Patrice Wendling

CHICAGO – A quick, computerized screening test for dementia may be one step closer to reality.

Researchers at the University of Florida Alzheimer's Center and Research Institute have developed the Dementia Screening Battery, a self-administered test that takes about 15 minutes to complete on a laptop computer.

In contrast, the currently widely used Mini-Mental State Examination (MMSE) is administered by a trained professional and can take up to 90 minutes to complete.

The computerized screener can be used with even severely demented populations, and all tests in the battery were based on tests in the public domain to minimize costs, principal investigator Dr. Kenneth M. Heilman and colleagues reported in a poster at the annual meeting of the American Academy of Neurology.

“The availability of a self-administered computerized cognitive screening test could improve public-health awareness of dementia and lead to earlier treatment, as well as reduce the burdens of time and staff training for primary care providers,” Dr. Heilman, distinguished professor and program director department of neurology, University of Florida, Gainesville, said in an interview.

The investigators tested the Dementia Screening Battery in 39 healthy adults (mean age 64 years) and 66 adults (mean age 72 years) who were diagnosed by a behavioral neurologist as having abnormal cognition, including mild cognitive impairment in 19, probable Alzheimer's disease in 17, and other dementias in 30.

All participants were given the MMSE, and assessed for ideomotor apraxia and executive dysfunction. The traditional Hopkins Verbal Learning Test and Boston Naming Test were given to 90% of patients and 62% of controls.

There were no significant differences between the screening battery and MMSE performance, although there was a trend for superior performance of the MMSE in identifying patients in the “other dementias” group, the investigators reported.

A laptop total score of 75 proved to be the optimal cutoff point, providing the maximal specificity (72%) and sensitivity (92%).

The area under the receiver operating characteristics (ROC) curve was high at 0.94 and comparable with the MMSE at 0.95.

Subtests of memory, naming, praxis, and orientation from the Dementia Screening Battery significantly correlated with standard domain-related neuropsychological tests. The Pearson Correlation between the laptop total score and the MMSE was significant at 0.80.

The investigators acknowledged the generally high level of education (mean 15 years) and computer literacy in the patients, who were selected from an academic referral practice. There also may have been a selection bias because of the consenting process, as patients who are intimidated by computers or whose dementia severity precluded their likelihood of successfully completing the test may have refused to participate.

Future steps include implementation of reaction times, the addition of more sensitive tests for frontal-executive dysfunction, simplification of the keyboard, and testing the device on a communitywide level.

All tests in the computerized battery were based on tests in the public domain to minimize costs. DR. HEILMAN

CHICAGO – A quick, computerized screening test for dementia may be one step closer to reality.

Researchers at the University of Florida Alzheimer's Center and Research Institute have developed the Dementia Screening Battery, a self-administered test that takes about 15 minutes to complete on a laptop computer.

In contrast, the currently widely used Mini-Mental State Examination (MMSE) is administered by a trained professional and can take up to 90 minutes to complete.

The computerized screener can be used with even severely demented populations, and all tests in the battery were based on tests in the public domain to minimize costs, principal investigator Dr. Kenneth M. Heilman and colleagues reported in a poster at the annual meeting of the American Academy of Neurology.

“The availability of a self-administered computerized cognitive screening test could improve public-health awareness of dementia and lead to earlier treatment, as well as reduce the burdens of time and staff training for primary care providers,” Dr. Heilman, distinguished professor and program director department of neurology, University of Florida, Gainesville, said in an interview.

The investigators tested the Dementia Screening Battery in 39 healthy adults (mean age 64 years) and 66 adults (mean age 72 years) who were diagnosed by a behavioral neurologist as having abnormal cognition, including mild cognitive impairment in 19, probable Alzheimer's disease in 17, and other dementias in 30.

All participants were given the MMSE, and assessed for ideomotor apraxia and executive dysfunction. The traditional Hopkins Verbal Learning Test and Boston Naming Test were given to 90% of patients and 62% of controls.

There were no significant differences between the screening battery and MMSE performance, although there was a trend for superior performance of the MMSE in identifying patients in the “other dementias” group, the investigators reported.

A laptop total score of 75 proved to be the optimal cutoff point, providing the maximal specificity (72%) and sensitivity (92%).

The area under the receiver operating characteristics (ROC) curve was high at 0.94 and comparable with the MMSE at 0.95.

Subtests of memory, naming, praxis, and orientation from the Dementia Screening Battery significantly correlated with standard domain-related neuropsychological tests. The Pearson Correlation between the laptop total score and the MMSE was significant at 0.80.

The investigators acknowledged the generally high level of education (mean 15 years) and computer literacy in the patients, who were selected from an academic referral practice. There also may have been a selection bias because of the consenting process, as patients who are intimidated by computers or whose dementia severity precluded their likelihood of successfully completing the test may have refused to participate.

Future steps include implementation of reaction times, the addition of more sensitive tests for frontal-executive dysfunction, simplification of the keyboard, and testing the device on a communitywide level.

All tests in the computerized battery were based on tests in the public domain to minimize costs. DR. HEILMAN

CHICAGO – A quick, computerized screening test for dementia may be one step closer to reality.

Researchers at the University of Florida Alzheimer's Center and Research Institute have developed the Dementia Screening Battery, a self-administered test that takes about 15 minutes to complete on a laptop computer.

In contrast, the currently widely used Mini-Mental State Examination (MMSE) is administered by a trained professional and can take up to 90 minutes to complete.

The computerized screener can be used with even severely demented populations, and all tests in the battery were based on tests in the public domain to minimize costs, principal investigator Dr. Kenneth M. Heilman and colleagues reported in a poster at the annual meeting of the American Academy of Neurology.

“The availability of a self-administered computerized cognitive screening test could improve public-health awareness of dementia and lead to earlier treatment, as well as reduce the burdens of time and staff training for primary care providers,” Dr. Heilman, distinguished professor and program director department of neurology, University of Florida, Gainesville, said in an interview.

The investigators tested the Dementia Screening Battery in 39 healthy adults (mean age 64 years) and 66 adults (mean age 72 years) who were diagnosed by a behavioral neurologist as having abnormal cognition, including mild cognitive impairment in 19, probable Alzheimer's disease in 17, and other dementias in 30.

All participants were given the MMSE, and assessed for ideomotor apraxia and executive dysfunction. The traditional Hopkins Verbal Learning Test and Boston Naming Test were given to 90% of patients and 62% of controls.

