Patrice Wendling

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had re-created a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had re-created a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records,” Dr. Nance, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had re-created a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

LOS ANGELES — Cortisporin Otic did not cause ototoxicity and was cost effective when used for 5 days after ear tube placement surgery in children, according to a large retrospective review at a tertiary otologic center.

Newer fluoroquinolone agents are effective, but the cost is significant, Leonard P. Berenholz, M.D., reported at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The motivation for this study began after our entire group felt significant pressure to prescribe only fluoroquinolones, which perhaps many of you have felt as well,” he said.

Dr. Berenholz and his colleagues at the Lippy Ear Group in Warren, Ohio, found no evidence of clinical ototoxicity in 500 children who received Cortisporin (neomycin, polymyxin B sulfates, and hydrocortisone otic solution) or a generic equivalent for 5 days after ventilation tube placement.

Audiometric testing after tube placement showed normal hearing in 872 (94.4%) of the 924 ears. A conductive hearing loss was found in 33 ears (3.6%).

A sensorineural hearing loss was present in 19 cases (2.1%). The loss existed prior to surgery in all 19 cases, and there was no deterioration postoperatively, he said.

An analysis showed the total cost for using Cortisporin or a generic was $15,500 at $31 a bottle. That compares with $45,000 if Floxin (ofloxacin otic solution 0.3%) had been prescribed at $90 per bottle, and $49,500 if Ciprodex (ciprofloxacin 0.3% and dexamethasone 0.1% sterile otic suspension) had been prescribed at $99 per bottle.

The investigators also contacted national trial lawyer associations and found no ototoxicity cases settled in or out of court, he said.

The makers of Ciprodex and Floxin see things differently.

“The FDA label for products containing aminoglycosides such as Cortisporin indicate the potential risk when there is an open tympanic membrane,” said Paul Cockrum, Pharm.D., manager of clinical market support for Alcon Inc., which manufactures Ciprodex. “So if a physician prescribes this product, then he is open to potential liability. Since Cortisporin offers no clinical benefits, any cost benefits are outweighed by the risk of ototoxicity.”

He also noted that a consensus panel was formed in 2004 at the request of the American Academy of Otolaryngology-Head and Neck Surgery Foundation due to rising legal claims against physicians, recommendations by British and Canadian medical organizations to limit the use of potentially ototoxic ototopical antibiotics, the availability of nonototoxic preparations, and a lack of an evidence-based review of these issues.

The panel said, when possible, topical antibiotic preparations free of potential ototoxicity should be used. But the academy has elected not to convert the recommendations to official policy, said Kenneth Satterfield, media relations director for the academy.

The approved label for Cortisporin-TC Otic states that, “Neomycin can induce permanent sensorineural hearing loss due to cochlear damage, mainly destruction of hair cells in the organ of Corti” and that “ototoxicity and nephrotoxicity have also been reported,” commented Melvyn Bloom, M.D., director of medical services and safety for Daiichi Pharmaceutical Corp., which markets Floxin Otic.

Based on his findings, Dr. Berenholz recommends using Cortisporin for less than 1 week and reserving the tertiary character of fluoroquinolones for resistant or acute cases or difficult chronic ears.

“It would be a shame if 10 years from now we have problems with resistance to topical fluoroquinolones, although none have been reported,” he said.

A three-arm study is planned to evaluate children who had ear tubes placed without postoperative topical antibiotic drops and those who received Cortisporin or Ciprodex.

LOS ANGELES — Cortisporin Otic did not cause ototoxicity and was cost effective when used for 5 days after ear tube placement surgery in children, according to a large retrospective review at a tertiary otologic center.

Newer fluoroquinolone agents are effective, but the cost is significant, Leonard P. Berenholz, M.D., reported at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The motivation for this study began after our entire group felt significant pressure to prescribe only fluoroquinolones, which perhaps many of you have felt as well,” he said.

Dr. Berenholz and his colleagues at the Lippy Ear Group in Warren, Ohio, found no evidence of clinical ototoxicity in 500 children who received Cortisporin (neomycin, polymyxin B sulfates, and hydrocortisone otic solution) or a generic equivalent for 5 days after ventilation tube placement.

Audiometric testing after tube placement showed normal hearing in 872 (94.4%) of the 924 ears. A conductive hearing loss was found in 33 ears (3.6%).

A sensorineural hearing loss was present in 19 cases (2.1%). The loss existed prior to surgery in all 19 cases, and there was no deterioration postoperatively, he said.

An analysis showed the total cost for using Cortisporin or a generic was $15,500 at $31 a bottle. That compares with $45,000 if Floxin (ofloxacin otic solution 0.3%) had been prescribed at $90 per bottle, and $49,500 if Ciprodex (ciprofloxacin 0.3% and dexamethasone 0.1% sterile otic suspension) had been prescribed at $99 per bottle.

The investigators also contacted national trial lawyer associations and found no ototoxicity cases settled in or out of court, he said.

The makers of Ciprodex and Floxin see things differently.

