Jeff Evans

This 57-year-old Asian woman presented with a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for the past 10 years. Courtesy Dr. Michael Kalisiak

A history of idiopathic peripheral neuropathy may reflect underlying leprosy, Michael Kalisiak, M.D., said at the annual conference of the Canadian Dermatology Association.

The diagnosis of leprosy is often delayed in the United States and Canada because of the low prevalence of the disease. Most cases in such countries occur in immigrants from endemic areas or in people who have traveled extensively.

The time from infection to diagnosis ranges from 3 months to 40 years, but it averages 2–4 years for leprosy, said Dr. Kalisiak, a second-year dermatology resident at the University of Alberta, Edmonton.

Leprosy's clinical manifestation—purely cutaneous or neural or localized or a mixture—may vary depending on the immune response of the patient and can have a wide range of differential diagnoses, he noted during a poster session at the conference.

He described the case of a 57-year-old Asian woman who presented with a recent eruption of a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for 10 years.

The woman's origin from Singapore and her extensive history of living in nine countries from age 26 to 39 years until she immigrated to Canada was crucial in leading to her diagnosis of borderline lepromatous leprosy.

Her countries of residence included Iran, Trinidad, Scotland, United States, Indonesia, the Netherlands, and Norway, with brief periods in Kenya and Ecuador; some of these countries have an intermediate incidence of leprosy.

For 3 years prior to her skin manifestations, the patient visited neurologists for her neuropathic symptoms, which initially occurred as numbness and occasional pain in her left anterior thigh and later spread to her left hand and left and right lower legs.

She also reported decreased grip strength in her left hand. The neurologists discovered many motor and sensory deficits in those areas but excluded any common causes of neuropathy after extensive testing. Their diagnosis was idiopathic polyneuropathy, Dr. Kalisiak said.

On staining with hematoxylin and eosin, skin biopsies of the faint erythematous patches showed mild, nonspecific perivascular and periappendigeal infiltrate, whereas biopsies from the nodules contained a heavy infiltrate in the deep dermis and beyond. Fite's stain revealed numerous lepra bacilli in the biopsy specimens (in red on biopsy of a nodule).

Nasal scrapings also tested positive for acid-fast bacilli and polymerase chain reaction confirmed the presence of Mycobacterium leprae.

Dr. Kalisiak and his colleagues began daily treatment with 600 mg of rifampin, 100 mg of dapsone, 50 mg of clofazimine. The regimen also included gabapentin for neuropathic pain that will be continued for at least 1 year.

“Undiagnosed peripheral neuropathy should prompt consideration of leprosy as a diagnosis,” concluded Dr. Kalisiak, who received the best poster award at the conference.

This 57-year-old Asian woman presented with a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for the past 10 years. Courtesy Dr. Michael Kalisiak

A history of idiopathic peripheral neuropathy may reflect underlying leprosy, Michael Kalisiak, M.D., said at the annual conference of the Canadian Dermatology Association.

The diagnosis of leprosy is often delayed in the United States and Canada because of the low prevalence of the disease. Most cases in such countries occur in immigrants from endemic areas or in people who have traveled extensively.

The time from infection to diagnosis ranges from 3 months to 40 years, but it averages 2–4 years for leprosy, said Dr. Kalisiak, a second-year dermatology resident at the University of Alberta, Edmonton.

Leprosy's clinical manifestation—purely cutaneous or neural or localized or a mixture—may vary depending on the immune response of the patient and can have a wide range of differential diagnoses, he noted during a poster session at the conference.

He described the case of a 57-year-old Asian woman who presented with a recent eruption of a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for 10 years.

The woman's origin from Singapore and her extensive history of living in nine countries from age 26 to 39 years until she immigrated to Canada was crucial in leading to her diagnosis of borderline lepromatous leprosy.

Her countries of residence included Iran, Trinidad, Scotland, United States, Indonesia, the Netherlands, and Norway, with brief periods in Kenya and Ecuador; some of these countries have an intermediate incidence of leprosy.

For 3 years prior to her skin manifestations, the patient visited neurologists for her neuropathic symptoms, which initially occurred as numbness and occasional pain in her left anterior thigh and later spread to her left hand and left and right lower legs.

She also reported decreased grip strength in her left hand. The neurologists discovered many motor and sensory deficits in those areas but excluded any common causes of neuropathy after extensive testing. Their diagnosis was idiopathic polyneuropathy, Dr. Kalisiak said.

On staining with hematoxylin and eosin, skin biopsies of the faint erythematous patches showed mild, nonspecific perivascular and periappendigeal infiltrate, whereas biopsies from the nodules contained a heavy infiltrate in the deep dermis and beyond. Fite's stain revealed numerous lepra bacilli in the biopsy specimens (in red on biopsy of a nodule).

Nasal scrapings also tested positive for acid-fast bacilli and polymerase chain reaction confirmed the presence of Mycobacterium leprae.

Dr. Kalisiak and his colleagues began daily treatment with 600 mg of rifampin, 100 mg of dapsone, 50 mg of clofazimine. The regimen also included gabapentin for neuropathic pain that will be continued for at least 1 year.

“Undiagnosed peripheral neuropathy should prompt consideration of leprosy as a diagnosis,” concluded Dr. Kalisiak, who received the best poster award at the conference.

This 57-year-old Asian woman presented with a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for the past 10 years. Courtesy Dr. Michael Kalisiak

A history of idiopathic peripheral neuropathy may reflect underlying leprosy, Michael Kalisiak, M.D., said at the annual conference of the Canadian Dermatology Association.

The diagnosis of leprosy is often delayed in the United States and Canada because of the low prevalence of the disease. Most cases in such countries occur in immigrants from endemic areas or in people who have traveled extensively.

The time from infection to diagnosis ranges from 3 months to 40 years, but it averages 2–4 years for leprosy, said Dr. Kalisiak, a second-year dermatology resident at the University of Alberta, Edmonton.

Leprosy's clinical manifestation—purely cutaneous or neural or localized or a mixture—may vary depending on the immune response of the patient and can have a wide range of differential diagnoses, he noted during a poster session at the conference.

He described the case of a 57-year-old Asian woman who presented with a recent eruption of a dozen dull, erythematous papules and nodules on her extremities and numerous well-demarcated, faintly erythematous patches on her chest and back. She had had symptoms of peripheral neuropathy for 10 years.

The woman's origin from Singapore and her extensive history of living in nine countries from age 26 to 39 years until she immigrated to Canada was crucial in leading to her diagnosis of borderline lepromatous leprosy.

Her countries of residence included Iran, Trinidad, Scotland, United States, Indonesia, the Netherlands, and Norway, with brief periods in Kenya and Ecuador; some of these countries have an intermediate incidence of leprosy.

For 3 years prior to her skin manifestations, the patient visited neurologists for her neuropathic symptoms, which initially occurred as numbness and occasional pain in her left anterior thigh and later spread to her left hand and left and right lower legs.

She also reported decreased grip strength in her left hand. The neurologists discovered many motor and sensory deficits in those areas but excluded any common causes of neuropathy after extensive testing. Their diagnosis was idiopathic polyneuropathy, Dr. Kalisiak said.

On staining with hematoxylin and eosin, skin biopsies of the faint erythematous patches showed mild, nonspecific perivascular and periappendigeal infiltrate, whereas biopsies from the nodules contained a heavy infiltrate in the deep dermis and beyond. Fite's stain revealed numerous lepra bacilli in the biopsy specimens (in red on biopsy of a nodule).

Nasal scrapings also tested positive for acid-fast bacilli and polymerase chain reaction confirmed the presence of Mycobacterium leprae.

Dr. Kalisiak and his colleagues began daily treatment with 600 mg of rifampin, 100 mg of dapsone, 50 mg of clofazimine. The regimen also included gabapentin for neuropathic pain that will be continued for at least 1 year.

“Undiagnosed peripheral neuropathy should prompt consideration of leprosy as a diagnosis,” concluded Dr. Kalisiak, who received the best poster award at the conference.

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation. These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees will meet this month to come up with a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines. The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, the report says psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation. These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees will meet this month to come up with a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines. The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, the report says psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

WASHINGTON — Detailed ethical codes from professional organizations would help set a clearer path for health professionals to follow on national security-related issues.

That sentiment was expressed by several experts at a recent panel discussion on the medical ethics of military medical professionals' interrogations sponsored by the Center for American Progress.

Active and retired medical officers also think the policy that guides medical personnel in these matters needs to be clarified, Stephen Xenakis, M.D., said at the meeting. Dr. Xenakis, formerly the commanding general of the Southeast Regional Army Medical Command, is now the director of child and adolescent psychiatry at the Psychiatric Institute of Washington.