There were no significant differences between the screening battery and MMSE performance, although there was a trend for superior performance of the MMSE in identifying patients in the “other dementias” group, the investigators reported.

A laptop total score of 75 proved to be the optimal cutoff point, providing the maximal specificity (72%) and sensitivity (92%).

The area under the receiver operating characteristics (ROC) curve was high at 0.94 and comparable with the MMSE at 0.95.

Subtests of memory, naming, praxis, and orientation from the Dementia Screening Battery significantly correlated with standard domain-related neuropsychological tests. The Pearson Correlation between the laptop total score and the MMSE was significant at 0.80.

The investigators acknowledged the generally high level of education (mean 15 years) and computer literacy in the patients, who were selected from an academic referral practice. There also may have been a selection bias because of the consenting process, as patients who are intimidated by computers or whose dementia severity precluded their likelihood of successfully completing the test may have refused to participate.

Future steps include implementation of reaction times, the addition of more sensitive tests for frontal-executive dysfunction, simplification of the keyboard, and testing the device on a communitywide level.

All tests in the computerized battery were based on tests in the public domain to minimize costs. DR. HEILMAN

CHICAGO — Placing an automated external defibrillator in the homes of patients with a previous anterior wall MI did not reduce mortality in a large randomized, multicenter trial.

The primary end point of death from any cause was not significantly different between patients who were randomized to the control response of calling emergency medical services and performing CPR, and patients who were randomized to use of an automated external defibrillator (AED), followed by calling emergency services and performing CPR.

With a median follow-up of 37 months, 228 of the 3,506 (6.5%) patients in the control group died, compared with 222 of the 3,495 (6.4%) patients in the AED group (hazard ratio 0.97), principal investigator Dr. Gust H. Bardy and his associates reported at the annual meeting of the American College of Cardiology.

Of the 450 deaths in the Home Automated External Defibrillator Trial (HAT), cardiac death occurred in 129 patients in the control arm and in 138 patients in the AED group; noncardiac death occurred in 89 control patients and 81 AED patients; and tachyarrhythmia occurred in 84 control patients and 85 AED patients. Thirteen deaths could not be classified.

Patients enrolled in HAT were not candidates for implantation of a cardioverter-defibrillator. In addition, unlike standard care, they were advised about the risk of sudden cardiac arrest, said Dr. Bardy of the Seattle Institute for Cardiac Research. The patients' median age was 62 years, and their median left ventricular ejection fraction was 45%.

AEDs were used in 32 patients, of which 14 received an appropriate shock. Of those 14 patients, 9 died within 48 hours, 1 died 48 hours after shock was delivered, and only 4 (28.6%) survived to the study's end. There were no inappropriate shocks in the study, which was sponsored by the National Heart, Lung, and Blood Institute and performed at 178 clinical sites in seven countries. Of note, AEDs were used by neighbors or visitors in seven patients in cardiac arrest, and two of those patients survived long term, he said.

With the exception of diabetes, there was no significant interaction between AED use and any outcome with regard to age (65 years or older vs. younger than 65 years), gender, Q-wave versus non-Q-wave MI status, heart failure class, revascularization, or nationality (United States vs. all other countries).

The lack of benefit observed with home AED therapy in HAT is likely attributable to the lower than expected rate of overall mortality and sudden cardiac arrest, Dr. Bardy explained. This probably reflects the participants' excellent adherence to pharmacologic therapies, such as β-blockers, ACE inhibitors, and statins; their high rate of previous revascularization (72%); and their increased awareness of the risk of sudden cardiac death.

In addition, the study was based on the assumption that patients would be at home and in the presence of their spouses or partners more than 50% of the time. In reality, only 117 events occurred at home, and only 58 of those were witnessed. About one-third of deaths started at night, and many of the daytime patients were in asystole, said Dr. Bardy, who disclosed relationships with Cameron Health Inc.

Dr. Bruce D. Lindsay, a discussant and director of cardiac electrophysiology at Washington University, St. Louis, asked Dr. Bardy to speculate on whether there would be a benefit in recommending home AEDs for higher-risk MI patients during the 3-month period recommended in the guidelines before primary prevention therapy can begin. Dr. Bardy responded that there is no downside to the device and that all MI patients should be made aware of the risk of sudden cardiac arrest and CPR techniques.

“They need to know that this is only one small part of their overall care post MI,” he said. Based on the data, however, he said he couldn't vigorously recommend that high-risk patients buy a home AED. “But I wouldn't argue against it, if someone wanted to do it.”

Anecdotally, families were happy to have a home AED, he said, even if the patient ultimately died. Survivors were “ebullient” that it was available.

In two cases, the device advised the spouse or partner not to shock, and the patient died. In one case, the patient inadvertently turned off the device.

CHICAGO — Placing an automated external defibrillator in the homes of patients with a previous anterior wall MI did not reduce mortality in a large randomized, multicenter trial.

The primary end point of death from any cause was not significantly different between patients who were randomized to the control response of calling emergency medical services and performing CPR, and patients who were randomized to use of an automated external defibrillator (AED), followed by calling emergency services and performing CPR.

With a median follow-up of 37 months, 228 of the 3,506 (6.5%) patients in the control group died, compared with 222 of the 3,495 (6.4%) patients in the AED group (hazard ratio 0.97), principal investigator Dr. Gust H. Bardy and his associates reported at the annual meeting of the American College of Cardiology.

Of the 450 deaths in the Home Automated External Defibrillator Trial (HAT), cardiac death occurred in 129 patients in the control arm and in 138 patients in the AED group; noncardiac death occurred in 89 control patients and 81 AED patients; and tachyarrhythmia occurred in 84 control patients and 85 AED patients. Thirteen deaths could not be classified.

Patients enrolled in HAT were not candidates for implantation of a cardioverter-defibrillator. In addition, unlike standard care, they were advised about the risk of sudden cardiac arrest, said Dr. Bardy of the Seattle Institute for Cardiac Research. The patients' median age was 62 years, and their median left ventricular ejection fraction was 45%.

AEDs were used in 32 patients, of which 14 received an appropriate shock. Of those 14 patients, 9 died within 48 hours, 1 died 48 hours after shock was delivered, and only 4 (28.6%) survived to the study's end. There were no inappropriate shocks in the study, which was sponsored by the National Heart, Lung, and Blood Institute and performed at 178 clinical sites in seven countries. Of note, AEDs were used by neighbors or visitors in seven patients in cardiac arrest, and two of those patients survived long term, he said.