“The FDA label for products containing aminoglycosides such as Cortisporin indicate the potential risk when there is an open tympanic membrane,” said Paul Cockrum, Pharm.D., manager of clinical market support for Alcon Inc., which manufactures Ciprodex. “So if a physician prescribes this product, then he is open to potential liability. Since Cortisporin offers no clinical benefits, any cost benefits are outweighed by the risk of ototoxicity.”

He also noted that a consensus panel was formed in 2004 at the request of the American Academy of Otolaryngology-Head and Neck Surgery Foundation due to rising legal claims against physicians, recommendations by British and Canadian medical organizations to limit the use of potentially ototoxic ototopical antibiotics, the availability of nonototoxic preparations, and a lack of an evidence-based review of these issues.

The panel said, when possible, topical antibiotic preparations free of potential ototoxicity should be used. But the academy has elected not to convert the recommendations to official policy, said Kenneth Satterfield, media relations director for the academy.

The approved label for Cortisporin-TC Otic states that, “Neomycin can induce permanent sensorineural hearing loss due to cochlear damage, mainly destruction of hair cells in the organ of Corti” and that “ototoxicity and nephrotoxicity have also been reported,” commented Melvyn Bloom, M.D., director of medical services and safety for Daiichi Pharmaceutical Corp., which markets Floxin Otic.

Based on his findings, Dr. Berenholz recommends using Cortisporin for less than 1 week and reserving the tertiary character of fluoroquinolones for resistant or acute cases or difficult chronic ears.

“It would be a shame if 10 years from now we have problems with resistance to topical fluoroquinolones, although none have been reported,” he said.

A three-arm study is planned to evaluate children who had ear tubes placed without postoperative topical antibiotic drops and those who received Cortisporin or Ciprodex.

LOS ANGELES — Cortisporin Otic did not cause ototoxicity and was cost effective when used for 5 days after ear tube placement surgery in children, according to a large retrospective review at a tertiary otologic center.

Newer fluoroquinolone agents are effective, but the cost is significant, Leonard P. Berenholz, M.D., reported at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The motivation for this study began after our entire group felt significant pressure to prescribe only fluoroquinolones, which perhaps many of you have felt as well,” he said.

Dr. Berenholz and his colleagues at the Lippy Ear Group in Warren, Ohio, found no evidence of clinical ototoxicity in 500 children who received Cortisporin (neomycin, polymyxin B sulfates, and hydrocortisone otic solution) or a generic equivalent for 5 days after ventilation tube placement.

Audiometric testing after tube placement showed normal hearing in 872 (94.4%) of the 924 ears. A conductive hearing loss was found in 33 ears (3.6%).

A sensorineural hearing loss was present in 19 cases (2.1%). The loss existed prior to surgery in all 19 cases, and there was no deterioration postoperatively, he said.

An analysis showed the total cost for using Cortisporin or a generic was $15,500 at $31 a bottle. That compares with $45,000 if Floxin (ofloxacin otic solution 0.3%) had been prescribed at $90 per bottle, and $49,500 if Ciprodex (ciprofloxacin 0.3% and dexamethasone 0.1% sterile otic suspension) had been prescribed at $99 per bottle.

The investigators also contacted national trial lawyer associations and found no ototoxicity cases settled in or out of court, he said.

The makers of Ciprodex and Floxin see things differently.

“The FDA label for products containing aminoglycosides such as Cortisporin indicate the potential risk when there is an open tympanic membrane,” said Paul Cockrum, Pharm.D., manager of clinical market support for Alcon Inc., which manufactures Ciprodex. “So if a physician prescribes this product, then he is open to potential liability. Since Cortisporin offers no clinical benefits, any cost benefits are outweighed by the risk of ototoxicity.”

He also noted that a consensus panel was formed in 2004 at the request of the American Academy of Otolaryngology-Head and Neck Surgery Foundation due to rising legal claims against physicians, recommendations by British and Canadian medical organizations to limit the use of potentially ototoxic ototopical antibiotics, the availability of nonototoxic preparations, and a lack of an evidence-based review of these issues.

The panel said, when possible, topical antibiotic preparations free of potential ototoxicity should be used. But the academy has elected not to convert the recommendations to official policy, said Kenneth Satterfield, media relations director for the academy.

The approved label for Cortisporin-TC Otic states that, “Neomycin can induce permanent sensorineural hearing loss due to cochlear damage, mainly destruction of hair cells in the organ of Corti” and that “ototoxicity and nephrotoxicity have also been reported,” commented Melvyn Bloom, M.D., director of medical services and safety for Daiichi Pharmaceutical Corp., which markets Floxin Otic.

Based on his findings, Dr. Berenholz recommends using Cortisporin for less than 1 week and reserving the tertiary character of fluoroquinolones for resistant or acute cases or difficult chronic ears.

“It would be a shame if 10 years from now we have problems with resistance to topical fluoroquinolones, although none have been reported,” he said.

