doctor, have you washed your hands?” every time they see a physician touch their child. “My answer is supposed to be, 'Yes, I have. Thank you for asking,'” she said.

Other efforts to prevent spread include disinfecting surfaces exposed to infectious secretions, grouping hospitalized patients with RSV, and promoting breast-feeding.

One strategy to prevent infection in high-risk premature infants is to administer palivizumab (Synagis), which has been shown to reduce RSV-related hospitalizations in this patient population by more than 50%. “The down side of Synagis is you have to give it before exposure and you have to give it every 30 days,” Dr. Ackerman commented. “This is really a problem because you have to give it before you're ever exposed and you have to give it frequently.”

She also noted that there are no data to address the use of palivizumab in children older than 2 years of age or in those with cerebral palsy, neurologic disease, metabolic disease, or immunodeficiency.

Dr. Ackerman disclosed that she is on the speakers' bureau for GlaxoSmithKline Inc., maker of Zovirax (generic name acyclovir) and for AstraZeneca.

SAN DIEGO — When precision matters, robotic surgery offers visual features that are “unparalleled by any other laparoscopic or open operation,” William E. Kelley Jr., M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

But cost and patient benefits need to be considered before adopting robotic surgery on a widespread basis in any surgical discipline, advised Dr. Kelley, a general surgeon who practices in Richmond, Va.

Dr. Kelley, who chairs the society's special interest group committee on robotic surgery, considers the term to be an unfortunate one. “Robotic surgery is not performed by robots, which are independently operated, pre-programmed machines … This is computer-enhanced minimally invasive surgery. It's truly three-dimensional, and it's under the surgeon's control.”

Computer-enhanced surgery has been used for the last 10-12 years in orthopedic surgery for drilling the femoral shaft with a precision that is “about 10 times” better than that achievable by a surgeon without computer assistance,” he said.

In addition, the devices are equipped with electronic filtering, “which means no matter how late the surgeon's been up, no matter how many cups of coffee the surgeon's had that day, and no matter how many operations [he's] done, there is zero tremor in the instrument,” Dr. Kelley said.

The devices also have motion scaling, “so the very forced movement of the surgeon's hand can become translated into a very fine motion at the incident tip,” he explained. “There's forearm support, and it's a 3-D magnifying field with six degrees of freedom: up-down, side-to-side, in and out, rotation, pitch, and yaw.”

Traditional surgery cannot achieve the flexibility of the instrumentation. “The movements are simultaneous and fluid. It's direct and intuitive. It also conveys true ambidexterity to almost any surgeon within minutes of sitting down at the instrument,” he said.

In gynecology, most applications have been limited to infertility surgery for tuboplasty and tubal reanastomosis, although some centers use robots for laparoscopically assisted vaginal hysterectomy.

“Gynecologic experience has been relatively varied,” he said. “We're at the safety and efficacy stage. Operating time, costs of start-up, and learning curves are higher with robotics, but those [factors] are expected to decrease with time.”

In general surgery, robotic systems have enhanced laparoscopic Heller myotomy, esophagectomy, pancreatectomy, pyloroplasty when performed at the time of antireflux surgery, and fashioning the posterior suture lines of Toupet fundoplication. Dr. Kelley likened the technology's use in general surgery to “where we were in 1990 with laparoscopic surgery.”

In vascular surgery, experience is growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. Dr. Kelley described one 54-year-old with a failed iliac stent that he treated with robot-assisted aortofemoral bypass. The patient stayed in the hospital for 2.5 days and was golfing at 2 weeks.

Cardiothoracic applications are “the most spectacular examples” of robotic surgery, with uses for mitral valve replacement and coronary artery bypass graft (CABG).

Robotic surgery is associated with shortened hospital stays and rapid resumption of normal activities. Consider sternotomy and minimally invasive surgery: Would you rather wait a month before being able to drive a car or have no postoperative driving restrictions?

The medical literature documents a clear length of stay advantage in vascular procedures, prostatectomy, and cardiac procedures, he said.