With the exception of diabetes, there was no significant interaction between AED use and any outcome with regard to age (65 years or older vs. younger than 65 years), gender, Q-wave versus non-Q-wave MI status, heart failure class, revascularization, or nationality (United States vs. all other countries).

The lack of benefit observed with home AED therapy in HAT is likely attributable to the lower than expected rate of overall mortality and sudden cardiac arrest, Dr. Bardy explained. This probably reflects the participants' excellent adherence to pharmacologic therapies, such as β-blockers, ACE inhibitors, and statins; their high rate of previous revascularization (72%); and their increased awareness of the risk of sudden cardiac death.

In addition, the study was based on the assumption that patients would be at home and in the presence of their spouses or partners more than 50% of the time. In reality, only 117 events occurred at home, and only 58 of those were witnessed. About one-third of deaths started at night, and many of the daytime patients were in asystole, said Dr. Bardy, who disclosed relationships with Cameron Health Inc.

Dr. Bruce D. Lindsay, a discussant and director of cardiac electrophysiology at Washington University, St. Louis, asked Dr. Bardy to speculate on whether there would be a benefit in recommending home AEDs for higher-risk MI patients during the 3-month period recommended in the guidelines before primary prevention therapy can begin. Dr. Bardy responded that there is no downside to the device and that all MI patients should be made aware of the risk of sudden cardiac arrest and CPR techniques.

“They need to know that this is only one small part of their overall care post MI,” he said. Based on the data, however, he said he couldn't vigorously recommend that high-risk patients buy a home AED. “But I wouldn't argue against it, if someone wanted to do it.”

Anecdotally, families were happy to have a home AED, he said, even if the patient ultimately died. Survivors were “ebullient” that it was available.

In two cases, the device advised the spouse or partner not to shock, and the patient died. In one case, the patient inadvertently turned off the device.

CHICAGO — Placing an automated external defibrillator in the homes of patients with a previous anterior wall MI did not reduce mortality in a large randomized, multicenter trial.

The primary end point of death from any cause was not significantly different between patients who were randomized to the control response of calling emergency medical services and performing CPR, and patients who were randomized to use of an automated external defibrillator (AED), followed by calling emergency services and performing CPR.

With a median follow-up of 37 months, 228 of the 3,506 (6.5%) patients in the control group died, compared with 222 of the 3,495 (6.4%) patients in the AED group (hazard ratio 0.97), principal investigator Dr. Gust H. Bardy and his associates reported at the annual meeting of the American College of Cardiology.

Of the 450 deaths in the Home Automated External Defibrillator Trial (HAT), cardiac death occurred in 129 patients in the control arm and in 138 patients in the AED group; noncardiac death occurred in 89 control patients and 81 AED patients; and tachyarrhythmia occurred in 84 control patients and 85 AED patients. Thirteen deaths could not be classified.

Patients enrolled in HAT were not candidates for implantation of a cardioverter-defibrillator. In addition, unlike standard care, they were advised about the risk of sudden cardiac arrest, said Dr. Bardy of the Seattle Institute for Cardiac Research. The patients' median age was 62 years, and their median left ventricular ejection fraction was 45%.

AEDs were used in 32 patients, of which 14 received an appropriate shock. Of those 14 patients, 9 died within 48 hours, 1 died 48 hours after shock was delivered, and only 4 (28.6%) survived to the study's end. There were no inappropriate shocks in the study, which was sponsored by the National Heart, Lung, and Blood Institute and performed at 178 clinical sites in seven countries. Of note, AEDs were used by neighbors or visitors in seven patients in cardiac arrest, and two of those patients survived long term, he said.

With the exception of diabetes, there was no significant interaction between AED use and any outcome with regard to age (65 years or older vs. younger than 65 years), gender, Q-wave versus non-Q-wave MI status, heart failure class, revascularization, or nationality (United States vs. all other countries).

The lack of benefit observed with home AED therapy in HAT is likely attributable to the lower than expected rate of overall mortality and sudden cardiac arrest, Dr. Bardy explained. This probably reflects the participants' excellent adherence to pharmacologic therapies, such as β-blockers, ACE inhibitors, and statins; their high rate of previous revascularization (72%); and their increased awareness of the risk of sudden cardiac death.

In addition, the study was based on the assumption that patients would be at home and in the presence of their spouses or partners more than 50% of the time. In reality, only 117 events occurred at home, and only 58 of those were witnessed. About one-third of deaths started at night, and many of the daytime patients were in asystole, said Dr. Bardy, who disclosed relationships with Cameron Health Inc.

Dr. Bruce D. Lindsay, a discussant and director of cardiac electrophysiology at Washington University, St. Louis, asked Dr. Bardy to speculate on whether there would be a benefit in recommending home AEDs for higher-risk MI patients during the 3-month period recommended in the guidelines before primary prevention therapy can begin. Dr. Bardy responded that there is no downside to the device and that all MI patients should be made aware of the risk of sudden cardiac arrest and CPR techniques.

“They need to know that this is only one small part of their overall care post MI,” he said. Based on the data, however, he said he couldn't vigorously recommend that high-risk patients buy a home AED. “But I wouldn't argue against it, if someone wanted to do it.”

Anecdotally, families were happy to have a home AED, he said, even if the patient ultimately died. Survivors were “ebullient” that it was available.

In two cases, the device advised the spouse or partner not to shock, and the patient died. In one case, the patient inadvertently turned off the device.

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were not aware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns that occur in diabetes patients are the result of insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were not aware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns that occur in diabetes patients are the result of insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were not aware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns that occur in diabetes patients are the result of insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Evidence continues to mount that dopaminergic therapy increases the odds of impulse control disorders in patients with Parkinson's disease.

Dopamine agonist (DA)-treated patients had two- to threefold elevated odds of having a current impulse control disorder (ICD), compared with non-DA-treated patients (17% vs. 7%, odds ratio 2.72, P less than .001) in an international, cross-sectional study of 3,090 patients with idiopathic Parkinson's disease.