At Guantanamo Bay and Abu Ghraib prison, mental health professionals, such as psychiatrists and psychologists, are known to have observed interrogations, provided interrogators with the medical records of detainees, and in some cases, developed individualized interrogation plans or provided advice on how best to conduct an interrogation. These acts have been made public by various documents obtained through military sources, Freedom of Information Act requests, declassification, interviews with witnesses, or testimony (N. Engl. J. Med. 2005;352:3–6; N. Engl. J. Med. 2005;353:6–8).

“The legal barriers are likely to be crossed long before detainees' mental or physical health is implicated, particularly when those detainees are protected by the Geneva Conventions,” Jonathan H. Marks, said at the panel discussion.

“Medical personnel, if they stand by, will be complicit in violations of the Geneva Conventions if they approve of these techniques or fail to intervene,” said Mr. Marks, a barrister who is currently a fellow at Georgetown University Law Center, Washington.

The civilian leadership at the Pentagon has argued that when physicians and other health professionals serve in the interrogation process and other nontherapeutic roles, they are not acting as physicians or health professionals, and medical ethics do not apply, noted M. Gregg Bloche, M.D., a member of the panel. “This is a deeply disturbing argument with little or no precedent elsewhere,” said Dr. Bloche, a law professor at Georgetown.

In previous operations, the Army has worked on the principle of very detailed, exhaustive training for its medical personnel, Dr. Xenakis noted. The current operations lack “clear guidance for what one does when one confronts scenarios of large volumes of detainees who have recently been apprehended, how they will be triaged, how they will be held, how they will be interrogated.”

Dr. Xenakis said he would like to see the American Medical Association and the American Psychiatric Association define the guidance policy on what military medical personnel should and should not be expected to do. Such statements would be affirming to the internal principles and ethics of physicians and other health professionals, he added.

New absolute standards must limit the physician's role in the military to the doctor-patient relationship in which a physician cannot participate in interrogations, he suggested.

Indeed, the APA is in the process of hammering out a position on the role that mental health professionals should play in the interrogation of detainees at Guantanamo Bay and other prison sites around the world, Paul S. Appelbaum, M.D., told this newspaper.

Representatives from several key APA committees will meet this month to come up with a proposed position. That proposal will then go through a formal chain of approvals, including the APA assembly and the board of trustees, said Dr. Appelbaum, chairman of the APA's Council on Psychiatry and the Law and a former president of the organization.

However, the debate about this issue also needs to take place in the public domain, Edmund G. Howe, M.D., said in an interview.

Dr. Howe, professor of psychiatry and director of the program in ethics at the Uniformed Services University of the Health Sciences, Bethesda, Md., said he would like to see a code in print representing as many military and civilian views as possible.

Codes of ethics “can accomplish all sorts of things by giving general guidelines that most persons find useful and maybe [help them] do better than they would without those guidelines. The question here is, what are the pluses and minuses of any group's spelling out its particular moral priorities?” Dr. Howe said.

It would be problematic for the military to articulate its moral biases and perspectives and then impose them without outside input, Dr. Howe said. He added that while that might be obvious, it's less obvious that any organization—whether it be the AMA or the APA—also has its own biases and perspectives.

For example, why shouldn't the American Bar Association or a patients' association, for that matter, have its own code? “Is medical expertise tantamount to ethical expertise? No,” Dr. Howe said.

When patients sacrifice their money and personal privacy so that medical students can perform physical exams and develop their skills, society has implicit expectations about what the students will do with the knowledge they gain from encounters with patients. Some would say that there's an implicit promise from the doctor—like the Hippocratic Oath—when the patient is making those sacrifices in order for the doctor to do good. Then the question is, “Does doing good include getting involved in interrogations?” Dr. Howe asked.

Even if society is willing, in theory, to say that it will make these sacrifices so that students can be trained to become doctors to heal medical and psychiatric problems and also to save lives by participating in some way in interrogations, “it does not necessarily mean that it should fly, even if most psychiatrists would go along with it. Additional ethical assessment is necessary,” he said.

Contrary to the position taken by key experts, the American Psychological Association's approach to this issue appears to be different. That organization's Presidential Task Force states that psychologists can “serve in the role of supporting an interrogation” and make use of confidential information in medical records of detainees or prisoners to advise interrogators, as long as it is not used to the detriment of the individual's safety and well-being.

The task force's report does warn psychologists working in a national security-related setting that they should “clarify their role in situations where individuals may have an incorrect impression that psychologists are serving in a health care provider role.”

In addition, the report says psychologists should refrain from mixing potentially inconsistent roles with the same individual, in those cases when the roles “could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness … or otherwise risk exploitation or harm to the person with whom the professional relationship exists.”

In the panel discussion, Dr. Bloche argued that the American Psychological Association's statement “allows for a wholesale breach of confidentiality.”

However, Stephen Behnke, director of ethics for the American Psychological Association, said in an interview that there should be an absolute barrier between work that is treatment related and work related to interrogations.

“Under no circumstances should the two be mixed,” Mr. Behnke said.

He pointed out that his association had provided its task force report to the U.S. government and that training is needed.

But overcoming the obstacle of health care providers serving as consultants to interrogators by creating separate schools or training for each type, “doesn't really address what the real problems are,” Dr. Howe said.

The real problems are determining how humans should treat other humans—and who should decide, he asserted.

Predicting Crohn's Disease

Anti-Saccharomyces cerevisiae antibodies may be a marker in predicting future development of Crohn's disease but do not appear to be a marker of genetic susceptibility for the disease, according to two studies.

In 38 serum samples taken from 32 soldiers before they were diagnosed with Crohn's disease, Eran Israeli, M.D., of Hebrew University, Jerusalem, and colleagues reported that 10 tested positive for anti-S. cerevisiae antibodies (ASCA) vs. none of 95 control patients. The proportion of patients testing positive increased from 15% more than 60 months before diagnosis, to 37% within 36 months before diagnosis, to 55% after diagnosis. ASCA were present before and after diagnosis in 6 of the 11 patients who had samples after diagnosis. The geometric mean concentrations of ASCA also increased significantly as the time of diagnosis approached. The investigators suggested that it is too early to recommend monitoring of asymptomatic patients who are incidentally discovered to be ASCA positive (Gut 2005;54:1232–6).

A separate study of 98 mono- and dizygotic twin pairs conducted by Jonas Halfvarson, M.D., of örebro University Hospital (Sweden) and his associates found that ASCA were found in only 1 of 20 healthy twin siblings in monozygotic twin pairs that were discordant for Crohn's disease, compared with 7 of 27 healthy twin siblings in discordant dizygotic pairs. Titers of ASCA were not similar within discordant mono- or dizygotic twin pairs with Crohn's disease, and no independent factors were associated with ASCA titers and zygosity in a multivariate analysis. The findings suggest that “ASCA in healthy family members is a marker of shared environment,” the researchers said (Gut 2005;54:1237–43).

Lymphoma Risk in Treatment of IBD

Treatment of patients with inflammatory bowel disease with the immunomodulators azathioprine or 6-mercaptopurine is associated with about a fourfold increased risk of lymphoma, reported A. Kandiel of the Cleveland Clinic and colleagues.

In a metaanalysis of six studies, 11 cases of lymphoma occurred in 3,891 patients with inflammatory bowel disease, compared with an expected number of 2.63 cases based on rates reported by the Surveillance, Epidemiology, and End Results cancer registry; 9 of the cases were non-Hodgkin's lymphoma. By assuming a relative risk of lymphoma of 4, the number of patients needed to be treated with azathioprine or 6-mercaptopurine to cause one additional lymphoma per year ranged from 4,357 persons aged 20–29 years to 355 persons aged 70–79 years. “A conservative interpretation of our data is that IBD patients who receive immunomodulator medications are at higher risk of lymphoma than the general population, and that this increased risk could be due to the medication, disease activity, or both,” the investigators wrote (Gut 2005;54:1121–5).

Women Prefer Female Endoscopists

Nearly half of women prefer a female endoscopist for colorectal cancer screening, reported Stacy B. Menees, M.D., and her associates at the University of Michigan, Ann Arbor.

A questionnaire filled out by 202 of 212 women while waiting for their primary care physician (PCP) showed that 43% preferred a woman endoscopist; 69% of these women had a female PCP. Among women with a female preference, 87% were willing to wait more than 30 extra days for a woman and 14% would be willing to pay more for a woman. Overall, 5% of the respondents would refuse to undergo a colonoscopy unless guaranteed a woman. In a multivariate logistic regression analysis, having a female PCP and being currently employed were independent predictors of preferring a female endoscopist. Having previously undergone a colonoscopy was associated with a 61% lower likelihood of preferring a woman (Gastrointest. Endosc. 2005;62:219–23).