From the hospital's perspective, the first hospital in a community to offer robotic surgery can garner “huge media exposure,” but the associated costs can be hard to recoup.

The reduced need for operating personnel in certain cases and the shorter hospital stays will cover some costs, but “that's not going to make a $1.3 million instrument cheaper,” he acknowledged.

SAN DIEGO — When precision matters, robotic surgery offers visual features that are “unparalleled by any other laparoscopic or open operation,” William E. Kelley Jr., M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

But cost and patient benefits need to be considered before adopting robotic surgery on a widespread basis in any surgical discipline, advised Dr. Kelley, a general surgeon who practices in Richmond, Va.

Dr. Kelley, who chairs the society's special interest group committee on robotic surgery, considers the term to be an unfortunate one. “Robotic surgery is not performed by robots, which are independently operated, pre-programmed machines … This is computer-enhanced minimally invasive surgery. It's truly three-dimensional, and it's under the surgeon's control.”

Computer-enhanced surgery has been used for the last 10-12 years in orthopedic surgery for drilling the femoral shaft with a precision that is “about 10 times” better than that achievable by a surgeon without computer assistance,” he said.

In addition, the devices are equipped with electronic filtering, “which means no matter how late the surgeon's been up, no matter how many cups of coffee the surgeon's had that day, and no matter how many operations [he's] done, there is zero tremor in the instrument,” Dr. Kelley said.

The devices also have motion scaling, “so the very forced movement of the surgeon's hand can become translated into a very fine motion at the incident tip,” he explained. “There's forearm support, and it's a 3-D magnifying field with six degrees of freedom: up-down, side-to-side, in and out, rotation, pitch, and yaw.”

Traditional surgery cannot achieve the flexibility of the instrumentation. “The movements are simultaneous and fluid. It's direct and intuitive. It also conveys true ambidexterity to almost any surgeon within minutes of sitting down at the instrument,” he said.

In gynecology, most applications have been limited to infertility surgery for tuboplasty and tubal reanastomosis, although some centers use robots for laparoscopically assisted vaginal hysterectomy.

“Gynecologic experience has been relatively varied,” he said. “We're at the safety and efficacy stage. Operating time, costs of start-up, and learning curves are higher with robotics, but those [factors] are expected to decrease with time.”

In general surgery, robotic systems have enhanced laparoscopic Heller myotomy, esophagectomy, pancreatectomy, pyloroplasty when performed at the time of antireflux surgery, and fashioning the posterior suture lines of Toupet fundoplication. Dr. Kelley likened the technology's use in general surgery to “where we were in 1990 with laparoscopic surgery.”

In vascular surgery, experience is growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. Dr. Kelley described one 54-year-old with a failed iliac stent that he treated with robot-assisted aortofemoral bypass. The patient stayed in the hospital for 2.5 days and was golfing at 2 weeks.

Cardiothoracic applications are “the most spectacular examples” of robotic surgery, with uses for mitral valve replacement and coronary artery bypass graft (CABG).

Robotic surgery is associated with shortened hospital stays and rapid resumption of normal activities. Consider sternotomy and minimally invasive surgery: Would you rather wait a month before being able to drive a car or have no postoperative driving restrictions?

The medical literature documents a clear length of stay advantage in vascular procedures, prostatectomy, and cardiac procedures, he said.

From the hospital's perspective, the first hospital in a community to offer robotic surgery can garner “huge media exposure,” but the associated costs can be hard to recoup.

The reduced need for operating personnel in certain cases and the shorter hospital stays will cover some costs, but “that's not going to make a $1.3 million instrument cheaper,” he acknowledged.

SAN DIEGO — When precision matters, robotic surgery offers visual features that are “unparalleled by any other laparoscopic or open operation,” William E. Kelley Jr., M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

But cost and patient benefits need to be considered before adopting robotic surgery on a widespread basis in any surgical discipline, advised Dr. Kelley, a general surgeon who practices in Richmond, Va.