This pattern was observed across all four impulse control disorders assessed: pathological gambling (3.5% vs. 1.6%, OR 2.15), compulsive sexual behavior (4.4% vs. 1.7%, OR 2.59), compulsive buying (7.2% vs. 2.9%, OR 2.53), and binge-eating disorder (5.6% vs. 1.7%, OR 3.34), Dr. Daniel Weintraub and associates reported in a late-breaking poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Previous case reports and cross-sectional studies have suggested an association between DA treatment and ICDs in Parkinson's.

However, they have typically assessed convenience samples of patients, have had relatively small sample sizes, and have not concurrently assessed for all commonly reported ICDs in Parkinson's, according to Dr. Weintraub, a psychiatrist at the University of Pennsylvania, Philadelphia.

Patients in the current study were prospectively recruited from 46 movement disorder centers in the United States and Canada, and assessed using a modified Massachusetts Gambling Screen, a modified Minnesota Impulsive Disorders Interview for compulsive sexual behavior and buying, and DSM-IV Text-Revised proposed research criteria for binge eating.

Their mean age was 64 years, 420 patients (14%) had at least one current ICD, and 36% of patients with an ICD had more than one.

ICD frequencies were similar in patients treated with pramipexole (228 of 1,286, 18%) ropinirole (101/651, 16%) and pergolide (11/50, 22%), suggesting that DA treatment as a class may be a risk factor for ICD development in Parkinson's, the authors concluded.

An ICD was present in 18% of patients taking both a DA and levodopa, 14% of patients taking a dopamine agonist without levodopa, and 7% of patients taking levodopa without a DA.

Dr. Weintraub said that physicians should notify patients that ICDs are a potential adverse event associated with dopamine-agonist and levodopa treatment, and should conduct routine questioning in the context of clinical care.

Dr. Weintraub acknowledged that ICDs have been reported as a complication of deep brain stimulation, but said most patients with an ICD prior to surgery do better after surgery, probably because of decreased medication.

In a logistic regression analysis, independent risk factors for ICD development included: age of 65 years or younger (OR 2.39), dopamine agonist treatment (OR 2.76) and higher DA dosage (greater than 150 mg, OR 2.15), levodopa treatment (OR 1.53) and higher levodopa dosage (greater than 450 mg, OR 1.45), not being married (OR 1.47), and self-reported family history of gambling problems (OR 2.21).

The study was funded by Boehringer Ingelheim. Dr. Weintraub has received consulting fees, honoraria, or grant support from Boehringer Ingelheim, BrainCells, EMD Serono, Novartis, Ovation, and Wyeth.

Impulse Control Disorders Often Go Undiagnosed

Impulse control disorders in Parkinson's disease are often undiagnosed as patients tend to deny or minimize their existence, according to Dr. Howard D. Weiss, a neurologist with Sinai Hospital in Baltimore.

Among 165 patients with idiopathic Parkinson's followed in community-based neurology practices, 23 (14%) were diagnosed with a current or past impulse control disorder (ICD). Nine patients had multiple ICD diagnoses.

However, only 10 cases were identified before participation in the study, according to Dr. Weiss, who reported the findings in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

In 12 cases, the family member was the crucial source of information necessary to make the diagnosis. “We often lack the time or [fail to] ask the right questions,” Dr. Weiss said in an interview.

In one case, a daughter reported that her father was spending large amounts of money at the race track. When specifically asked if he went to the track, said he had no reason to go because he didn't gamble.

Another patient said she was a churchgoer and didn't believe in gambling. However, when asked if she bought lottery tickets, she admitted to spending $200 a week on tickets and said they were like a magnet she couldn't resist.

Patients with a current or past ICD were significantly younger than were those without an ICD (mean 60 vs. 67 years), had an earlier age of Parkinson's onset (50 vs. 60 years) and diagnosis (51 vs. 61 years), had longer disease duration (10.3 vs. 7 years), had worse Unified Parkinson's Disease Rating Scale motor scores (23.4 vs. 17.5), and used higher doses of dopaminergic medications (917 vs. 589 total daily L-dopa equivalents).

Patients treated with dopamine agonists had an increased odds of developing an ICD (odds ratio 7.1). The odds increased further with a combination of a dopamine agonist and L-dopa (OR 9.9). Levodopa alone was not significantly associated with an ICD.

CHICAGO — Evidence continues to mount that dopaminergic therapy increases the odds of impulse control disorders in patients with Parkinson's disease.

Dopamine agonist (DA)-treated patients had two- to threefold elevated odds of having a current impulse control disorder (ICD), compared with non-DA-treated patients (17% vs. 7%, odds ratio 2.72, P less than .001) in an international, cross-sectional study of 3,090 patients with idiopathic Parkinson's disease.

This pattern was observed across all four impulse control disorders assessed: pathological gambling (3.5% vs. 1.6%, OR 2.15), compulsive sexual behavior (4.4% vs. 1.7%, OR 2.59), compulsive buying (7.2% vs. 2.9%, OR 2.53), and binge-eating disorder (5.6% vs. 1.7%, OR 3.34), Dr. Daniel Weintraub and associates reported in a late-breaking poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Previous case reports and cross-sectional studies have suggested an association between DA treatment and ICDs in Parkinson's.

However, they have typically assessed convenience samples of patients, have had relatively small sample sizes, and have not concurrently assessed for all commonly reported ICDs in Parkinson's, according to Dr. Weintraub, a psychiatrist at the University of Pennsylvania, Philadelphia.

Patients in the current study were prospectively recruited from 46 movement disorder centers in the United States and Canada, and assessed using a modified Massachusetts Gambling Screen, a modified Minnesota Impulsive Disorders Interview for compulsive sexual behavior and buying, and DSM-IV Text-Revised proposed research criteria for binge eating.

Their mean age was 64 years, 420 patients (14%) had at least one current ICD, and 36% of patients with an ICD had more than one.

ICD frequencies were similar in patients treated with pramipexole (228 of 1,286, 18%) ropinirole (101/651, 16%) and pergolide (11/50, 22%), suggesting that DA treatment as a class may be a risk factor for ICD development in Parkinson's, the authors concluded.

An ICD was present in 18% of patients taking both a DA and levodopa, 14% of patients taking a dopamine agonist without levodopa, and 7% of patients taking levodopa without a DA.

Dr. Weintraub said that physicians should notify patients that ICDs are a potential adverse event associated with dopamine-agonist and levodopa treatment, and should conduct routine questioning in the context of clinical care.

Dr. Weintraub acknowledged that ICDs have been reported as a complication of deep brain stimulation, but said most patients with an ICD prior to surgery do better after surgery, probably because of decreased medication.