A three-arm study is planned to evaluate children who had ear tubes placed without postoperative topical antibiotic drops and those who received Cortisporin or Ciprodex.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records.” Dr. Nance, a resident, said.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrated could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records.” Dr. Nance, a resident, said.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrated could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

“The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records.” Dr. Nance, a resident, said.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were “near misses.”

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the “track changes” function on word processors.

The authors further suggest that communication failures such as this case illustrated could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could be equipped with a message system similar to e-mail that notifies parties when a message has been retrieved.

“There were human errors in both cases, but electronic records should be designed better to reduce the risk of error,” Dr. Nance said.

CHICAGO – The use of complementary and alternative medicine is very common among children with autistic spectrum disorders, according to two poster presentations at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Seventy-four percent of the 112 families of children with autistic spectrum disorders (ASDs) from Children's Hospital in Boston reported having used some type of complementary and alternative medicine (CAM). A Canadian study showed 91% of 183 families surveyed had used a CAM of any type.

“People are doing a lot of things that they aren't telling their pediatrician about, unless they ask,” Leonard Rappaport, M.D., director of the developmental medicine center at Children's Hospital, Boston, said. “This is something that needs to be reinforced continually with pediatricians.”

The most common CAM therapies were modified diet (38%), vitamins/minerals (30%), food supplements (23%), and prayer/shaman (16%), according to the Boston study, led by Ellen Hanson, Ph.D.

“No one in our group would say there is a cure for autistic spectrum disorders, but if you go online you'll find 20–30 sites that say there is a potential cure,” Dr. Rappaport said. “I doubt any of these things work appreciably, but it helps the family find some peace when they are working so hard to help their children.”

The most frequently used interventions were conventional therapies such as educational techniques (89%), sensory therapies (71%), and prescription drugs (50%). CAM use was associated with having a more severe form of ASD. There was some suggestion that CAM use was associated with longer time since diagnosis, and with higher education level in mothers.

Very few families reported that any of the interventions were harmful. Most reported that their chief considerations when choosing CAM were unacceptable side effects with prescription medications, or concern about the side effects and safety of prescription medications.

In a separate presentation, a cross-sectional survey of a study population of children aged 3–18 years (mean 8.9 years) diagnosed with any ASD in southern Alberta showed that the most common types of CAM used were vitamins and minerals (63%), mind-body therapies (51%), dietary-nutritional therapies (48%), natural therapies such as St. John's wort, Kava, and homeopathy (39%), and anti-yeast therapies (31%).

The most common reasons for CAM use were: to improve symptoms of autism (43%), to improve mental and emotional well-being (39%), to improve health (36%), a belief it could not hurt (28%), a belief that conventional medicine did not have any answers (22%), and a belief in holistic health (20%).

“Only 10% of families used CAM because they wanted to heal their child of ASD, so this is a pretty aware population,” said lead investigator W. Ben Gibbard, M.D., of the University of Calgary (Alt.).

The mean number of therapies used was 10, but “some patients are up to 80 therapies that they've tried,” Dr. Gibbard said.

CHICAGO – The use of complementary and alternative medicine is very common among children with autistic spectrum disorders, according to two poster presentations at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Seventy-four percent of the 112 families of children with autistic spectrum disorders (ASDs) from Children's Hospital in Boston reported having used some type of complementary and alternative medicine (CAM). A Canadian study showed 91% of 183 families surveyed had used a CAM of any type.

“People are doing a lot of things that they aren't telling their pediatrician about, unless they ask,” Leonard Rappaport, M.D., director of the developmental medicine center at Children's Hospital, Boston, said. “This is something that needs to be reinforced continually with pediatricians.”

The most common CAM therapies were modified diet (38%), vitamins/minerals (30%), food supplements (23%), and prayer/shaman (16%), according to the Boston study, led by Ellen Hanson, Ph.D.

“No one in our group would say there is a cure for autistic spectrum disorders, but if you go online you'll find 20–30 sites that say there is a potential cure,” Dr. Rappaport said. “I doubt any of these things work appreciably, but it helps the family find some peace when they are working so hard to help their children.”

The most frequently used interventions were conventional therapies such as educational techniques (89%), sensory therapies (71%), and prescription drugs (50%). CAM use was associated with having a more severe form of ASD. There was some suggestion that CAM use was associated with longer time since diagnosis, and with higher education level in mothers.

Very few families reported that any of the interventions were harmful. Most reported that their chief considerations when choosing CAM were unacceptable side effects with prescription medications, or concern about the side effects and safety of prescription medications.

In a separate presentation, a cross-sectional survey of a study population of children aged 3–18 years (mean 8.9 years) diagnosed with any ASD in southern Alberta showed that the most common types of CAM used were vitamins and minerals (63%), mind-body therapies (51%), dietary-nutritional therapies (48%), natural therapies such as St. John's wort, Kava, and homeopathy (39%), and anti-yeast therapies (31%).

The most common reasons for CAM use were: to improve symptoms of autism (43%), to improve mental and emotional well-being (39%), to improve health (36%), a belief it could not hurt (28%), a belief that conventional medicine did not have any answers (22%), and a belief in holistic health (20%).