Dr. Kelley, who chairs the society's special interest group committee on robotic surgery, considers the term to be an unfortunate one. “Robotic surgery is not performed by robots, which are independently operated, pre-programmed machines … This is computer-enhanced minimally invasive surgery. It's truly three-dimensional, and it's under the surgeon's control.”

Computer-enhanced surgery has been used for the last 10-12 years in orthopedic surgery for drilling the femoral shaft with a precision that is “about 10 times” better than that achievable by a surgeon without computer assistance,” he said.

In addition, the devices are equipped with electronic filtering, “which means no matter how late the surgeon's been up, no matter how many cups of coffee the surgeon's had that day, and no matter how many operations [he's] done, there is zero tremor in the instrument,” Dr. Kelley said.

The devices also have motion scaling, “so the very forced movement of the surgeon's hand can become translated into a very fine motion at the incident tip,” he explained. “There's forearm support, and it's a 3-D magnifying field with six degrees of freedom: up-down, side-to-side, in and out, rotation, pitch, and yaw.”

Traditional surgery cannot achieve the flexibility of the instrumentation. “The movements are simultaneous and fluid. It's direct and intuitive. It also conveys true ambidexterity to almost any surgeon within minutes of sitting down at the instrument,” he said.

In gynecology, most applications have been limited to infertility surgery for tuboplasty and tubal reanastomosis, although some centers use robots for laparoscopically assisted vaginal hysterectomy.

“Gynecologic experience has been relatively varied,” he said. “We're at the safety and efficacy stage. Operating time, costs of start-up, and learning curves are higher with robotics, but those [factors] are expected to decrease with time.”

In general surgery, robotic systems have enhanced laparoscopic Heller myotomy, esophagectomy, pancreatectomy, pyloroplasty when performed at the time of antireflux surgery, and fashioning the posterior suture lines of Toupet fundoplication. Dr. Kelley likened the technology's use in general surgery to “where we were in 1990 with laparoscopic surgery.”

In vascular surgery, experience is growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. Dr. Kelley described one 54-year-old with a failed iliac stent that he treated with robot-assisted aortofemoral bypass. The patient stayed in the hospital for 2.5 days and was golfing at 2 weeks.

Cardiothoracic applications are “the most spectacular examples” of robotic surgery, with uses for mitral valve replacement and coronary artery bypass graft (CABG).

Robotic surgery is associated with shortened hospital stays and rapid resumption of normal activities. Consider sternotomy and minimally invasive surgery: Would you rather wait a month before being able to drive a car or have no postoperative driving restrictions?

The medical literature documents a clear length of stay advantage in vascular procedures, prostatectomy, and cardiac procedures, he said.

From the hospital's perspective, the first hospital in a community to offer robotic surgery can garner “huge media exposure,” but the associated costs can be hard to recoup.

The reduced need for operating personnel in certain cases and the shorter hospital stays will cover some costs, but “that's not going to make a $1.3 million instrument cheaper,” he acknowledged.

LAS VEGAS — If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with the following infections:

P Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said. He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1–2 months of treatment before initiating the biologic agent,” he said.

P Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. Avoid live virus vaccines, he warned. Do not give the yellow fever vaccine to a patient on one of these agents.

P Viral infections. Make sure these patients are vaccinated for hepatitis A and B. If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with the following infections:

P Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said. He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1–2 months of treatment before initiating the biologic agent,” he said.

P Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. Avoid live virus vaccines, he warned. Do not give the yellow fever vaccine to a patient on one of these agents.

P Viral infections. Make sure these patients are vaccinated for hepatitis A and B. If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with the following infections:

P Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said. He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1–2 months of treatment before initiating the biologic agent,” he said.

P Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. Avoid live virus vaccines, he warned. Do not give the yellow fever vaccine to a patient on one of these agents.

P Viral infections. Make sure these patients are vaccinated for hepatitis A and B. If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS — New data based on the use of confocal microscopy confirm that treating actinic keratoses with imiquimod stimulates immune activation, Dr. Roger I. Ceilley said at the Fall Clinical Dermatology Conference.