In a logistic regression analysis, independent risk factors for ICD development included: age of 65 years or younger (OR 2.39), dopamine agonist treatment (OR 2.76) and higher DA dosage (greater than 150 mg, OR 2.15), levodopa treatment (OR 1.53) and higher levodopa dosage (greater than 450 mg, OR 1.45), not being married (OR 1.47), and self-reported family history of gambling problems (OR 2.21).

The study was funded by Boehringer Ingelheim. Dr. Weintraub has received consulting fees, honoraria, or grant support from Boehringer Ingelheim, BrainCells, EMD Serono, Novartis, Ovation, and Wyeth.

Impulse Control Disorders Often Go Undiagnosed

Impulse control disorders in Parkinson's disease are often undiagnosed as patients tend to deny or minimize their existence, according to Dr. Howard D. Weiss, a neurologist with Sinai Hospital in Baltimore.

Among 165 patients with idiopathic Parkinson's followed in community-based neurology practices, 23 (14%) were diagnosed with a current or past impulse control disorder (ICD). Nine patients had multiple ICD diagnoses.

However, only 10 cases were identified before participation in the study, according to Dr. Weiss, who reported the findings in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

In 12 cases, the family member was the crucial source of information necessary to make the diagnosis. “We often lack the time or [fail to] ask the right questions,” Dr. Weiss said in an interview.

In one case, a daughter reported that her father was spending large amounts of money at the race track. When specifically asked if he went to the track, said he had no reason to go because he didn't gamble.

Another patient said she was a churchgoer and didn't believe in gambling. However, when asked if she bought lottery tickets, she admitted to spending $200 a week on tickets and said they were like a magnet she couldn't resist.

Patients with a current or past ICD were significantly younger than were those without an ICD (mean 60 vs. 67 years), had an earlier age of Parkinson's onset (50 vs. 60 years) and diagnosis (51 vs. 61 years), had longer disease duration (10.3 vs. 7 years), had worse Unified Parkinson's Disease Rating Scale motor scores (23.4 vs. 17.5), and used higher doses of dopaminergic medications (917 vs. 589 total daily L-dopa equivalents).

Patients treated with dopamine agonists had an increased odds of developing an ICD (odds ratio 7.1). The odds increased further with a combination of a dopamine agonist and L-dopa (OR 9.9). Levodopa alone was not significantly associated with an ICD.

CHICAGO — Evidence continues to mount that dopaminergic therapy increases the odds of impulse control disorders in patients with Parkinson's disease.

Dopamine agonist (DA)-treated patients had two- to threefold elevated odds of having a current impulse control disorder (ICD), compared with non-DA-treated patients (17% vs. 7%, odds ratio 2.72, P less than .001) in an international, cross-sectional study of 3,090 patients with idiopathic Parkinson's disease.

This pattern was observed across all four impulse control disorders assessed: pathological gambling (3.5% vs. 1.6%, OR 2.15), compulsive sexual behavior (4.4% vs. 1.7%, OR 2.59), compulsive buying (7.2% vs. 2.9%, OR 2.53), and binge-eating disorder (5.6% vs. 1.7%, OR 3.34), Dr. Daniel Weintraub and associates reported in a late-breaking poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

Previous case reports and cross-sectional studies have suggested an association between DA treatment and ICDs in Parkinson's.

However, they have typically assessed convenience samples of patients, have had relatively small sample sizes, and have not concurrently assessed for all commonly reported ICDs in Parkinson's, according to Dr. Weintraub, a psychiatrist at the University of Pennsylvania, Philadelphia.

Patients in the current study were prospectively recruited from 46 movement disorder centers in the United States and Canada, and assessed using a modified Massachusetts Gambling Screen, a modified Minnesota Impulsive Disorders Interview for compulsive sexual behavior and buying, and DSM-IV Text-Revised proposed research criteria for binge eating.

Their mean age was 64 years, 420 patients (14%) had at least one current ICD, and 36% of patients with an ICD had more than one.

ICD frequencies were similar in patients treated with pramipexole (228 of 1,286, 18%) ropinirole (101/651, 16%) and pergolide (11/50, 22%), suggesting that DA treatment as a class may be a risk factor for ICD development in Parkinson's, the authors concluded.

An ICD was present in 18% of patients taking both a DA and levodopa, 14% of patients taking a dopamine agonist without levodopa, and 7% of patients taking levodopa without a DA.

Dr. Weintraub said that physicians should notify patients that ICDs are a potential adverse event associated with dopamine-agonist and levodopa treatment, and should conduct routine questioning in the context of clinical care.

Dr. Weintraub acknowledged that ICDs have been reported as a complication of deep brain stimulation, but said most patients with an ICD prior to surgery do better after surgery, probably because of decreased medication.

In a logistic regression analysis, independent risk factors for ICD development included: age of 65 years or younger (OR 2.39), dopamine agonist treatment (OR 2.76) and higher DA dosage (greater than 150 mg, OR 2.15), levodopa treatment (OR 1.53) and higher levodopa dosage (greater than 450 mg, OR 1.45), not being married (OR 1.47), and self-reported family history of gambling problems (OR 2.21).

The study was funded by Boehringer Ingelheim. Dr. Weintraub has received consulting fees, honoraria, or grant support from Boehringer Ingelheim, BrainCells, EMD Serono, Novartis, Ovation, and Wyeth.

Impulse Control Disorders Often Go Undiagnosed

Impulse control disorders in Parkinson's disease are often undiagnosed as patients tend to deny or minimize their existence, according to Dr. Howard D. Weiss, a neurologist with Sinai Hospital in Baltimore.

Among 165 patients with idiopathic Parkinson's followed in community-based neurology practices, 23 (14%) were diagnosed with a current or past impulse control disorder (ICD). Nine patients had multiple ICD diagnoses.

However, only 10 cases were identified before participation in the study, according to Dr. Weiss, who reported the findings in a poster at the 12th International Congress of Parkinson's Disease and Movement Disorders.

In 12 cases, the family member was the crucial source of information necessary to make the diagnosis. “We often lack the time or [fail to] ask the right questions,” Dr. Weiss said in an interview.

In one case, a daughter reported that her father was spending large amounts of money at the race track. When specifically asked if he went to the track, said he had no reason to go because he didn't gamble.