Comparisons of Hemorrhoid Removal

Removal of symptomatic third- and fourth-degree hemorrhoids by either hemorroidopexy with the Proximate PPH stapler or hemorrhoidectomy with LigaSure bipolar diathermy achieves similar levels of postoperative pain, operative ease, and time until return to normal activities, according to a double-blind randomized study.

Matthias Kraemer, M.D., of the St. Barbara Clinic in Hamm-Heessen, Germany, and his colleagues reported results from a total of 50 patients randomized equally to either therapy. Neither technique had any differences in the duration of operation, immediate complications, or the surgeon's immediate postoperative assessment of the result and ease of the procedure. At weeks 3 and 6 of follow-up, patients did not have any difference in pain scores, satisfaction, level of personal activity, rate of hospitalization, or the time to and mode of their first defecation (Dis. Colon Rectum 2005;48:1517–22).

Predicting Crohn's Disease

Anti-Saccharomyces cerevisiae antibodies may be a marker in predicting future development of Crohn's disease but do not appear to be a marker of genetic susceptibility for the disease, according to two studies.

In 38 serum samples taken from 32 soldiers before they were diagnosed with Crohn's disease, Eran Israeli, M.D., of Hebrew University, Jerusalem, and colleagues reported that 10 tested positive for anti-S. cerevisiae antibodies (ASCA) vs. none of 95 control patients. The proportion of patients testing positive increased from 15% more than 60 months before diagnosis, to 37% within 36 months before diagnosis, to 55% after diagnosis. ASCA were present before and after diagnosis in 6 of the 11 patients who had samples after diagnosis. The geometric mean concentrations of ASCA also increased significantly as the time of diagnosis approached. The investigators suggested that it is too early to recommend monitoring of asymptomatic patients who are incidentally discovered to be ASCA positive (Gut 2005;54:1232–6).

A separate study of 98 mono- and dizygotic twin pairs conducted by Jonas Halfvarson, M.D., of örebro University Hospital (Sweden) and his associates found that ASCA were found in only 1 of 20 healthy twin siblings in monozygotic twin pairs that were discordant for Crohn's disease, compared with 7 of 27 healthy twin siblings in discordant dizygotic pairs. Titers of ASCA were not similar within discordant mono- or dizygotic twin pairs with Crohn's disease, and no independent factors were associated with ASCA titers and zygosity in a multivariate analysis. The findings suggest that “ASCA in healthy family members is a marker of shared environment,” the researchers said (Gut 2005;54:1237–43).

Lymphoma Risk in Treatment of IBD

Treatment of patients with inflammatory bowel disease with the immunomodulators azathioprine or 6-mercaptopurine is associated with about a fourfold increased risk of lymphoma, reported A. Kandiel of the Cleveland Clinic and colleagues.

In a metaanalysis of six studies, 11 cases of lymphoma occurred in 3,891 patients with inflammatory bowel disease, compared with an expected number of 2.63 cases based on rates reported by the Surveillance, Epidemiology, and End Results cancer registry; 9 of the cases were non-Hodgkin's lymphoma. By assuming a relative risk of lymphoma of 4, the number of patients needed to be treated with azathioprine or 6-mercaptopurine to cause one additional lymphoma per year ranged from 4,357 persons aged 20–29 years to 355 persons aged 70–79 years. “A conservative interpretation of our data is that IBD patients who receive immunomodulator medications are at higher risk of lymphoma than the general population, and that this increased risk could be due to the medication, disease activity, or both,” the investigators wrote (Gut 2005;54:1121–5).

Women Prefer Female Endoscopists

Nearly half of women prefer a female endoscopist for colorectal cancer screening, reported Stacy B. Menees, M.D., and her associates at the University of Michigan, Ann Arbor.

A questionnaire filled out by 202 of 212 women while waiting for their primary care physician (PCP) showed that 43% preferred a woman endoscopist; 69% of these women had a female PCP. Among women with a female preference, 87% were willing to wait more than 30 extra days for a woman and 14% would be willing to pay more for a woman. Overall, 5% of the respondents would refuse to undergo a colonoscopy unless guaranteed a woman. In a multivariate logistic regression analysis, having a female PCP and being currently employed were independent predictors of preferring a female endoscopist. Having previously undergone a colonoscopy was associated with a 61% lower likelihood of preferring a woman (Gastrointest. Endosc. 2005;62:219–23).

Comparisons of Hemorrhoid Removal

Removal of symptomatic third- and fourth-degree hemorrhoids by either hemorroidopexy with the Proximate PPH stapler or hemorrhoidectomy with LigaSure bipolar diathermy achieves similar levels of postoperative pain, operative ease, and time until return to normal activities, according to a double-blind randomized study.

Matthias Kraemer, M.D., of the St. Barbara Clinic in Hamm-Heessen, Germany, and his colleagues reported results from a total of 50 patients randomized equally to either therapy. Neither technique had any differences in the duration of operation, immediate complications, or the surgeon's immediate postoperative assessment of the result and ease of the procedure. At weeks 3 and 6 of follow-up, patients did not have any difference in pain scores, satisfaction, level of personal activity, rate of hospitalization, or the time to and mode of their first defecation (Dis. Colon Rectum 2005;48:1517–22).

Predicting Crohn's Disease

Anti-Saccharomyces cerevisiae antibodies may be a marker in predicting future development of Crohn's disease but do not appear to be a marker of genetic susceptibility for the disease, according to two studies.

In 38 serum samples taken from 32 soldiers before they were diagnosed with Crohn's disease, Eran Israeli, M.D., of Hebrew University, Jerusalem, and colleagues reported that 10 tested positive for anti-S. cerevisiae antibodies (ASCA) vs. none of 95 control patients. The proportion of patients testing positive increased from 15% more than 60 months before diagnosis, to 37% within 36 months before diagnosis, to 55% after diagnosis. ASCA were present before and after diagnosis in 6 of the 11 patients who had samples after diagnosis. The geometric mean concentrations of ASCA also increased significantly as the time of diagnosis approached. The investigators suggested that it is too early to recommend monitoring of asymptomatic patients who are incidentally discovered to be ASCA positive (Gut 2005;54:1232–6).

A separate study of 98 mono- and dizygotic twin pairs conducted by Jonas Halfvarson, M.D., of örebro University Hospital (Sweden) and his associates found that ASCA were found in only 1 of 20 healthy twin siblings in monozygotic twin pairs that were discordant for Crohn's disease, compared with 7 of 27 healthy twin siblings in discordant dizygotic pairs. Titers of ASCA were not similar within discordant mono- or dizygotic twin pairs with Crohn's disease, and no independent factors were associated with ASCA titers and zygosity in a multivariate analysis. The findings suggest that “ASCA in healthy family members is a marker of shared environment,” the researchers said (Gut 2005;54:1237–43).

Lymphoma Risk in Treatment of IBD

Treatment of patients with inflammatory bowel disease with the immunomodulators azathioprine or 6-mercaptopurine is associated with about a fourfold increased risk of lymphoma, reported A. Kandiel of the Cleveland Clinic and colleagues.

In a metaanalysis of six studies, 11 cases of lymphoma occurred in 3,891 patients with inflammatory bowel disease, compared with an expected number of 2.63 cases based on rates reported by the Surveillance, Epidemiology, and End Results cancer registry; 9 of the cases were non-Hodgkin's lymphoma. By assuming a relative risk of lymphoma of 4, the number of patients needed to be treated with azathioprine or 6-mercaptopurine to cause one additional lymphoma per year ranged from 4,357 persons aged 20–29 years to 355 persons aged 70–79 years. “A conservative interpretation of our data is that IBD patients who receive immunomodulator medications are at higher risk of lymphoma than the general population, and that this increased risk could be due to the medication, disease activity, or both,” the investigators wrote (Gut 2005;54:1121–5).

Women Prefer Female Endoscopists

Nearly half of women prefer a female endoscopist for colorectal cancer screening, reported Stacy B. Menees, M.D., and her associates at the University of Michigan, Ann Arbor.

A questionnaire filled out by 202 of 212 women while waiting for their primary care physician (PCP) showed that 43% preferred a woman endoscopist; 69% of these women had a female PCP. Among women with a female preference, 87% were willing to wait more than 30 extra days for a woman and 14% would be willing to pay more for a woman. Overall, 5% of the respondents would refuse to undergo a colonoscopy unless guaranteed a woman. In a multivariate logistic regression analysis, having a female PCP and being currently employed were independent predictors of preferring a female endoscopist. Having previously undergone a colonoscopy was associated with a 61% lower likelihood of preferring a woman (Gastrointest. Endosc. 2005;62:219–23).