Dr. Ceilley said that in an ongoing unpublished double-blind, vehicle-controlled, randomized study being conducted by Dr. Abel Torres of Loma Linda (Calif.) University, and his associates, the investigators used reverse transcriptase/polymerase chain reaction and gene array analysis to determine imiquimod's effect on gene expression on actinic keratosis (AK) lesions. Confocal microscopy was performed on the study area as an adjunctive diagnostic procedure.

Imiquimod treatment of AK lesions resulted in the differential gene expression indicative of the recruitment and activation of macrophages, dendritic cells, cytotoxic T cells, and natural killer cells to the site of AK lesions, said Dr. Ceilley, clinical professor of dermatology at the University of Iowa, West Des Moines. The investigators also observed increases in the expression of cytolytic and cytotoxic genes with known antitumor activity as well as proapoptotic genes.

“The proliferation of activity decreased while the genes that were associated with tumor suppression were increased,” he said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “The gene changes were consistent with what they saw on confocal microscopy.”

The findings lend further support to the idea that the decrease of AK lesion burden may also decrease the likelihood of squamous cell carcinoma (SCC) development. “There is a clear progression from photo damage to squamous cell carcinoma,” Dr. Ceilley said. “In fact, we should view this as a syndrome rather than individual conditions because when you get squamous cell and basal cell carcinomas you almost always have photodamage and actinic keratoses along with them.”

This association is important given a recent population-based study (JAMA 2005; 294:681-90) that noted a significant increase in the prevalence of squamous and basal cell carcinomas among men and women younger than age 40 years who lived in Olmstead County, Minn., between 1976 and 2003.

“Because we're talking about a syndrome, [spotting an AK] needs to be a wake-up call,” he remarked at the meeting. “If a patient gets an AK, they deserve a full skin examination. I typically will cryo the hypertropic lesions and then use topical treatment along with it. You also need to use sunscreens for photoprotection. I typically have the patient on a retinoid as well, and there is some evidence that topical systemic antioxidants may be useful.”

He said that while there “isn't much difference” between imiquimod, diclofenac, and 5-fluorouracil for treating AKs, “I think what we need now are studies to help us determine which is the best, which is going to give permanent remission, and which is going to prevent SCC. The rationale for cancer field therapy is that patients have numerous AKs, and they are going to have the whole area treated, and the goal is to get rid of as many AKs as you can, not only the clinically apparent lesions but the subclinical ones.”

Dr. Ceilley added that imiquimod “seems to be the most effective as far as cancer field treatment and has the best data, but certainly the other topical treatments can be used as well.”

In his practice of using imiquimod for AKs, his initial treatment involves three applications per week for 4-8 weeks. “Most of the time it's in the 4-week range,” he said.

LAS VEGAS — New data based on the use of confocal microscopy confirm that treating actinic keratoses with imiquimod stimulates immune activation, Dr. Roger I. Ceilley said at the Fall Clinical Dermatology Conference.

Dr. Ceilley said that in an ongoing unpublished double-blind, vehicle-controlled, randomized study being conducted by Dr. Abel Torres of Loma Linda (Calif.) University, and his associates, the investigators used reverse transcriptase/polymerase chain reaction and gene array analysis to determine imiquimod's effect on gene expression on actinic keratosis (AK) lesions. Confocal microscopy was performed on the study area as an adjunctive diagnostic procedure.

Imiquimod treatment of AK lesions resulted in the differential gene expression indicative of the recruitment and activation of macrophages, dendritic cells, cytotoxic T cells, and natural killer cells to the site of AK lesions, said Dr. Ceilley, clinical professor of dermatology at the University of Iowa, West Des Moines. The investigators also observed increases in the expression of cytolytic and cytotoxic genes with known antitumor activity as well as proapoptotic genes.

“The proliferation of activity decreased while the genes that were associated with tumor suppression were increased,” he said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “The gene changes were consistent with what they saw on confocal microscopy.”