Another patient said she was a churchgoer and didn't believe in gambling. However, when asked if she bought lottery tickets, she admitted to spending $200 a week on tickets and said they were like a magnet she couldn't resist.

Patients with a current or past ICD were significantly younger than were those without an ICD (mean 60 vs. 67 years), had an earlier age of Parkinson's onset (50 vs. 60 years) and diagnosis (51 vs. 61 years), had longer disease duration (10.3 vs. 7 years), had worse Unified Parkinson's Disease Rating Scale motor scores (23.4 vs. 17.5), and used higher doses of dopaminergic medications (917 vs. 589 total daily L-dopa equivalents).

Patients treated with dopamine agonists had an increased odds of developing an ICD (odds ratio 7.1). The odds increased further with a combination of a dopamine agonist and L-dopa (OR 9.9). Levodopa alone was not significantly associated with an ICD.

CHICAGO — High-dose dexamethasone pulse therapy is a good alternative to daily prednisone as first-line treatment of subacute inflammatory myopathies, Dr. Janneke van de Vlekkert reported at the annual meeting of the American Academy of Neurology.

In a prospective, multicenter, double-blind trial of 62 newly diagnosed adults with dermatomyositis or nonspecific myositis, significant difference was seen at 18 months in the composite score of six clinical outcome measures among patients receiving prednisone 70 or 90 mg/day versus those who received six cycles of oral dexamethasone 40 mg/day for 4 consecutive days at 28-day intervals.

The mean composite score was 2.8 (median 2.0) in both treatment groups, Dr. van de Vlekkert and associates reported.

No significant differences were observed among the 30 patients treated with dexamethasone and the 32 treated with prednisone for the six outcomes that comprised the composite score. These included remission (5 vs. 9 patients, respectively), remission less than 3 months (2 vs. 3 patients), no relapse (16 vs. 20 patients), Medical Research Council sum score at least 138 out of 140 (16 vs. 16 patients), visual analog scale score of 0-2 for muscle pain (18 vs. 13 patients), and no cushingoid appearance (18 vs. 13 patients).

The mean time until remission was 58 weeks in both groups, while the median time until relapse was 44 weeks in the dexamethasone group and 60 weeks in the prednisone group.

Based on these findings, the study was halted prematurely after inclusion of 62 patients instead of the planned 80 patients.

Side effects occurred in significantly fewer patients treated with dexamethasone than in patients with prednisone, including any side effect (22 vs. 29, respectively), diabetes mellitus (1 vs. 10), and mood changes (8 vs. 20), Dr. van de Vlekkert of the Academic Medical Center, Amsterdam, and associates reported.

The improved side effect profile is notable, as daily high-dose prednisone is the standard treatment of subacute inflammatory myopathies, and major drawbacks of long-term therapy with prednisone are its side effects, the investigators noted.

Dr. van de Vlekkert disclosed no conflict of interest related to the study, which was supported by the Princess Beatrix Fund, the Hague, the Netherlands.

CHICAGO — High-dose dexamethasone pulse therapy is a good alternative to daily prednisone as first-line treatment of subacute inflammatory myopathies, Dr. Janneke van de Vlekkert reported at the annual meeting of the American Academy of Neurology.

In a prospective, multicenter, double-blind trial of 62 newly diagnosed adults with dermatomyositis or nonspecific myositis, significant difference was seen at 18 months in the composite score of six clinical outcome measures among patients receiving prednisone 70 or 90 mg/day versus those who received six cycles of oral dexamethasone 40 mg/day for 4 consecutive days at 28-day intervals.

The mean composite score was 2.8 (median 2.0) in both treatment groups, Dr. van de Vlekkert and associates reported.

No significant differences were observed among the 30 patients treated with dexamethasone and the 32 treated with prednisone for the six outcomes that comprised the composite score. These included remission (5 vs. 9 patients, respectively), remission less than 3 months (2 vs. 3 patients), no relapse (16 vs. 20 patients), Medical Research Council sum score at least 138 out of 140 (16 vs. 16 patients), visual analog scale score of 0-2 for muscle pain (18 vs. 13 patients), and no cushingoid appearance (18 vs. 13 patients).

The mean time until remission was 58 weeks in both groups, while the median time until relapse was 44 weeks in the dexamethasone group and 60 weeks in the prednisone group.

Based on these findings, the study was halted prematurely after inclusion of 62 patients instead of the planned 80 patients.

Side effects occurred in significantly fewer patients treated with dexamethasone than in patients with prednisone, including any side effect (22 vs. 29, respectively), diabetes mellitus (1 vs. 10), and mood changes (8 vs. 20), Dr. van de Vlekkert of the Academic Medical Center, Amsterdam, and associates reported.

The improved side effect profile is notable, as daily high-dose prednisone is the standard treatment of subacute inflammatory myopathies, and major drawbacks of long-term therapy with prednisone are its side effects, the investigators noted.

Dr. van de Vlekkert disclosed no conflict of interest related to the study, which was supported by the Princess Beatrix Fund, the Hague, the Netherlands.

CHICAGO — High-dose dexamethasone pulse therapy is a good alternative to daily prednisone as first-line treatment of subacute inflammatory myopathies, Dr. Janneke van de Vlekkert reported at the annual meeting of the American Academy of Neurology.

In a prospective, multicenter, double-blind trial of 62 newly diagnosed adults with dermatomyositis or nonspecific myositis, significant difference was seen at 18 months in the composite score of six clinical outcome measures among patients receiving prednisone 70 or 90 mg/day versus those who received six cycles of oral dexamethasone 40 mg/day for 4 consecutive days at 28-day intervals.

The mean composite score was 2.8 (median 2.0) in both treatment groups, Dr. van de Vlekkert and associates reported.

No significant differences were observed among the 30 patients treated with dexamethasone and the 32 treated with prednisone for the six outcomes that comprised the composite score. These included remission (5 vs. 9 patients, respectively), remission less than 3 months (2 vs. 3 patients), no relapse (16 vs. 20 patients), Medical Research Council sum score at least 138 out of 140 (16 vs. 16 patients), visual analog scale score of 0-2 for muscle pain (18 vs. 13 patients), and no cushingoid appearance (18 vs. 13 patients).

The mean time until remission was 58 weeks in both groups, while the median time until relapse was 44 weeks in the dexamethasone group and 60 weeks in the prednisone group.

Based on these findings, the study was halted prematurely after inclusion of 62 patients instead of the planned 80 patients.