Comparisons of Hemorrhoid Removal

Removal of symptomatic third- and fourth-degree hemorrhoids by either hemorroidopexy with the Proximate PPH stapler or hemorrhoidectomy with LigaSure bipolar diathermy achieves similar levels of postoperative pain, operative ease, and time until return to normal activities, according to a double-blind randomized study.

Matthias Kraemer, M.D., of the St. Barbara Clinic in Hamm-Heessen, Germany, and his colleagues reported results from a total of 50 patients randomized equally to either therapy. Neither technique had any differences in the duration of operation, immediate complications, or the surgeon's immediate postoperative assessment of the result and ease of the procedure. At weeks 3 and 6 of follow-up, patients did not have any difference in pain scores, satisfaction, level of personal activity, rate of hospitalization, or the time to and mode of their first defecation (Dis. Colon Rectum 2005;48:1517–22).

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received left ventricular assist devices (LVADs) at the German Heart Institute in Berlin since 1987, the 116 patients who were older than 60 years were 2.5 times more likely to have a negative long-term outcome after LVAD implantation than were the younger patients.

Negative long-term outcomes included no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

All age groups (younger than 18 years, 18–40 years, 41–60 years, and older than 60 years) had similar short-term outcomes for 30-day survival, heart transplantation, and weaning from LVAD during the first 30 days.

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received left ventricular assist devices (LVADs) at the German Heart Institute in Berlin since 1987, the 116 patients who were older than 60 years were 2.5 times more likely to have a negative long-term outcome after LVAD implantation than were the younger patients.

Negative long-term outcomes included no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

All age groups (younger than 18 years, 18–40 years, 41–60 years, and older than 60 years) had similar short-term outcomes for 30-day survival, heart transplantation, and weaning from LVAD during the first 30 days.

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received left ventricular assist devices (LVADs) at the German Heart Institute in Berlin since 1987, the 116 patients who were older than 60 years were 2.5 times more likely to have a negative long-term outcome after LVAD implantation than were the younger patients.

Negative long-term outcomes included no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

All age groups (younger than 18 years, 18–40 years, 41–60 years, and older than 60 years) had similar short-term outcomes for 30-day survival, heart transplantation, and weaning from LVAD during the first 30 days.

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term, survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received LVADs at the German Heart Institute, Berlin, since 1987, the 116 patients who were older than 60 years were 2.5 times more likely than younger patients to have a negative long-term outcome, such as no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term, survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received LVADs at the German Heart Institute, Berlin, since 1987, the 116 patients who were older than 60 years were 2.5 times more likely than younger patients to have a negative long-term outcome, such as no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

WASHINGTON — Receipt of a left ventricular assist device at an older age may adversely affect long-term, but not short-term, survival with the device, Evgenij V. Potapov, M.D., reported at the annual conference of the American Society for Artificial Internal Organs.

In a review of 403 patients who have received LVADs at the German Heart Institute, Berlin, since 1987, the 116 patients who were older than 60 years were 2.5 times more likely than younger patients to have a negative long-term outcome, such as no heart transplantation, an inability to wean off the LVAD within 6 months, support for less than 6 months in patients with permanent implants, and failure to continue support for more than 6 months in other patients, said Dr. Potapov, a cardiothoracic surgeon at the institute.

No risk factor significantly predicted a negative long-term outcome in patients older than age 60.

“Postcardiotomy support in older patients should be performed in really selective cases,” he said.

QUEBEC CITY — Dosages of the androgen receptor blocker flutamide at 125 mg/day appear to be effective in treating acne in women who have not responded to other medications, James C. Shaw, M.D., reported at the annual conference of the Canadian Dermatology Association.

Flutamide has been reported to be effective in treating acne at doses of 500 mg/day and 250 mg/day. But flutamide has not been used as widely as other androgen receptor blockers such as cyproterone acetate and spironolactone because of an incidence of hepatotoxicity ranging from 1% to 5% at dosages greater than 500 mg/day and in isolated cases at 250 mg/day, according to Dr. Shaw of the division of dermatology at the University of Toronto.

In a review of 32 consecutive women aged 14–51 years who received a prescription for flutamide at 125 mg/day, 17 of the 21 patients who returned for follow-up visits had marked improvement of their acne. The length of treatment in the 21 patients ranged from about 2 months to 21 months, Dr. Shaw and his associates wrote on a poster.

Overall, five women discontinued treatment because of emotional lability (two patients), minor GI distress (two), or a slightly elevated level of alanine aminotransferase (one). With the exception of four patients, none the women had responded adequately to or had tolerated other therapies.

Dr. Shaw said that he regularly conducts liver function tests. Flutamide has been associated with developmental abnormalities in exposed fetal rats, so all patients must be advised about contraceptive use during treatment. The drug is most often used to treat prostate cancer in men and hirsutism in women.

This patient's acne was refractory to treatment with isotretinoin.

Her acne responded to 8 months of flutamide 125 mg/day plus oral contraceptives. Photos courtesy Dr. James C. Shaw

QUEBEC CITY — Dosages of the androgen receptor blocker flutamide at 125 mg/day appear to be effective in treating acne in women who have not responded to other medications, James C. Shaw, M.D., reported at the annual conference of the Canadian Dermatology Association.

Flutamide has been reported to be effective in treating acne at doses of 500 mg/day and 250 mg/day. But flutamide has not been used as widely as other androgen receptor blockers such as cyproterone acetate and spironolactone because of an incidence of hepatotoxicity ranging from 1% to 5% at dosages greater than 500 mg/day and in isolated cases at 250 mg/day, according to Dr. Shaw of the division of dermatology at the University of Toronto.

In a review of 32 consecutive women aged 14–51 years who received a prescription for flutamide at 125 mg/day, 17 of the 21 patients who returned for follow-up visits had marked improvement of their acne. The length of treatment in the 21 patients ranged from about 2 months to 21 months, Dr. Shaw and his associates wrote on a poster.

Overall, five women discontinued treatment because of emotional lability (two patients), minor GI distress (two), or a slightly elevated level of alanine aminotransferase (one). With the exception of four patients, none the women had responded adequately to or had tolerated other therapies.

Dr. Shaw said that he regularly conducts liver function tests. Flutamide has been associated with developmental abnormalities in exposed fetal rats, so all patients must be advised about contraceptive use during treatment. The drug is most often used to treat prostate cancer in men and hirsutism in women.

This patient's acne was refractory to treatment with isotretinoin.

Her acne responded to 8 months of flutamide 125 mg/day plus oral contraceptives. Photos courtesy Dr. James C. Shaw

QUEBEC CITY — Dosages of the androgen receptor blocker flutamide at 125 mg/day appear to be effective in treating acne in women who have not responded to other medications, James C. Shaw, M.D., reported at the annual conference of the Canadian Dermatology Association.

Flutamide has been reported to be effective in treating acne at doses of 500 mg/day and 250 mg/day. But flutamide has not been used as widely as other androgen receptor blockers such as cyproterone acetate and spironolactone because of an incidence of hepatotoxicity ranging from 1% to 5% at dosages greater than 500 mg/day and in isolated cases at 250 mg/day, according to Dr. Shaw of the division of dermatology at the University of Toronto.

In a review of 32 consecutive women aged 14–51 years who received a prescription for flutamide at 125 mg/day, 17 of the 21 patients who returned for follow-up visits had marked improvement of their acne. The length of treatment in the 21 patients ranged from about 2 months to 21 months, Dr. Shaw and his associates wrote on a poster.

Overall, five women discontinued treatment because of emotional lability (two patients), minor GI distress (two), or a slightly elevated level of alanine aminotransferase (one). With the exception of four patients, none the women had responded adequately to or had tolerated other therapies.

Dr. Shaw said that he regularly conducts liver function tests. Flutamide has been associated with developmental abnormalities in exposed fetal rats, so all patients must be advised about contraceptive use during treatment. The drug is most often used to treat prostate cancer in men and hirsutism in women.

This patient's acne was refractory to treatment with isotretinoin.

Her acne responded to 8 months of flutamide 125 mg/day plus oral contraceptives. Photos courtesy Dr. James C. Shaw

HERSHEY, PA. — A new onset of dermatitis in an auto mechanic should raise clinical suspicion for contact allergy to isothiazolinone preservatives found in many car repair and maintenance products, Bruce A. Brod, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

In an illustrative case of allergic contact dermatitis to isothiazolinones, Dr. Brod described a nonatopic male auto mechanic who owned a diesel fuel station and auto repair shop. The man presented with a 5-month history of a “horrific, nearly erythrodermic” dermatitis involving his hands, arms, legs, and trunk. While he responded very well to systemic steroids, the dermatitis would completely clear when he was away from work for weeklong vacations.