The findings lend further support to the idea that the decrease of AK lesion burden may also decrease the likelihood of squamous cell carcinoma (SCC) development. “There is a clear progression from photo damage to squamous cell carcinoma,” Dr. Ceilley said. “In fact, we should view this as a syndrome rather than individual conditions because when you get squamous cell and basal cell carcinomas you almost always have photodamage and actinic keratoses along with them.”

This association is important given a recent population-based study (JAMA 2005; 294:681-90) that noted a significant increase in the prevalence of squamous and basal cell carcinomas among men and women younger than age 40 years who lived in Olmstead County, Minn., between 1976 and 2003.

“Because we're talking about a syndrome, [spotting an AK] needs to be a wake-up call,” he remarked at the meeting. “If a patient gets an AK, they deserve a full skin examination. I typically will cryo the hypertropic lesions and then use topical treatment along with it. You also need to use sunscreens for photoprotection. I typically have the patient on a retinoid as well, and there is some evidence that topical systemic antioxidants may be useful.”

He said that while there “isn't much difference” between imiquimod, diclofenac, and 5-fluorouracil for treating AKs, “I think what we need now are studies to help us determine which is the best, which is going to give permanent remission, and which is going to prevent SCC. The rationale for cancer field therapy is that patients have numerous AKs, and they are going to have the whole area treated, and the goal is to get rid of as many AKs as you can, not only the clinically apparent lesions but the subclinical ones.”

Dr. Ceilley added that imiquimod “seems to be the most effective as far as cancer field treatment and has the best data, but certainly the other topical treatments can be used as well.”

In his practice of using imiquimod for AKs, his initial treatment involves three applications per week for 4-8 weeks. “Most of the time it's in the 4-week range,” he said.

LAS VEGAS — New data based on the use of confocal microscopy confirm that treating actinic keratoses with imiquimod stimulates immune activation, Dr. Roger I. Ceilley said at the Fall Clinical Dermatology Conference.

Dr. Ceilley said that in an ongoing unpublished double-blind, vehicle-controlled, randomized study being conducted by Dr. Abel Torres of Loma Linda (Calif.) University, and his associates, the investigators used reverse transcriptase/polymerase chain reaction and gene array analysis to determine imiquimod's effect on gene expression on actinic keratosis (AK) lesions. Confocal microscopy was performed on the study area as an adjunctive diagnostic procedure.

Imiquimod treatment of AK lesions resulted in the differential gene expression indicative of the recruitment and activation of macrophages, dendritic cells, cytotoxic T cells, and natural killer cells to the site of AK lesions, said Dr. Ceilley, clinical professor of dermatology at the University of Iowa, West Des Moines. The investigators also observed increases in the expression of cytolytic and cytotoxic genes with known antitumor activity as well as proapoptotic genes.

“The proliferation of activity decreased while the genes that were associated with tumor suppression were increased,” he said at the conference, sponsored by the Center for Bio-Medical Communication Inc. “The gene changes were consistent with what they saw on confocal microscopy.”

The findings lend further support to the idea that the decrease of AK lesion burden may also decrease the likelihood of squamous cell carcinoma (SCC) development. “There is a clear progression from photo damage to squamous cell carcinoma,” Dr. Ceilley said. “In fact, we should view this as a syndrome rather than individual conditions because when you get squamous cell and basal cell carcinomas you almost always have photodamage and actinic keratoses along with them.”

This association is important given a recent population-based study (JAMA 2005; 294:681-90) that noted a significant increase in the prevalence of squamous and basal cell carcinomas among men and women younger than age 40 years who lived in Olmstead County, Minn., between 1976 and 2003.

“Because we're talking about a syndrome, [spotting an AK] needs to be a wake-up call,” he remarked at the meeting. “If a patient gets an AK, they deserve a full skin examination. I typically will cryo the hypertropic lesions and then use topical treatment along with it. You also need to use sunscreens for photoprotection. I typically have the patient on a retinoid as well, and there is some evidence that topical systemic antioxidants may be useful.”