Side effects occurred in significantly fewer patients treated with dexamethasone than in patients with prednisone, including any side effect (22 vs. 29, respectively), diabetes mellitus (1 vs. 10), and mood changes (8 vs. 20), Dr. van de Vlekkert of the Academic Medical Center, Amsterdam, and associates reported.

The improved side effect profile is notable, as daily high-dose prednisone is the standard treatment of subacute inflammatory myopathies, and major drawbacks of long-term therapy with prednisone are its side effects, the investigators noted.

Dr. van de Vlekkert disclosed no conflict of interest related to the study, which was supported by the Princess Beatrix Fund, the Hague, the Netherlands.

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating initially minor foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns in diabetic patients result from insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating initially minor foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns in diabetic patients result from insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns and once a burn occurs, the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

“You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem,” he said. “This is a duration-of-contact problem.”

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating initially minor foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

“This is not only a disease that leaves a scar, but a disease that won't heal,” he said. “These are high-risk patients and once you have a wound, it can lead to a cascade of events.

“One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation,” said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005. Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%–15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1–25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations. There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

“All diabetic patients should be taught about the risk of foot burns,” Dr. Greenhalgh concluded. “All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet.”

Most foot burns in diabetic patients result from insensate feet. Courtesy Dr. David Greenhalgh

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng

CHICAGO — Use of the Versajet Hydrosurgery system was associated with less blood loss and a larger area of excision than was the Goulian-Weck knife in a retrospective study of 50 patients with burn wounds.

The average estimated blood loss was 174 mL for patients who had their wounds excised with the Versajet system, compared with 659 mL for wounds excised with a Goulian-Weck knife. The difference was significant, Dr. Laura S. Johnson said at the annual meeting of the American Burn Association.

The study's primary end point of blood loss in milliliters as a function of area excised in centimeters squared was significantly lower in the Versajet group than in the Goulian-Weck knife group (mean 0.28 cc/cm

The findings suggest that the Versajet system could allow for earlier excision of burn wounds, perhaps as early as the resuscitation period, Dr. Johnson and her colleagues at the burn center of the Washington (D.C.) Hospital Center concluded.

Dr. James Jeng, associate director of the burn center, said in an interview that they've used the Versajet system since it gained U.S. approval for wound debridement roughly 2 years ago, and that its biggest benefit lies in its ability to discriminate between live and dead tissue.

"This knife is not dumb; it just doesn't cut where you put it, but discriminates between live and dead tissue based on tensile strength," he said. "Necrotic tissue has lower tensile strength, so we can dial down the strength [of the water jet] to partition live from dead tissue. It's pretty much replaced the cold knife for me. This is a poor man's laser ablation."

The Versajet system uses a pressure pump to force a stream of sterile saline through a small jet nozzle at the end of a handpiece, producing both a high-velocity stream and a local vacuum on the surface of the debridement area. The stream is directed backward across the operating window and into an evacuation collector tube in the handpiece, which also collects any debris or contaminants.

The review included 50 patients (mean age 40 years) with full- and split-thickness burns ranging in percentage of total body surface area from 5% to more than 50%. Excisions were performed as early as day 1, and were carried out over a 6-month period by Dr. Jeng.

Researchers calculated the estimated blood loss (EBL) by using blood-soaked laparotomy tapes for patients undergoing Goulian-Weck knife excision and by measuring the fluid in the evacuation tube and subtracting the amount of saline used during excision.

Dr. Johnson, a surgical resident, noted that the EBL for the Goulian-Weck knife group was higher than in published reports. However, the EBL for the Versajet group was significantly lower than traditional literature results for early excision, suggesting that the Versajet system does have benefit during this period, she said.

Dr. Jeng said that pre- and postoperative hematocrit levels don't take into account intraoperative fluid administration and equilibration issues, and that his group is looking into intraoperative optical recording and colorimetric cineanalysis for future studies.

The investigators received no funding for the study, and disclosed no relevant conflicts of interest.

Versajet discriminates between live and dead tissue based on tensile strength. Courtesy Dr. James Jeng

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — Patients with diabetes have an increased risk for foot burns, and once a burn occurs the morbidity and mortality are quite high, Dr. David Greenhalgh said at the annual meeting of the American Burn Association.

A patient might sustain a foot burn without being aware of the injury because of impaired sensation in the feet. Insensate feet lead to prolonged exposure and deeper burns. Walking on hot surfaces, soaking in hot water, and even car heaters can cause foot burns.

"You don't feel the pain after soaking your feet for a half-hour, and that leads to the problem," he said. "This is a duration-of-contact problem."

The neurovascular changes associated with diabetes might also lead to impaired burn wound healing. Impaired healing leads to higher graft loss and an increased risk of amputation, said Dr. Greenhalgh, professor and chief of burn surgery, University of California Davis Medical Center, Sacramento.

Dr. Greenhalgh described his own experiences treating small foot burn cases, including a patient with insensate feet who had been admitted for walking on hot asphalt, which resulted in transmetatarsal and below-knee amputations.

Another patient with insensate feet returned home from a walk over hot rocks at a river bed to discover blood oozing from his feet. After lengthy treatment, four of the patient's toes were amputated.

"This is not only a disease that leaves a scar, but a disease that won't heal," he said. "These are high-risk patients and once you have a wound, it can lead to a cascade of events.

"One minute you've got a patient with ulcers between the toes, the next you're sticking a hemostat up their foot draining pus out of their plantar, and then you're doing a below-the-knee amputation," said Dr. Greenhalgh.

He reported on a chart review of 27 patients, mean age 52 years, with diabetes who sustained foot burns from January 2000 to December 2005.

Of these, 22 (81%) had burns resulting from insensate feet. In 16 patients, including 15 with insensate burns, the patients were unaware of their feet having been injured, he said.

Burns were caused by soaking feet in hot water (7), putting feet near a heater or a radiator (6), walking on a hot surface (2), having contact with a heating pad (1), and being exposed to other sources (11).

Most (93%) of the patients were male, 16 were taking insulin, and 6 were diagnosed as having insulin-dependent diabetes.

Mean burn size was 4.7% of total body surface area (range 0.5%-15%), and 69% were full-thickness burns. Despite the small burn size, the mean length of hospital stay was 10 days (range 1-25) and 11 days for the insensate burns.