“Only 10% of families used CAM because they wanted to heal their child of ASD, so this is a pretty aware population,” said lead investigator W. Ben Gibbard, M.D., of the University of Calgary (Alt.).

The mean number of therapies used was 10, but “some patients are up to 80 therapies that they've tried,” Dr. Gibbard said.

CHICAGO – The use of complementary and alternative medicine is very common among children with autistic spectrum disorders, according to two poster presentations at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Seventy-four percent of the 112 families of children with autistic spectrum disorders (ASDs) from Children's Hospital in Boston reported having used some type of complementary and alternative medicine (CAM). A Canadian study showed 91% of 183 families surveyed had used a CAM of any type.

“People are doing a lot of things that they aren't telling their pediatrician about, unless they ask,” Leonard Rappaport, M.D., director of the developmental medicine center at Children's Hospital, Boston, said. “This is something that needs to be reinforced continually with pediatricians.”

The most common CAM therapies were modified diet (38%), vitamins/minerals (30%), food supplements (23%), and prayer/shaman (16%), according to the Boston study, led by Ellen Hanson, Ph.D.

“No one in our group would say there is a cure for autistic spectrum disorders, but if you go online you'll find 20–30 sites that say there is a potential cure,” Dr. Rappaport said. “I doubt any of these things work appreciably, but it helps the family find some peace when they are working so hard to help their children.”

The most frequently used interventions were conventional therapies such as educational techniques (89%), sensory therapies (71%), and prescription drugs (50%). CAM use was associated with having a more severe form of ASD. There was some suggestion that CAM use was associated with longer time since diagnosis, and with higher education level in mothers.

Very few families reported that any of the interventions were harmful. Most reported that their chief considerations when choosing CAM were unacceptable side effects with prescription medications, or concern about the side effects and safety of prescription medications.

In a separate presentation, a cross-sectional survey of a study population of children aged 3–18 years (mean 8.9 years) diagnosed with any ASD in southern Alberta showed that the most common types of CAM used were vitamins and minerals (63%), mind-body therapies (51%), dietary-nutritional therapies (48%), natural therapies such as St. John's wort, Kava, and homeopathy (39%), and anti-yeast therapies (31%).

The most common reasons for CAM use were: to improve symptoms of autism (43%), to improve mental and emotional well-being (39%), to improve health (36%), a belief it could not hurt (28%), a belief that conventional medicine did not have any answers (22%), and a belief in holistic health (20%).

“Only 10% of families used CAM because they wanted to heal their child of ASD, so this is a pretty aware population,” said lead investigator W. Ben Gibbard, M.D., of the University of Calgary (Alt.).

The mean number of therapies used was 10, but “some patients are up to 80 therapies that they've tried,” Dr. Gibbard said.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

"The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records," Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were "near misses."

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the "track changes" function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could come with a message system similar to e-mail that notifies parties when a message has been retrieved.

"There were human errors in both cases, but electronic records should be designed better to reduce the risk of error," he said.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

"The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records," Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were "near misses."

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the "track changes" function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could come with a message system similar to e-mail that notifies parties when a message has been retrieved.

"There were human errors in both cases, but electronic records should be designed better to reduce the risk of error," he said.

LOS ANGELES — Electronic health records have been proposed as one way to reduce medical errors, but their design can contribute to errors as well, Melonie Nance, M.D., said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

"The way doctors work, and the way we think about patient problems and diseases is often completely mismatched with the way things are presented in electronic records," Dr. Nance, a resident, said in an interview.

Dr. Nance and her colleagues at the University of Pittsburgh analyzed two cases of preventable medical errors that occurred in part because of computer interface design. In neither case did the error lead to patient injury, thus both were "near misses."

In the first case, a resident reviewed the pathology report of an operative biopsy prior to a composite resection and noted that the diagnosis was squamous cell carcinoma, but failed to recognize that the date of the biopsy was from the previous year.

In the electronic record used, multiple pathology reports were displayed on the same screen. Further, pathology and operative reports were stored in separate categories and were not linked, even though both reports resulted from the same procedure. The problem consisted of both time-line and data-fragmentation errors.

Rather than presenting critical data in a way that links related information, the electronic record in this case had recreated a problem seen with traditional paper files where information is stored by data type, Dr. Nance said.

Standardized time lines, unambiguous links between related information, and data organized by problem are all potential solutions to this problem, Dr. Nance said. For example, pathology reports of a head and neck cancer should be displayed with other information about the specific cancer, whereas reports of a liver biopsy should be linked to other information about the patient's liver disease.

In the second case, a patient was discharged in acute renal failure 30 minutes after the renal failure had been noted and documented by the critical care fellow. The fellow had entered the diagnosis into the electronic record at the end of a lengthy note but had not communicated the information to the otolaryngology resident who discharged the patient. The error was discovered quickly and the patient was readmitted 2 hours later.