Besides patch testing with the North American Contact Dermatitis Group standard series, Dr. Brod also used an oil and cooling fluid series, a plastic and glue series, a rubber additive series, and a corticosteroid series. The most relevant positive results on patch testing included the isothiazolinones 5-chloro-2-methyl-4-iso- thiazolin-3-one (MCI), 2-methyl-4-isothiazolin-3-one (MI), and 2-n-octyl-4-isothiazolin-3-one (OIT), said Dr. Brod of the department of dermatology at the University of Pennsylvania, Philadelphia.

He began a search for isothiazolinones in the patient's environment. “It's quite an undertaking in somebody who works around a lot of [industrial] products in an auto shop.” After searching for isothiazolinones in the patient's personal care products, such as his moisturizers, cleansers, and topical medications, Dr. Brod read through material data safety sheets for the industrial chemicals and products in the auto shop and called companies to learn about the chemicals in motor oils and other automotive fluids.

“As a last resort and just an afterthought, we asked him if he worked with any sort of adhesives because there have been some reports of octyl-isothiazolinone present in some adhesives,” Dr. Brod said.

The man reported working with a silicone gasket sealant. Material data safety sheets did not identify OIT in the sealant, but the toxicologist working for the sealant's manufacturer confirmed its presence.

Although the mechanic's widespread dermatitis improved when he avoided the sealant, he still had the condition on his hands and forearms at a 2-month follow-up visit. The man admitted to pumping diesel fuel for customers at the fuel station since his duties at work had become limited because of his avoidance of numerous auto parts and products. A toxicologist working for the oil company confirmed that some of the businesses that refine oil for the company (which does not have its own oil refinery) added OIT and MCI to their storage tanks.

The patient's dermatitis cleared almost completely when be began avoiding the diesel fuel. Isothiazolinones are added to diesel fuel because diesel's high water content makes it vulnerable to microbial overgrowth. A bus mechanic in the Netherlands also has been reported to react to MCI/MI in diesel fuel (Contact Derm. 1996;34:64–5).

Besides silicone sealants, the fungicide OIT (also known under the trade names Kathon 893 and Skane M-8) is found in products such as wallpaper adhesives, water-based paints, cutting oils, and leather preservatives. Allergic contact dermatitis to OIT has been reported in painters, paint factory workers, and laboratory workers. No nonoccupational cases have been published, because OIT is “not really used in the personal care industry,” Dr. Brod said.

The North American Contact Dermatitis Group's 2001–2002 study of patch testing of 65 allergens on 4,913 patients showed that 2.3% of patients had positive reactions to MCI and MI. Of the patients with positive reactions, 88% had a current or past episode of dermatitis from exposure to MCI and MI.

HERSHEY, PA. — A new onset of dermatitis in an auto mechanic should raise clinical suspicion for contact allergy to isothiazolinone preservatives found in many car repair and maintenance products, Bruce A. Brod, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

In an illustrative case of allergic contact dermatitis to isothiazolinones, Dr. Brod described a nonatopic male auto mechanic who owned a diesel fuel station and auto repair shop. The man presented with a 5-month history of a “horrific, nearly erythrodermic” dermatitis involving his hands, arms, legs, and trunk. While he responded very well to systemic steroids, the dermatitis would completely clear when he was away from work for weeklong vacations.

Besides patch testing with the North American Contact Dermatitis Group standard series, Dr. Brod also used an oil and cooling fluid series, a plastic and glue series, a rubber additive series, and a corticosteroid series. The most relevant positive results on patch testing included the isothiazolinones 5-chloro-2-methyl-4-iso- thiazolin-3-one (MCI), 2-methyl-4-isothiazolin-3-one (MI), and 2-n-octyl-4-isothiazolin-3-one (OIT), said Dr. Brod of the department of dermatology at the University of Pennsylvania, Philadelphia.

He began a search for isothiazolinones in the patient's environment. “It's quite an undertaking in somebody who works around a lot of [industrial] products in an auto shop.” After searching for isothiazolinones in the patient's personal care products, such as his moisturizers, cleansers, and topical medications, Dr. Brod read through material data safety sheets for the industrial chemicals and products in the auto shop and called companies to learn about the chemicals in motor oils and other automotive fluids.

“As a last resort and just an afterthought, we asked him if he worked with any sort of adhesives because there have been some reports of octyl-isothiazolinone present in some adhesives,” Dr. Brod said.

The man reported working with a silicone gasket sealant. Material data safety sheets did not identify OIT in the sealant, but the toxicologist working for the sealant's manufacturer confirmed its presence.

Although the mechanic's widespread dermatitis improved when he avoided the sealant, he still had the condition on his hands and forearms at a 2-month follow-up visit. The man admitted to pumping diesel fuel for customers at the fuel station since his duties at work had become limited because of his avoidance of numerous auto parts and products. A toxicologist working for the oil company confirmed that some of the businesses that refine oil for the company (which does not have its own oil refinery) added OIT and MCI to their storage tanks.

The patient's dermatitis cleared almost completely when be began avoiding the diesel fuel. Isothiazolinones are added to diesel fuel because diesel's high water content makes it vulnerable to microbial overgrowth. A bus mechanic in the Netherlands also has been reported to react to MCI/MI in diesel fuel (Contact Derm. 1996;34:64–5).

Besides silicone sealants, the fungicide OIT (also known under the trade names Kathon 893 and Skane M-8) is found in products such as wallpaper adhesives, water-based paints, cutting oils, and leather preservatives. Allergic contact dermatitis to OIT has been reported in painters, paint factory workers, and laboratory workers. No nonoccupational cases have been published, because OIT is “not really used in the personal care industry,” Dr. Brod said.

The North American Contact Dermatitis Group's 2001–2002 study of patch testing of 65 allergens on 4,913 patients showed that 2.3% of patients had positive reactions to MCI and MI. Of the patients with positive reactions, 88% had a current or past episode of dermatitis from exposure to MCI and MI.

HERSHEY, PA. — A new onset of dermatitis in an auto mechanic should raise clinical suspicion for contact allergy to isothiazolinone preservatives found in many car repair and maintenance products, Bruce A. Brod, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

In an illustrative case of allergic contact dermatitis to isothiazolinones, Dr. Brod described a nonatopic male auto mechanic who owned a diesel fuel station and auto repair shop. The man presented with a 5-month history of a “horrific, nearly erythrodermic” dermatitis involving his hands, arms, legs, and trunk. While he responded very well to systemic steroids, the dermatitis would completely clear when he was away from work for weeklong vacations.

Besides patch testing with the North American Contact Dermatitis Group standard series, Dr. Brod also used an oil and cooling fluid series, a plastic and glue series, a rubber additive series, and a corticosteroid series. The most relevant positive results on patch testing included the isothiazolinones 5-chloro-2-methyl-4-iso- thiazolin-3-one (MCI), 2-methyl-4-isothiazolin-3-one (MI), and 2-n-octyl-4-isothiazolin-3-one (OIT), said Dr. Brod of the department of dermatology at the University of Pennsylvania, Philadelphia.

He began a search for isothiazolinones in the patient's environment. “It's quite an undertaking in somebody who works around a lot of [industrial] products in an auto shop.” After searching for isothiazolinones in the patient's personal care products, such as his moisturizers, cleansers, and topical medications, Dr. Brod read through material data safety sheets for the industrial chemicals and products in the auto shop and called companies to learn about the chemicals in motor oils and other automotive fluids.

“As a last resort and just an afterthought, we asked him if he worked with any sort of adhesives because there have been some reports of octyl-isothiazolinone present in some adhesives,” Dr. Brod said.

The man reported working with a silicone gasket sealant. Material data safety sheets did not identify OIT in the sealant, but the toxicologist working for the sealant's manufacturer confirmed its presence.

Although the mechanic's widespread dermatitis improved when he avoided the sealant, he still had the condition on his hands and forearms at a 2-month follow-up visit. The man admitted to pumping diesel fuel for customers at the fuel station since his duties at work had become limited because of his avoidance of numerous auto parts and products. A toxicologist working for the oil company confirmed that some of the businesses that refine oil for the company (which does not have its own oil refinery) added OIT and MCI to their storage tanks.

The patient's dermatitis cleared almost completely when be began avoiding the diesel fuel. Isothiazolinones are added to diesel fuel because diesel's high water content makes it vulnerable to microbial overgrowth. A bus mechanic in the Netherlands also has been reported to react to MCI/MI in diesel fuel (Contact Derm. 1996;34:64–5).

Besides silicone sealants, the fungicide OIT (also known under the trade names Kathon 893 and Skane M-8) is found in products such as wallpaper adhesives, water-based paints, cutting oils, and leather preservatives. Allergic contact dermatitis to OIT has been reported in painters, paint factory workers, and laboratory workers. No nonoccupational cases have been published, because OIT is “not really used in the personal care industry,” Dr. Brod said.