Skin grafting was required in 14 patients (52%). Five patients needed to be regrafted at least once, and one patient required four grafting procedures. Six patients required readmission, and three patients underwent amputations.

There were 16 complications, with 11 episodes of infections, mostly cellulitis. Three patients died.

"All diabetic patients should be taught about the risk of foot burns," Dr. Greenhalgh concluded.

"All patients with loss of sensation should never be exposed to heated water, heating pads, or heaters, or walk outside with bare feet," he said.

An audience member remarked that she's treated several burn injuries among her patients as a result of home treatment of chronic diabetic foot ulcers. Dr. Greenhalgh said he has not observed this, but said it is possible with extended foot soaks, as it takes just 6-8 hours at 43.5° C or 109° F to create a superficial burn.

A minor foot burn in a diabetes patient could lead to below-the-knee amputation. Courtesy Dr. David Greenhalgh

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — The use of topical mafenide acetate on burn wounds was associated with a higher incidence of fungal infection than was silver sulfadiazine in a retrospective analysis of 111 patients.

The chart review was initiated after physicians at the regional burn center of Miami Valley Hospital, Dayton, Ohio, observed more fungal infections after replacing the application of saline soaks for 24 hours followed by silver sulfadiazine 1% cream (Silvadene) with only the application of mafenide acetate 5% solution (Sulfamylon) as the topical antibiotic of choice for initial antimicrobial therapy.

The change in burn wound treatment protocol was made in 2002 in an effort to improve patient outcomes, and has since been reversed, according to research coordinator Ryan Shapiro, on behalf principal investigator Dr. R. Michael Johnson, at the annual meeting of the American Burn Association.

From 1998 to 2006, 42 patients were treated twice daily with silver sulfadiazine, and 69 with mafenide acetate solution. The silver sulfadiazine group was significantly younger than the mafenide acetate group (mean age, 38 vs. 48 years), less likely to have a central line (16 vs. 43 patients), and more likely to have shorter ICU stays (4 vs. 10 days) and shorter total hospital stays (23.5 vs. 34 days).

Nonsignificant differences between the silver sulfadiazine and mafenide acetate groups included mean total body surface area burned (27% vs. 29%), inhalation injury (14 vs. 25 patients), and mortality (6 vs. 13 patients).

Univariate analysis showed that patients receiving mafenide acetate solution had twice the rate of burn infection or systemic fungal infection (48%) than did patients receiving silver sulfadiazine (24%), reported the investigators, who disclosed no relevant conflicts of interest.

Patients receiving mafenide acetate also had four times the rate of systemic fungal infections (27.5%) than did patients receiving silver sulfadiazine (7%). Both outcomes were statistically significant.

Significant predictors of fungal infection on univariate analysis included age, length of ICU stay, total length of stay, presence of a central line, and use of mafenide acetate.

However, in multivariate logistic regression analysis, only length of ICU stay and total length of stay remained as independent predictors of fungal infection, according to Dr. Johnson, chief of plastic surgery at Miami Valley Hospital, and colleagues.

The overall higher fungal infection rate in the series was higher than expected, and could be the result of an increase in the age of patients being treated rather than the choice of topical antibiotic, the investigators noted.

Although the protocol was changed back to using silver sulfadiazine cream in 2006, mafenide acetate is still used in the burn unit at the physician's discretion, they indicated.

Audience member Dr. Debra A. Reilly, director of the burn center and a surgeon at the University of Nebraska Medical Center in Omaha, recounted similar problems with mafenide acetate and fungal infections, but cautioned the audience not to discard the drug, calling it a "very useful product" with a long track record.

Dr. Reilly suggested adding the antifungal nystatin, with the caveat that it must be combined with mafenide acetate suspension and not mafenide acetate solution.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Skin graft donor site wounds treated with Silverlon dressing healed significantly faster than those treated with standard Xeroform gauze, albeit at a greater cost to the pocketbook.

Silverlon (Argentum Medical, LLC), a silver-impregnated wound dressing widely used in the treatment of partial thickness burns, also provided better initial postoperative and overall pain relief at the donor site than Xeroform (Tyco Healthcare Group), according to results of a small, prospective randomized trial.

However, Silverlon was associated with significantly greater daily wound care time by nurses than Xeroform (6 minutes vs. 2 minutes) and significantly higher cost per donor site ($22.99 vs. $0.47), Dr. Michael C. Albrecht and colleagues reported in a poster at the annual meeting of the American Burn Association.

"Because of the frequency of serial excision and grafting procedures in large burns and the necessity of rapid donor site healing while minimizing discomfort to the patient, Silverlon appears to be a superior dressing compared to Xeroform in achieving these goals," Dr. Albrecht and colleagues concluded.

The study included 18 men, mean age 26.6 years, with burns covering an average 8.5% (range 2%-20%) of total body surface area who were admitted to the U.S. Army Institute of Surgical Research (USAISR) burn unit from December 2005 to March 2007. Patients had symmetrically paired donor sites harvested by the same physician, and received both the Xeroform and Silverlon dressings, randomized to each donor site. The average time to wound healing was 10.2 days with Silverlon versus 11.4 days with Xeroform.

Although a single day improvement in wound healing does not sound dramatically different, it is clinically important to patients who require frequent reharvesting of donor sites to achieve complete wound coverage, Dr. Albrecht, a burn surgeon and principal investigator for dressing studies at the USAISR, said in an interview.

Over the previous 3 years at the USAISR, an average of 17% of all excision and grafting procedures required reharvesting of the donor sites.

Pain scores on a 10-point verbal scale were significantly lower with Silverlon than Xeroform on postoperative days 1-3; and were significantly lower overall with Silverlon (2.04 vs. 2.66).

There were no differences with inflammation indices or infection rates between the two dressings. At a mean of 48 days post surgery, scar quality was similar with Silverlon versus Xeroform, as determined by a modified Vancouver Burn Scar Assessment Scale (2.63 vs. 2.31) and by an independent and blinded reviewer using a 14-point scale (6.05 vs. 6.94), said Dr. Albrecht, who reported no conflicts of interest.

Significantly more patients preferred the Silverlon dressing than the Xeroform gauze (64% vs. 23%), while 13% had no preference. Xeroform gauze remains the standard dressing in the USAISR burn unit, said Dr. Albrecht, who suggested that resistance to change, rather than the higher cost of Silverlon, has kept Xeroform on the shelves.

ELSEVIER GLOBAL MEDICAL NEWS