The primary problem in this case was that data entry was mistaken for thorough communication. Critical patient information was hidden from the discharging physician and the record contained excessive information.

Dr. Nance and her colleagues suggested that a severity scale could be used to bring attention to important information such as abnormal lab data. Copied-and-pasted notes, a strategy often used to generate complete documentation, could be marked with color coding, time stamps, or a notation similar to the "track changes" function on word processors.

The authors further suggest that communication failures such as this case illustrates could be reduced with an automated warning system triggered by attempts to discharge patients with worsening conditions. Electronic medical records also could come with a message system similar to e-mail that notifies parties when a message has been retrieved.

"There were human errors in both cases, but electronic records should be designed better to reduce the risk of error," he said.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes. Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18). The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

"Routine reporting does not approximate volume," said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. "There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes."

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, diagnostic imaging, and laboratory investigations, whereas staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes. Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18). The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

"Routine reporting does not approximate volume," said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. "There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes."

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, diagnostic imaging, and laboratory investigations, whereas staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

QUEBEC CITY — Clinicians, staff, and patients report medical errors in distinctly different ways, Robert L. Phillips Jr., M.D., said at the annual meeting of the North American Primary Care Research Group.

Patients tend to file fewer reports, while clinicians and staff are far more likely to report errors of process rather than errors of knowledge and skill.

Such variances are important to consider as error reporting becomes mandatory. The Patient Safety and Quality Improvement Act of 2005 (S. 544), signed into law this summer, establishes a voluntary system to report errors and near misses.

Dr. Phillips presented a study in which 10 family medicine clinics were asked to routinely report errors over a 10-week period. Additionally, on 5 intensive days, they were asked to report every error. Errors could be of omission or commission.

The reports were anonymous and could be filed by mail, phone, or the Internet. Reporting took about 3–5 minutes. Of the eligible reporting population, 401 (86%) clinicians and staff signed consent forms.

A total of 726 events were reported, of which 717 had at least one error. There were a total of 935 errors.

Just over half of the reports came from staff (384), a little over one-third from physicians (278), and relatively few from residents (46) and nurse practitioners and physician assistants (18). The majority of reports came over the Internet (546), while 180 were mailed.

Although most of the reports were filed on routine versus intensive-reporting days (440 vs. 265), there was a disproportionate amount filed on the 5 intensive-reporting days.

"Routine reporting does not approximate volume," said Dr. Phillips, director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington. "There has to be some other mechanism than routine reporting if you want to get at [errors], especially the common, less harmful mistakes."

The top errors were chart completeness and availability (176), medication (127), appointments (111), filing (84), laboratory work (82), and communication with patients (65).

Analysis revealed that 96% of the errors reported were process errors, suggesting that clinicians and staff either recognize more process errors or are reluctant to report errors of knowledge and skill, he said.

Clinicians were significantly more likely to report errors concerning medications, diagnostic imaging, and laboratory investigations, whereas staff members were more likely to report errors related to patient communication and appointments.

One of the more striking findings was that patients filed only 126 reports, of which 18 were actual errors. Of these, 6 were related to waiting too long, 2 were mistaken identity, and 10 cited a variety of issues, including credit card theft and even clinician-induced fear. Most patient reports were sent by mail.

While such insights are important, it's not clear if the overall lack of patient reporting is due to patients not seeing errors or if another tool is needed to collect the data, he said.

The audience suggested that patients may report less often because acknowledging an error might make them feel more at risk.

The analysis revealed that 706 reports indicated errors that caused health consequences or harm. There were no deaths, but nearly a quarter of the patients involved experienced some health consequence.

Reports from both staff and clinicians suggest that patients with complex health issues are vulnerable to more serious harm.

Of the reports that had multiple errors, 4 reports had four errors, 33 had three errors, and 183 had two. In 93 of these cases, a cascade of errors occurred as a result of an initial error, which usually involved an incomplete or unavailable chart.

The Robert Graham Center is a division of the American Academy of Family Physicians.

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

QUEBEC CITY — Residents trained using the vertical strip clinical breast exam are significantly more likely to detect and be able to describe small breast masses, Elizabeth Steiner, M.D., reported at the annual meeting of the North American Primary Care Research Group.

The vertical strip three-pressure method examines the breast in overlapping vertical strips using the pads of the first three fingers with light, then medium, then deep pressure. It covers a wide area of the chest from the clavicle down to the inframammary ridge and out to the lymph nodes.

Unlike the standard concentric circle or wedge methods, it includes the entire nipple-areolar complex where 15%–20% of breast cancers originate, said Dr. Steiner of Oregon Health and Science University, Portland.

The method has been endorsed as the best breast exam method by the Centers for Disease Control and Prevention and the American Cancer Society (CA Cancer J. Clin. 2004;54:327–44). But it has a drawback: It takes 3–5 minutes per breast to perform.

“One of the things we get from diagnosticians is that this takes too long,” Dr. Steiner said in an interview. “But the one factor that has been shown to make a difference in every study about breast exam sensitivity is the time you take. In our study, for every 15 seconds you took, it made you 29% more likely to find a 3-mm mass.”