The North American Contact Dermatitis Group's 2001–2002 study of patch testing of 65 allergens on 4,913 patients showed that 2.3% of patients had positive reactions to MCI and MI. Of the patients with positive reactions, 88% had a current or past episode of dermatitis from exposure to MCI and MI.

HERSHEY, PA. — The right pair of gloves can make all the difference to patients who develop contact dermatitis from the chemicals they are exposed to on the job, Matthew J. Zirwas, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

“There's a big importance to whenever you are investigating occupational cases and going to be doing glove recommendation that you really take a thorough glove history, and you really look at what that patient is doing, and what a glove will need to do,” advised Dr. Zirwas, director of the contact and occupational dermatitis center at the University of Pittsburgh.

Dr. Zirwas described a case of a printing press operator who presented with a 6-month history of psoriasiform, fissuring, patchy dermatitis on the dorsal part of his hands and forearms. He had performed the same job of working with and cleaning metal plates and a printing press with a mixture of very strong solvents for 5 years. His dermatitis would improve when he was absent from work for 1 week but would return shortly after he returned.

The patient said that about 7 of 50–60 other employees in the shop had the same condition. Patch tests to a modified North American Contact Dermatitis Group panel, a panel of different rubbers, selected chemicals from the patient's workplace, and samples of printed materials all yielded negative results. The man used his nitrile work gloves for about 2 weeks at a time and noted that his hands often felt wet under the gloves after several days of use even though no liquid was visible when the gloves were removed. “I always try to have patients bring their gloves in so that I can examine them,” Dr. Zirwas said.

The nitrile work gloves offered pretty good chemical resistance, he said, but are subject to degradation and permeation by certain chemicals, such as methanol, methyl isobutyl ketone, acetone, toluene, propyl acetate, and xylene.

“You need to think about [permeation and] degradation as starting from the minute that that chemical comes in contact with the glove,” he recommended. One week or even 2 or 3 days after the printing press operator began using his gloves, they were “severely degraded and really providing no barrier at all.”

Despite the limitations of the nitrile gloves, Dr. Zirwas decided that the nitrile gloves would be safe for the patient to use if he used them for shorter periods because of the intermittent nature of the patient's chemical exposure. Plus, “he didn't think that his shop would be very interested in switching gloves,” Dr. Zirwas said.

By changing the gloves at the end of every 4-hour shift, the man had dramatic improvement in dermatitis during the next month. “Even though these gloves were not the ideal glove to protect him against the chemicals he was exposed to, by having him use the gloves appropriately, we were able to continue using the gloves and still get him better,” he said.

Another man working as a countertop assembler presented to Dr. Zirwas with a 1-year history of itchy, burning dermatitis on his fingertips that was associated with tingling and paresthesias that improved when he was away from work. The patient had tried using several kinds of gloves with no improvement in his condition.

Patch testing was done with a variety of different panels including a modified North American Contact Dermatitis Group standard series and plastic, glue, and rubber panels; all of these came out negative until he tested positive to multiple acrylates, including methyl methacrylate. Methacrylates are known to penetrate almost all types of rubber and can cause paresthesias similar to those reported by the countertop assembler, Dr. Zirwas noted.

The patient held the nozzle of the glue gun that dispensed methyl methacrylate throughout the day with the most severely affected fingers. The patient did not think that polyvinyl alcohol gloves would provide enough protection for him since he also encountered alcohols and water-based products at work, both of which can penetrate polyvinyl alcohol materials. The gloves also did not provide good dexterity.

Two kinds of multilayer laminate gloves—Silvershield (also known as 4H) and Barrier gloves—incorporate a hydrophilic/polar layer between two hydrophobic/nonpolar layers. Both gloves are nonelastic, thin-film materials that provide poor dexterity, fit, and resistance to cuts, abrasions, and tears. “The best way you could describe them to a patient is to say 'essentially put a garbage bag on each hand and try to do your job,'” he said.

Silvershield gloves have slightly better chemical protection than Barrier, Dr. Zirwas said, but Barriers are made to be right- and left-hand specific with a liner that disperses moistures and decreases slippage. Both gloves offer protection against methyl methacrylate. The patient switched to Barriers he changed weekly unless obvious damage occurred. He wore disposable elastic gloves over the Barriers for better dexterity.

The patient reported about 90%–95% improvement in his dermatitis and near resolution of his neuropathic symptoms after 6 weeks.

Solvent dermatitis can be the result of chemical exposure that occurs even through protective gloves.

This case of hand dermatitis is the result of methyl methacrylate exposures through poorly protective gloves. Photos courtesy Dr. Matthew J. Zirwas

HERSHEY, PA. — The right pair of gloves can make all the difference to patients who develop contact dermatitis from the chemicals they are exposed to on the job, Matthew J. Zirwas, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

“There's a big importance to whenever you are investigating occupational cases and going to be doing glove recommendation that you really take a thorough glove history, and you really look at what that patient is doing, and what a glove will need to do,” advised Dr. Zirwas, director of the contact and occupational dermatitis center at the University of Pittsburgh.

Dr. Zirwas described a case of a printing press operator who presented with a 6-month history of psoriasiform, fissuring, patchy dermatitis on the dorsal part of his hands and forearms. He had performed the same job of working with and cleaning metal plates and a printing press with a mixture of very strong solvents for 5 years. His dermatitis would improve when he was absent from work for 1 week but would return shortly after he returned.

The patient said that about 7 of 50–60 other employees in the shop had the same condition. Patch tests to a modified North American Contact Dermatitis Group panel, a panel of different rubbers, selected chemicals from the patient's workplace, and samples of printed materials all yielded negative results. The man used his nitrile work gloves for about 2 weeks at a time and noted that his hands often felt wet under the gloves after several days of use even though no liquid was visible when the gloves were removed. “I always try to have patients bring their gloves in so that I can examine them,” Dr. Zirwas said.

The nitrile work gloves offered pretty good chemical resistance, he said, but are subject to degradation and permeation by certain chemicals, such as methanol, methyl isobutyl ketone, acetone, toluene, propyl acetate, and xylene.

“You need to think about [permeation and] degradation as starting from the minute that that chemical comes in contact with the glove,” he recommended. One week or even 2 or 3 days after the printing press operator began using his gloves, they were “severely degraded and really providing no barrier at all.”

Despite the limitations of the nitrile gloves, Dr. Zirwas decided that the nitrile gloves would be safe for the patient to use if he used them for shorter periods because of the intermittent nature of the patient's chemical exposure. Plus, “he didn't think that his shop would be very interested in switching gloves,” Dr. Zirwas said.

By changing the gloves at the end of every 4-hour shift, the man had dramatic improvement in dermatitis during the next month. “Even though these gloves were not the ideal glove to protect him against the chemicals he was exposed to, by having him use the gloves appropriately, we were able to continue using the gloves and still get him better,” he said.

Another man working as a countertop assembler presented to Dr. Zirwas with a 1-year history of itchy, burning dermatitis on his fingertips that was associated with tingling and paresthesias that improved when he was away from work. The patient had tried using several kinds of gloves with no improvement in his condition.

Patch testing was done with a variety of different panels including a modified North American Contact Dermatitis Group standard series and plastic, glue, and rubber panels; all of these came out negative until he tested positive to multiple acrylates, including methyl methacrylate. Methacrylates are known to penetrate almost all types of rubber and can cause paresthesias similar to those reported by the countertop assembler, Dr. Zirwas noted.

The patient held the nozzle of the glue gun that dispensed methyl methacrylate throughout the day with the most severely affected fingers. The patient did not think that polyvinyl alcohol gloves would provide enough protection for him since he also encountered alcohols and water-based products at work, both of which can penetrate polyvinyl alcohol materials. The gloves also did not provide good dexterity.

Two kinds of multilayer laminate gloves—Silvershield (also known as 4H) and Barrier gloves—incorporate a hydrophilic/polar layer between two hydrophobic/nonpolar layers. Both gloves are nonelastic, thin-film materials that provide poor dexterity, fit, and resistance to cuts, abrasions, and tears. “The best way you could describe them to a patient is to say 'essentially put a garbage bag on each hand and try to do your job,'” he said.

Silvershield gloves have slightly better chemical protection than Barrier, Dr. Zirwas said, but Barriers are made to be right- and left-hand specific with a liner that disperses moistures and decreases slippage. Both gloves offer protection against methyl methacrylate. The patient switched to Barriers he changed weekly unless obvious damage occurred. He wore disposable elastic gloves over the Barriers for better dexterity.

The patient reported about 90%–95% improvement in his dermatitis and near resolution of his neuropathic symptoms after 6 weeks.