He said that while there “isn't much difference” between imiquimod, diclofenac, and 5-fluorouracil for treating AKs, “I think what we need now are studies to help us determine which is the best, which is going to give permanent remission, and which is going to prevent SCC. The rationale for cancer field therapy is that patients have numerous AKs, and they are going to have the whole area treated, and the goal is to get rid of as many AKs as you can, not only the clinically apparent lesions but the subclinical ones.”

Dr. Ceilley added that imiquimod “seems to be the most effective as far as cancer field treatment and has the best data, but certainly the other topical treatments can be used as well.”

In his practice of using imiquimod for AKs, his initial treatment involves three applications per week for 4-8 weeks. “Most of the time it's in the 4-week range,” he said.

A 5-year-old Hispanic girl presented with an 18-month history of nonhealing, slightly painful, firm, 1- to 4-cm plaques on her left arm, and a sinus draining serosanguineous fluid. She had been living in Mexico at the time of onset and had no history of trauma, fever, cough, or weight loss. What's your diagnosis?

SAN DIEGO — Differential diagnoses included cutaneous tuberculosis, mycetoma, leishmaniasis, botryomycosis, coccidioidomycosis, osteomyelitis, bone and soft tissue tumors, and other deep fungal or atypical mycobacterial infections.

Diagnostic tests—including complete blood count, chemistry panel, and x-rays of the chest and left arm—were all negative.

Skin biopsy revealed a suppurative granuloma with deeply basophilic granules in the dermis. Gram stain revealed gram-positive branched bacteria. Culture was diagnostic for actinomycetoma, as it grew Nocardia brasiliensis, Dr. Justine Hyoju Yun said at the annual meeting of the Society for Pediatric Dermatology.

First-line treatment for actinomycetoma is 5-10 mg/kg per day of trimethoprim and 25-50 mg/kg per day of sulfamethoxazole in two to four divided dosages. Immunocompetent patients should be treated for 3 months, and immunocompromised patients should be treated for 6 months.

Dr. Yun's patient was started on 160 mg oral trimethoprim and 800 mg oral sulfamethoxazole daily in two divided doses for 3 months. She has responded well to treatment, with residual atrophic pink plaques on physical exam.

Mycetoma is a chronic, granulomatous infection of the skin and subcutaneous tissues caused by either bacteria or fungi. Untreated, it can spread locally to adjacent muscle and bone.

Firm, painless nodules usually appear on the foot, but also may affect the hands, arms, chest, and buttocks. Tubercles and draining sinuses may develop, as well as ulceration and scarring.

Actinomycetoma is caused by actinomycetes, whereas eumycetoma is caused by fungi. They are clinically indistinguishable but are treated differently. Causative microorganisms include the Actinomadura species, Nocardia species, and Streptomyces species. N. brasiliensis is implicated in 98% of cases in Mexico, said Dr. Yun, a dermatology resident at King/Drew Medical Center, Los Angeles.

In the West, mycetoma is most common in Mexico, followed by Venezuela and Argentina. It affects males more often than females (5:1).

Left untreated, mycetoma can spread locally from skin to subcutaneous fascia and bone.

Culture and biochemical testing are necessary to identify the causative agent, as this determines treatment. However, Nocardia species are difficult to culture and can take up to 3 weeks to grow.

Photos courtesy Dr. Justine Hyoju Yun

A 5-year-old Hispanic girl presented with an 18-month history of nonhealing, slightly painful, firm, 1- to 4-cm plaques on her left arm, and a sinus draining serosanguineous fluid. She had been living in Mexico at the time of onset and had no history of trauma, fever, cough, or weight loss. What's your diagnosis?

SAN DIEGO — Differential diagnoses included cutaneous tuberculosis, mycetoma, leishmaniasis, botryomycosis, coccidioidomycosis, osteomyelitis, bone and soft tissue tumors, and other deep fungal or atypical mycobacterial infections.

Diagnostic tests—including complete blood count, chemistry panel, and x-rays of the chest and left arm—were all negative.