In the study, 72 first-year residents were trained using a 1− to 2-hour online self-study with a video and a 2.5-hour practicum with trained faculty using silicone breast models and a patient surrogate. A total of 93 second-year residents received no training in the vertical strip method beyond what they'd received in medical school.

Standardized, structured clinical exams were performed 3–6 months after training using a silicone model, and were evaluated by trained (but not blinded) observers. Residents who were unavailable because of their clinical responsibilities were excluded from analysis.

A 3-mm mass was detected by 42 of 50 (84%) trained residents and 30 of 65 (46%) untrained residents. The difference was statistically significant.

Of those finding a mass, 62% of trained and 10% of untrained residents were able to document their findings using at least five of eight standardized descriptors.

About 85% of trained residents were able to find a mass within 6 minutes, compared with about 45% of untrained residents.

When the concentric circle or wedge methods with only one or two levels of pressure were used, 70% of trained vs. 40% of untrained residents were able to find the mass.

“We believe that this confirms the consensus report recommending the vertical strip, three-pressure method as the most sensitive technique, but also that thorough training improves sensitivity regardless of technique used,” Dr. Steiner said.

Based on the study's findings, Oregon recently became the first state to approve reimbursement for the vertical strip breast exam separate from a comprehensive women's health exam.

This could lead the way toward greater national acceptance of the method, and also encourage more physicians to teach their patients to use this method at home, said Dr. Steiner.

“A lot of women don't feel very skilled [at the breast self-exam],” she said. “We can do a better job of teaching women to do this exam.”

QUEBEC CITY — Residents trained using the vertical strip clinical breast exam are significantly more likely to detect and be able to describe small breast masses, Elizabeth Steiner, M.D., reported at the annual meeting of the North American Primary Care Research Group.

The vertical strip three-pressure method examines the breast in overlapping vertical strips using the pads of the first three fingers with light, then medium, then deep pressure. It covers a wide area of the chest from the clavicle down to the inframammary ridge and out to the lymph nodes.

Unlike the standard concentric circle or wedge methods, it includes the entire nipple-areolar complex where 15%–20% of breast cancers originate, said Dr. Steiner of Oregon Health and Science University, Portland.

The method has been endorsed as the best breast exam method by the Centers for Disease Control and Prevention and the American Cancer Society (CA Cancer J. Clin. 2004;54:327–44). But it has a drawback: It takes 3–5 minutes per breast to perform.

“One of the things we get from diagnosticians is that this takes too long,” Dr. Steiner said in an interview. “But the one factor that has been shown to make a difference in every study about breast exam sensitivity is the time you take. In our study, for every 15 seconds you took, it made you 29% more likely to find a 3-mm mass.”

In the study, 72 first-year residents were trained using a 1− to 2-hour online self-study with a video and a 2.5-hour practicum with trained faculty using silicone breast models and a patient surrogate. A total of 93 second-year residents received no training in the vertical strip method beyond what they'd received in medical school.

Standardized, structured clinical exams were performed 3–6 months after training using a silicone model, and were evaluated by trained (but not blinded) observers. Residents who were unavailable because of their clinical responsibilities were excluded from analysis.

A 3-mm mass was detected by 42 of 50 (84%) trained residents and 30 of 65 (46%) untrained residents. The difference was statistically significant.

Of those finding a mass, 62% of trained and 10% of untrained residents were able to document their findings using at least five of eight standardized descriptors.

About 85% of trained residents were able to find a mass within 6 minutes, compared with about 45% of untrained residents.

When the concentric circle or wedge methods with only one or two levels of pressure were used, 70% of trained vs. 40% of untrained residents were able to find the mass.

“We believe that this confirms the consensus report recommending the vertical strip, three-pressure method as the most sensitive technique, but also that thorough training improves sensitivity regardless of technique used,” Dr. Steiner said.

Based on the study's findings, Oregon recently became the first state to approve reimbursement for the vertical strip breast exam separate from a comprehensive women's health exam.

This could lead the way toward greater national acceptance of the method, and also encourage more physicians to teach their patients to use this method at home, said Dr. Steiner.

“A lot of women don't feel very skilled [at the breast self-exam],” she said. “We can do a better job of teaching women to do this exam.”

QUEBEC CITY — Residents trained using the vertical strip clinical breast exam are significantly more likely to detect and be able to describe small breast masses, Elizabeth Steiner, M.D., reported at the annual meeting of the North American Primary Care Research Group.

The vertical strip three-pressure method examines the breast in overlapping vertical strips using the pads of the first three fingers with light, then medium, then deep pressure. It covers a wide area of the chest from the clavicle down to the inframammary ridge and out to the lymph nodes.

Unlike the standard concentric circle or wedge methods, it includes the entire nipple-areolar complex where 15%–20% of breast cancers originate, said Dr. Steiner of Oregon Health and Science University, Portland.