Solvent dermatitis can be the result of chemical exposure that occurs even through protective gloves.

This case of hand dermatitis is the result of methyl methacrylate exposures through poorly protective gloves. Photos courtesy Dr. Matthew J. Zirwas

HERSHEY, PA. — The right pair of gloves can make all the difference to patients who develop contact dermatitis from the chemicals they are exposed to on the job, Matthew J. Zirwas, M.D., said at a meeting on contact dermatitis sponsored by Pennsylvania State University.

“There's a big importance to whenever you are investigating occupational cases and going to be doing glove recommendation that you really take a thorough glove history, and you really look at what that patient is doing, and what a glove will need to do,” advised Dr. Zirwas, director of the contact and occupational dermatitis center at the University of Pittsburgh.

Dr. Zirwas described a case of a printing press operator who presented with a 6-month history of psoriasiform, fissuring, patchy dermatitis on the dorsal part of his hands and forearms. He had performed the same job of working with and cleaning metal plates and a printing press with a mixture of very strong solvents for 5 years. His dermatitis would improve when he was absent from work for 1 week but would return shortly after he returned.

The patient said that about 7 of 50–60 other employees in the shop had the same condition. Patch tests to a modified North American Contact Dermatitis Group panel, a panel of different rubbers, selected chemicals from the patient's workplace, and samples of printed materials all yielded negative results. The man used his nitrile work gloves for about 2 weeks at a time and noted that his hands often felt wet under the gloves after several days of use even though no liquid was visible when the gloves were removed. “I always try to have patients bring their gloves in so that I can examine them,” Dr. Zirwas said.

The nitrile work gloves offered pretty good chemical resistance, he said, but are subject to degradation and permeation by certain chemicals, such as methanol, methyl isobutyl ketone, acetone, toluene, propyl acetate, and xylene.

“You need to think about [permeation and] degradation as starting from the minute that that chemical comes in contact with the glove,” he recommended. One week or even 2 or 3 days after the printing press operator began using his gloves, they were “severely degraded and really providing no barrier at all.”

Despite the limitations of the nitrile gloves, Dr. Zirwas decided that the nitrile gloves would be safe for the patient to use if he used them for shorter periods because of the intermittent nature of the patient's chemical exposure. Plus, “he didn't think that his shop would be very interested in switching gloves,” Dr. Zirwas said.

By changing the gloves at the end of every 4-hour shift, the man had dramatic improvement in dermatitis during the next month. “Even though these gloves were not the ideal glove to protect him against the chemicals he was exposed to, by having him use the gloves appropriately, we were able to continue using the gloves and still get him better,” he said.

Another man working as a countertop assembler presented to Dr. Zirwas with a 1-year history of itchy, burning dermatitis on his fingertips that was associated with tingling and paresthesias that improved when he was away from work. The patient had tried using several kinds of gloves with no improvement in his condition.

Patch testing was done with a variety of different panels including a modified North American Contact Dermatitis Group standard series and plastic, glue, and rubber panels; all of these came out negative until he tested positive to multiple acrylates, including methyl methacrylate. Methacrylates are known to penetrate almost all types of rubber and can cause paresthesias similar to those reported by the countertop assembler, Dr. Zirwas noted.

The patient held the nozzle of the glue gun that dispensed methyl methacrylate throughout the day with the most severely affected fingers. The patient did not think that polyvinyl alcohol gloves would provide enough protection for him since he also encountered alcohols and water-based products at work, both of which can penetrate polyvinyl alcohol materials. The gloves also did not provide good dexterity.

Two kinds of multilayer laminate gloves—Silvershield (also known as 4H) and Barrier gloves—incorporate a hydrophilic/polar layer between two hydrophobic/nonpolar layers. Both gloves are nonelastic, thin-film materials that provide poor dexterity, fit, and resistance to cuts, abrasions, and tears. “The best way you could describe them to a patient is to say 'essentially put a garbage bag on each hand and try to do your job,'” he said.

Silvershield gloves have slightly better chemical protection than Barrier, Dr. Zirwas said, but Barriers are made to be right- and left-hand specific with a liner that disperses moistures and decreases slippage. Both gloves offer protection against methyl methacrylate. The patient switched to Barriers he changed weekly unless obvious damage occurred. He wore disposable elastic gloves over the Barriers for better dexterity.

The patient reported about 90%–95% improvement in his dermatitis and near resolution of his neuropathic symptoms after 6 weeks.

Solvent dermatitis can be the result of chemical exposure that occurs even through protective gloves.

This case of hand dermatitis is the result of methyl methacrylate exposures through poorly protective gloves. Photos courtesy Dr. Matthew J. Zirwas

Extra CT Colonography Findings

Extracolonic findings during CT colonography are common, but identify a substantial number of clinically important abnormalities in men, regardless of their risk for colorectal cancer, reported Judy Yee, M.D., of the University of California at San Francisco, and her colleagues.

CT colonography identified 596 extracolonic abnormalities in 315 of 500 male patients screened for colorectal cancer. Of 45 patients with abnormalities deemed clinically important, 35 had not been previously identified; they included renal and adrenal masses, pulmonary nodules, and abdominal aortic and iliac artery aneurysms (Radiology 2005;236:519–26).

The percentage of patients with clinically important extracolonic findings did not differ significantly between the 194 patients who were at average risk for colorectal cancer and the 306 who were at high risk (6.2% vs. 10.8%, respectively). Follow-up imaging studies were performed in 25 of the 35 patients with previously undiagnosed lesions; 13 of the patients required surgery or further monitoring. The cost of additional imaging performed because of extracolonic findings averaged $28 per patient.

Hemochromatosis Screening

Nearly all individuals who are identified as having hemochromatosis through genetic screening of cheek-brush samples for HFE mutations are willing to undergo management and treatment, according to a prospective study.

Martin B. Delatycki, M.B., of the University of Melbourne, and his associates detected homozygous Cys282Tyr mutations in HFE in 51 of 11,307 individuals who attended workplace screening sessions; 4 patients were already aware of their condition. Almost all of the newly identified homozygous individuals (46 of 47) agreed to enter into an appropriate program of medical management. In homozygous patients, elevated fasting transferrin saturation levels were found in 19 of 23 men and 11 of 23 women. All patients with high levels of serum transferrin underwent regular phlebotomy to reduce ferritin levels to within the normal range. Liver biopsies performed in four of the six men who met criteria for a biopsy showed either advanced precirrhotic liver fibrosis or moderate hemosiderosis with mild portal fibrosis (Lancet 2005;366:314–6).

New-Onset Diabetes as Marker New onset of diabetes in patients older than 50 years has the potential to be a marker for early pancreatic cancer, reported Suresh T. Chari, M.D., and colleagues at the Mayo Clinic, Rochester, Minn.

In a review of 2,122 Rochester residents who were 50 years or older and developed diabetes at some point during 1950 through 1994, 18 (0.85%) went on to have pancreatic cancer. The cancer was identified an average of about 6 months after diabetes criteria were met. In 10 of those patients, the cancer was diagnosed less than 6 months after first meeting criteria for diabetes. The crude 3-year incidence of pancreatic cancer in patients with diabetes 50 years of age or older was 310 per 100,000 patient-years. Diabetic patients with pancreatic cancer were about 4.5 times more likely to have first met criteria for diabetes on or after age 70 years than were diabetic patients without pancreatic cancer (Gastroenterology 2005;129:504–11).

“For hyperglycemia to be a clinically useful marker of early cancer one will have to screen asymptomatic individuals for hyperglycemia,” and the success of the strategy “will depend largely on our ability to differentiate pancreatic cancer-induced diabetes from type 2 diabetes using a serologic marker,” the investigators wrote. “Because our population was neither screened for diabetes nor [screened] for pancreatic cancer, the benefit of screening for pancreatic cancer using diabetes or hyperglycemia as a marker cannot be answered by the present study and deserves a prospective analysis.”

Hereditary Colorectal Ca

The median age of onset of colorectal cancer in individuals of families with mismatch repair gene mutations for hereditary nonpolyposis colorectal cancer may be much older than previously reported, according to Heather Hampel, M.D., of Ohio State University, Columbus, and her colleagues.

The median age at diagnosis was 54 years in men and 70 years in women in a group of 70 Finnish families at risk for hereditary nonpolyposis colorectal cancer (HNPCC) that comprised 88 probands and 373 individuals who tested positive for a germline mutation in MLH1 or MSH2 (Gastroenterology 2005;129:415–21).

Those ages are 10–15 years higher than the previous estimates of age at onset for colorectal cancer among HNPCC patients in the literature, which are typically 44–45 years. “Our data strongly suggest that in the diagnosis of HNPCC, limiting molecular studies to patients with an early age at diagnosis will miss many cases,” the researchers wrote. Microsatellite instability and immunohistochemical staining “would best be applied to all new colorectal cancer cases and not just to a limited high-risk subset.”