Skin biopsy revealed a suppurative granuloma with deeply basophilic granules in the dermis. Gram stain revealed gram-positive branched bacteria. Culture was diagnostic for actinomycetoma, as it grew Nocardia brasiliensis, Dr. Justine Hyoju Yun said at the annual meeting of the Society for Pediatric Dermatology.

First-line treatment for actinomycetoma is 5-10 mg/kg per day of trimethoprim and 25-50 mg/kg per day of sulfamethoxazole in two to four divided dosages. Immunocompetent patients should be treated for 3 months, and immunocompromised patients should be treated for 6 months.

Dr. Yun's patient was started on 160 mg oral trimethoprim and 800 mg oral sulfamethoxazole daily in two divided doses for 3 months. She has responded well to treatment, with residual atrophic pink plaques on physical exam.

Mycetoma is a chronic, granulomatous infection of the skin and subcutaneous tissues caused by either bacteria or fungi. Untreated, it can spread locally to adjacent muscle and bone.

Firm, painless nodules usually appear on the foot, but also may affect the hands, arms, chest, and buttocks. Tubercles and draining sinuses may develop, as well as ulceration and scarring.

Actinomycetoma is caused by actinomycetes, whereas eumycetoma is caused by fungi. They are clinically indistinguishable but are treated differently. Causative microorganisms include the Actinomadura species, Nocardia species, and Streptomyces species. N. brasiliensis is implicated in 98% of cases in Mexico, said Dr. Yun, a dermatology resident at King/Drew Medical Center, Los Angeles.

In the West, mycetoma is most common in Mexico, followed by Venezuela and Argentina. It affects males more often than females (5:1).

Left untreated, mycetoma can spread locally from skin to subcutaneous fascia and bone.

Culture and biochemical testing are necessary to identify the causative agent, as this determines treatment. However, Nocardia species are difficult to culture and can take up to 3 weeks to grow.

Photos courtesy Dr. Justine Hyoju Yun

A 5-year-old Hispanic girl presented with an 18-month history of nonhealing, slightly painful, firm, 1- to 4-cm plaques on her left arm, and a sinus draining serosanguineous fluid. She had been living in Mexico at the time of onset and had no history of trauma, fever, cough, or weight loss. What's your diagnosis?

SAN DIEGO — Differential diagnoses included cutaneous tuberculosis, mycetoma, leishmaniasis, botryomycosis, coccidioidomycosis, osteomyelitis, bone and soft tissue tumors, and other deep fungal or atypical mycobacterial infections.

Diagnostic tests—including complete blood count, chemistry panel, and x-rays of the chest and left arm—were all negative.

Skin biopsy revealed a suppurative granuloma with deeply basophilic granules in the dermis. Gram stain revealed gram-positive branched bacteria. Culture was diagnostic for actinomycetoma, as it grew Nocardia brasiliensis, Dr. Justine Hyoju Yun said at the annual meeting of the Society for Pediatric Dermatology.

First-line treatment for actinomycetoma is 5-10 mg/kg per day of trimethoprim and 25-50 mg/kg per day of sulfamethoxazole in two to four divided dosages. Immunocompetent patients should be treated for 3 months, and immunocompromised patients should be treated for 6 months.

Dr. Yun's patient was started on 160 mg oral trimethoprim and 800 mg oral sulfamethoxazole daily in two divided doses for 3 months. She has responded well to treatment, with residual atrophic pink plaques on physical exam.

Mycetoma is a chronic, granulomatous infection of the skin and subcutaneous tissues caused by either bacteria or fungi. Untreated, it can spread locally to adjacent muscle and bone.

Firm, painless nodules usually appear on the foot, but also may affect the hands, arms, chest, and buttocks. Tubercles and draining sinuses may develop, as well as ulceration and scarring.

Actinomycetoma is caused by actinomycetes, whereas eumycetoma is caused by fungi. They are clinically indistinguishable but are treated differently. Causative microorganisms include the Actinomadura species, Nocardia species, and Streptomyces species. N. brasiliensis is implicated in 98% of cases in Mexico, said Dr. Yun, a dermatology resident at King/Drew Medical Center, Los Angeles.