The method has been endorsed as the best breast exam method by the Centers for Disease Control and Prevention and the American Cancer Society (CA Cancer J. Clin. 2004;54:327–44). But it has a drawback: It takes 3–5 minutes per breast to perform.

“One of the things we get from diagnosticians is that this takes too long,” Dr. Steiner said in an interview. “But the one factor that has been shown to make a difference in every study about breast exam sensitivity is the time you take. In our study, for every 15 seconds you took, it made you 29% more likely to find a 3-mm mass.”

In the study, 72 first-year residents were trained using a 1− to 2-hour online self-study with a video and a 2.5-hour practicum with trained faculty using silicone breast models and a patient surrogate. A total of 93 second-year residents received no training in the vertical strip method beyond what they'd received in medical school.

Standardized, structured clinical exams were performed 3–6 months after training using a silicone model, and were evaluated by trained (but not blinded) observers. Residents who were unavailable because of their clinical responsibilities were excluded from analysis.

A 3-mm mass was detected by 42 of 50 (84%) trained residents and 30 of 65 (46%) untrained residents. The difference was statistically significant.

Of those finding a mass, 62% of trained and 10% of untrained residents were able to document their findings using at least five of eight standardized descriptors.

About 85% of trained residents were able to find a mass within 6 minutes, compared with about 45% of untrained residents.

When the concentric circle or wedge methods with only one or two levels of pressure were used, 70% of trained vs. 40% of untrained residents were able to find the mass.

“We believe that this confirms the consensus report recommending the vertical strip, three-pressure method as the most sensitive technique, but also that thorough training improves sensitivity regardless of technique used,” Dr. Steiner said.

Based on the study's findings, Oregon recently became the first state to approve reimbursement for the vertical strip breast exam separate from a comprehensive women's health exam.

This could lead the way toward greater national acceptance of the method, and also encourage more physicians to teach their patients to use this method at home, said Dr. Steiner.

“A lot of women don't feel very skilled [at the breast self-exam],” she said. “We can do a better job of teaching women to do this exam.”

PARIS — Cannabinoid agonists and opioid receptor antagonists are among the novel treatments being explored for chronic pruritus, Dr. med. Sonja Ständer reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Cannabinoid receptors are promising therapeutic targets because they play an important role in a variety of processes, including metabolic regulation, pain, craving, and anxiety. They can be influenced directly by agonists or antagonists, or indirectly through manipulation of the endocannabinoid metabolism.

Two cannabinoid receptors, CB1 and CB2, are the primary targets of endogenous cannabinoids, and are expressed in central and peripheral neurons.

Recent research by Dr. Ständer and colleagues at the University Hospital in Münster, Germany, has shown that CB1 and CB2 are also present in abundance in human cutaneous nerve fibers and mast cells (J. Dermatol. Sci. 2005;38:177–88).

“Since cannabinoid receptors are expressed on cutaneous nerve fibers, topical cannabinoid agonists directly inhibit the transmission of pruritus and therefore represent a promising new therapeutic modality,” she said.

In a pilot study, 22 patients with chronic pruritus, aged 25–82 years, were treated with one application of a topical cream containing a cannabinoid receptor agonist. Itching was significantly reduced in 14 of 22 patients, 8 patients were completely healed, and 8 were nonresponders.

Overall the response was very rapid, with patients experiencing relief within 2 days to 2 weeks, she said. The treatment was effective even in patients with a long history of itching.

Opioid receptor antagonists, developed to treat patients with opioid and alcohol dependence, represent another potential treatment. They block opioid receptors in the brain and spinal cord and activate pain-transmitting nerves, which themselves inhibit itch-transmitting neurons.

In a study of 133 patients with pruritic dermatoses and systemic diseases, naltrexone was evaluated at 25 mg in 6 patients (4.5%), at 50 mg in 61 (45.9%), at 75 mg in 4 (3%), at 100 mg in 57 (42.9%), and at 150 mg in 5 patients (3.8%). Therapy was maintained individually between 3 weeks and 6 years.

A significant reduction in itching, defined as a 40%–60% decrease, or complete relief was reported within 11 days in 86 of 133 (64.7%) patients, although 46 (34.6%) did not respond. Among patients with chronic pruritus of unknown origin, 15 of 19 (79%) responded to the therapy.

With the exception of 28 patients, itching usually recurred when the therapy was interrupted, she said.

Dr. Ständer stressed that patients should be informed before treatment with naltrexone of potential side effects, such as nausea and vomiting. Such side effects are common, but are limited to the first few days of treatment.

Finally, single case reports suggest that selective serotonin reuptake inhibitors (SSRIs) also may relieve chronic itching.

An ongoing study of 80 patients with chronic pruritus has shown that itching can be relieved after 4 days of treatment with either paroxetine (Paxil) or fluvoxamine (Luvox) applied in low therapeutic dosages.

This approach isn't recommended for elderly patients because of cardiovascular side effects, such as arrhythmias and increased bleeding, associated with SSRIs, she said.