Extra CT Colonography Findings

Extracolonic findings during CT colonography are common, but identify a substantial number of clinically important abnormalities in men, regardless of their risk for colorectal cancer, reported Judy Yee, M.D., of the University of California at San Francisco, and her colleagues.

CT colonography identified 596 extracolonic abnormalities in 315 of 500 male patients screened for colorectal cancer. Of 45 patients with abnormalities deemed clinically important, 35 had not been previously identified; they included renal and adrenal masses, pulmonary nodules, and abdominal aortic and iliac artery aneurysms (Radiology 2005;236:519–26).

The percentage of patients with clinically important extracolonic findings did not differ significantly between the 194 patients who were at average risk for colorectal cancer and the 306 who were at high risk (6.2% vs. 10.8%, respectively). Follow-up imaging studies were performed in 25 of the 35 patients with previously undiagnosed lesions; 13 of the patients required surgery or further monitoring. The cost of additional imaging performed because of extracolonic findings averaged $28 per patient.

Hemochromatosis Screening

Nearly all individuals who are identified as having hemochromatosis through genetic screening of cheek-brush samples for HFE mutations are willing to undergo management and treatment, according to a prospective study.

Martin B. Delatycki, M.B., of the University of Melbourne, and his associates detected homozygous Cys282Tyr mutations in HFE in 51 of 11,307 individuals who attended workplace screening sessions; 4 patients were already aware of their condition. Almost all of the newly identified homozygous individuals (46 of 47) agreed to enter into an appropriate program of medical management. In homozygous patients, elevated fasting transferrin saturation levels were found in 19 of 23 men and 11 of 23 women. All patients with high levels of serum transferrin underwent regular phlebotomy to reduce ferritin levels to within the normal range. Liver biopsies performed in four of the six men who met criteria for a biopsy showed either advanced precirrhotic liver fibrosis or moderate hemosiderosis with mild portal fibrosis (Lancet 2005;366:314–6).

New-Onset Diabetes as Marker New onset of diabetes in patients older than 50 years has the potential to be a marker for early pancreatic cancer, reported Suresh T. Chari, M.D., and colleagues at the Mayo Clinic, Rochester, Minn.

In a review of 2,122 Rochester residents who were 50 years or older and developed diabetes at some point during 1950 through 1994, 18 (0.85%) went on to have pancreatic cancer. The cancer was identified an average of about 6 months after diabetes criteria were met. In 10 of those patients, the cancer was diagnosed less than 6 months after first meeting criteria for diabetes. The crude 3-year incidence of pancreatic cancer in patients with diabetes 50 years of age or older was 310 per 100,000 patient-years. Diabetic patients with pancreatic cancer were about 4.5 times more likely to have first met criteria for diabetes on or after age 70 years than were diabetic patients without pancreatic cancer (Gastroenterology 2005;129:504–11).

“For hyperglycemia to be a clinically useful marker of early cancer one will have to screen asymptomatic individuals for hyperglycemia,” and the success of the strategy “will depend largely on our ability to differentiate pancreatic cancer-induced diabetes from type 2 diabetes using a serologic marker,” the investigators wrote. “Because our population was neither screened for diabetes nor [screened] for pancreatic cancer, the benefit of screening for pancreatic cancer using diabetes or hyperglycemia as a marker cannot be answered by the present study and deserves a prospective analysis.”

Hereditary Colorectal Ca

The median age of onset of colorectal cancer in individuals of families with mismatch repair gene mutations for hereditary nonpolyposis colorectal cancer may be much older than previously reported, according to Heather Hampel, M.D., of Ohio State University, Columbus, and her colleagues.

The median age at diagnosis was 54 years in men and 70 years in women in a group of 70 Finnish families at risk for hereditary nonpolyposis colorectal cancer (HNPCC) that comprised 88 probands and 373 individuals who tested positive for a germline mutation in MLH1 or MSH2 (Gastroenterology 2005;129:415–21).

Those ages are 10–15 years higher than the previous estimates of age at onset for colorectal cancer among HNPCC patients in the literature, which are typically 44–45 years. “Our data strongly suggest that in the diagnosis of HNPCC, limiting molecular studies to patients with an early age at diagnosis will miss many cases,” the researchers wrote. Microsatellite instability and immunohistochemical staining “would best be applied to all new colorectal cancer cases and not just to a limited high-risk subset.”

Extra CT Colonography Findings

Extracolonic findings during CT colonography are common, but identify a substantial number of clinically important abnormalities in men, regardless of their risk for colorectal cancer, reported Judy Yee, M.D., of the University of California at San Francisco, and her colleagues.

CT colonography identified 596 extracolonic abnormalities in 315 of 500 male patients screened for colorectal cancer. Of 45 patients with abnormalities deemed clinically important, 35 had not been previously identified; they included renal and adrenal masses, pulmonary nodules, and abdominal aortic and iliac artery aneurysms (Radiology 2005;236:519–26).

The percentage of patients with clinically important extracolonic findings did not differ significantly between the 194 patients who were at average risk for colorectal cancer and the 306 who were at high risk (6.2% vs. 10.8%, respectively). Follow-up imaging studies were performed in 25 of the 35 patients with previously undiagnosed lesions; 13 of the patients required surgery or further monitoring. The cost of additional imaging performed because of extracolonic findings averaged $28 per patient.

Hemochromatosis Screening

Nearly all individuals who are identified as having hemochromatosis through genetic screening of cheek-brush samples for HFE mutations are willing to undergo management and treatment, according to a prospective study.

Martin B. Delatycki, M.B., of the University of Melbourne, and his associates detected homozygous Cys282Tyr mutations in HFE in 51 of 11,307 individuals who attended workplace screening sessions; 4 patients were already aware of their condition. Almost all of the newly identified homozygous individuals (46 of 47) agreed to enter into an appropriate program of medical management. In homozygous patients, elevated fasting transferrin saturation levels were found in 19 of 23 men and 11 of 23 women. All patients with high levels of serum transferrin underwent regular phlebotomy to reduce ferritin levels to within the normal range. Liver biopsies performed in four of the six men who met criteria for a biopsy showed either advanced precirrhotic liver fibrosis or moderate hemosiderosis with mild portal fibrosis (Lancet 2005;366:314–6).

New-Onset Diabetes as Marker New onset of diabetes in patients older than 50 years has the potential to be a marker for early pancreatic cancer, reported Suresh T. Chari, M.D., and colleagues at the Mayo Clinic, Rochester, Minn.

In a review of 2,122 Rochester residents who were 50 years or older and developed diabetes at some point during 1950 through 1994, 18 (0.85%) went on to have pancreatic cancer. The cancer was identified an average of about 6 months after diabetes criteria were met. In 10 of those patients, the cancer was diagnosed less than 6 months after first meeting criteria for diabetes. The crude 3-year incidence of pancreatic cancer in patients with diabetes 50 years of age or older was 310 per 100,000 patient-years. Diabetic patients with pancreatic cancer were about 4.5 times more likely to have first met criteria for diabetes on or after age 70 years than were diabetic patients without pancreatic cancer (Gastroenterology 2005;129:504–11).

“For hyperglycemia to be a clinically useful marker of early cancer one will have to screen asymptomatic individuals for hyperglycemia,” and the success of the strategy “will depend largely on our ability to differentiate pancreatic cancer-induced diabetes from type 2 diabetes using a serologic marker,” the investigators wrote. “Because our population was neither screened for diabetes nor [screened] for pancreatic cancer, the benefit of screening for pancreatic cancer using diabetes or hyperglycemia as a marker cannot be answered by the present study and deserves a prospective analysis.”

Hereditary Colorectal Ca

The median age of onset of colorectal cancer in individuals of families with mismatch repair gene mutations for hereditary nonpolyposis colorectal cancer may be much older than previously reported, according to Heather Hampel, M.D., of Ohio State University, Columbus, and her colleagues.

The median age at diagnosis was 54 years in men and 70 years in women in a group of 70 Finnish families at risk for hereditary nonpolyposis colorectal cancer (HNPCC) that comprised 88 probands and 373 individuals who tested positive for a germline mutation in MLH1 or MSH2 (Gastroenterology 2005;129:415–21).

Those ages are 10–15 years higher than the previous estimates of age at onset for colorectal cancer among HNPCC patients in the literature, which are typically 44–45 years. “Our data strongly suggest that in the diagnosis of HNPCC, limiting molecular studies to patients with an early age at diagnosis will miss many cases,” the researchers wrote. Microsatellite instability and immunohistochemical staining “would best be applied to all new colorectal cancer cases and not just to a limited high-risk subset.”