In the West, mycetoma is most common in Mexico, followed by Venezuela and Argentina. It affects males more often than females (5:1).

Left untreated, mycetoma can spread locally from skin to subcutaneous fascia and bone.

Culture and biochemical testing are necessary to identify the causative agent, as this determines treatment. However, Nocardia species are difficult to culture and can take up to 3 weeks to grow.

Photos courtesy Dr. Justine Hyoju Yun

LAS VEGAS – If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with these infections:

▸ Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said.

He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1-2 months of treatment before initiating the biologic agent,” he said.

▸ Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. “You should not give these patients live virus vaccines,” he said. “If someone is traveling and they're on one of these agents, do not give them yellow fever vaccine.”

▸ Viral infections. Make sure these patients are vaccinated for hepatitis A and B. “Eventually we'll have the [human papillomavirus] vaccine and maybe these patients should get that as well once we know how effective that is,” Dr. Orenstein said. “If they're DNA positive for hepatitis B, they should be on treatment for hepatitis B.”

If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS – If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with these infections:

▸ Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said.

He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1-2 months of treatment before initiating the biologic agent,” he said.

▸ Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. “You should not give these patients live virus vaccines,” he said. “If someone is traveling and they're on one of these agents, do not give them yellow fever vaccine.”

▸ Viral infections. Make sure these patients are vaccinated for hepatitis A and B. “Eventually we'll have the [human papillomavirus] vaccine and maybe these patients should get that as well once we know how effective that is,” Dr. Orenstein said. “If they're DNA positive for hepatitis B, they should be on treatment for hepatitis B.”

If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

LAS VEGAS – If a patient on a tumor necrosis factor inhibitor such as infliximab or etanercept presents with the signs and symptoms of infection, stop the drug immediately, Dr. Robert Orenstein advised at a dermatology seminar sponsored by the Skin Disease Education Foundation.

“You should do a very aggressive evaluation [because] many of these infections are disseminated at the time they present,” said Dr. Orenstein of the divisions of general internal medicine and infectious diseases at Mayo Medical School, Rochester, Minn. “You should start empiric therapy based upon what you think is going on, and you should withhold the agent until the etiology is completed. Don't use these agents if the patient has an active infection.”

He discussed his approach to patients on a TNF inhibitor who present with these infections:

▸ Mycobacterial infections. Obtain a chest x-ray and a purified protein derivative (of tuberculin) skin test. As with AIDS patients, a 5-mm PPD skin test is considered positive.

“You also want to get an excellent history of exposure, particularly [from] people born in foreign countries or people who are at higher risk because of their profession, before you treat them,” Dr. Orenstein said.

He noted that the QuantiFERON-TB Gold assay, a commercially available blood test, may be “very helpful” in distinguishing patients with nontuberculous infection from those who are positive for Mycobacterium tuberculosis. It takes 24 hours to get the results.

It remains unclear whether treatment of a latent tuberculosis infection needs to be completed before a patient begins taking a TNF inhibitor. “Most of us would argue that we would like to treat tuberculosis first, and after that use the [TNF] agent. But sometimes that's not a possibility. So in general we would recommend at least 1-2 months of treatment before initiating the biologic agent,” he said.

▸ Bacterial infections. The best way to prevent bacterial infections is to make sure these patients get Pneumovax and the influenza vaccines. “You should not give these patients live virus vaccines,” he said. “If someone is traveling and they're on one of these agents, do not give them yellow fever vaccine.”

▸ Viral infections. Make sure these patients are vaccinated for hepatitis A and B. “Eventually we'll have the [human papillomavirus] vaccine and maybe these patients should get that as well once we know how effective that is,” Dr. Orenstein said. “If they're DNA positive for hepatitis B, they should be on treatment for hepatitis B.”

If a patient on a TNF inhibitor presents with disseminated shingles or disseminated herpes simplex, stop the agent. Treat the patient with aggressive antiviral therapy, he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.