PARIS — Cannabinoid agonists and opioid receptor antagonists are among the novel treatments being explored for chronic pruritus, Dr. med. Sonja Ständer reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Cannabinoid receptors are promising therapeutic targets because they play an important role in a variety of processes, including metabolic regulation, pain, craving, and anxiety. They can be influenced directly by agonists or antagonists, or indirectly through manipulation of the endocannabinoid metabolism.

Two cannabinoid receptors, CB1 and CB2, are the primary targets of endogenous cannabinoids, and are expressed in central and peripheral neurons.

Recent research by Dr. Ständer and colleagues at the University Hospital in Münster, Germany, has shown that CB1 and CB2 are also present in abundance in human cutaneous nerve fibers and mast cells (J. Dermatol. Sci. 2005;38:177–88).

“Since cannabinoid receptors are expressed on cutaneous nerve fibers, topical cannabinoid agonists directly inhibit the transmission of pruritus and therefore represent a promising new therapeutic modality,” she said.

In a pilot study, 22 patients with chronic pruritus, aged 25–82 years, were treated with one application of a topical cream containing a cannabinoid receptor agonist. Itching was significantly reduced in 14 of 22 patients, 8 patients were completely healed, and 8 were nonresponders.

Overall the response was very rapid, with patients experiencing relief within 2 days to 2 weeks, she said. The treatment was effective even in patients with a long history of itching.

Opioid receptor antagonists, developed to treat patients with opioid and alcohol dependence, represent another potential treatment. They block opioid receptors in the brain and spinal cord and activate pain-transmitting nerves, which themselves inhibit itch-transmitting neurons.

In a study of 133 patients with pruritic dermatoses and systemic diseases, naltrexone was evaluated at 25 mg in 6 patients (4.5%), at 50 mg in 61 (45.9%), at 75 mg in 4 (3%), at 100 mg in 57 (42.9%), and at 150 mg in 5 patients (3.8%). Therapy was maintained individually between 3 weeks and 6 years.

A significant reduction in itching, defined as a 40%–60% decrease, or complete relief was reported within 11 days in 86 of 133 (64.7%) patients, although 46 (34.6%) did not respond. Among patients with chronic pruritus of unknown origin, 15 of 19 (79%) responded to the therapy.

With the exception of 28 patients, itching usually recurred when the therapy was interrupted, she said.

Dr. Ständer stressed that patients should be informed before treatment with naltrexone of potential side effects, such as nausea and vomiting. Such side effects are common, but are limited to the first few days of treatment.

Finally, single case reports suggest that selective serotonin reuptake inhibitors (SSRIs) also may relieve chronic itching.

An ongoing study of 80 patients with chronic pruritus has shown that itching can be relieved after 4 days of treatment with either paroxetine (Paxil) or fluvoxamine (Luvox) applied in low therapeutic dosages.

This approach isn't recommended for elderly patients because of cardiovascular side effects, such as arrhythmias and increased bleeding, associated with SSRIs, she said.

PARIS — Cannabinoid agonists and opioid receptor antagonists are among the novel treatments being explored for chronic pruritus, Dr. med. Sonja Ständer reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Cannabinoid receptors are promising therapeutic targets because they play an important role in a variety of processes, including metabolic regulation, pain, craving, and anxiety. They can be influenced directly by agonists or antagonists, or indirectly through manipulation of the endocannabinoid metabolism.

Two cannabinoid receptors, CB1 and CB2, are the primary targets of endogenous cannabinoids, and are expressed in central and peripheral neurons.

Recent research by Dr. Ständer and colleagues at the University Hospital in Münster, Germany, has shown that CB1 and CB2 are also present in abundance in human cutaneous nerve fibers and mast cells (J. Dermatol. Sci. 2005;38:177–88).

“Since cannabinoid receptors are expressed on cutaneous nerve fibers, topical cannabinoid agonists directly inhibit the transmission of pruritus and therefore represent a promising new therapeutic modality,” she said.

In a pilot study, 22 patients with chronic pruritus, aged 25–82 years, were treated with one application of a topical cream containing a cannabinoid receptor agonist. Itching was significantly reduced in 14 of 22 patients, 8 patients were completely healed, and 8 were nonresponders.

Overall the response was very rapid, with patients experiencing relief within 2 days to 2 weeks, she said. The treatment was effective even in patients with a long history of itching.

Opioid receptor antagonists, developed to treat patients with opioid and alcohol dependence, represent another potential treatment. They block opioid receptors in the brain and spinal cord and activate pain-transmitting nerves, which themselves inhibit itch-transmitting neurons.

In a study of 133 patients with pruritic dermatoses and systemic diseases, naltrexone was evaluated at 25 mg in 6 patients (4.5%), at 50 mg in 61 (45.9%), at 75 mg in 4 (3%), at 100 mg in 57 (42.9%), and at 150 mg in 5 patients (3.8%). Therapy was maintained individually between 3 weeks and 6 years.

A significant reduction in itching, defined as a 40%–60% decrease, or complete relief was reported within 11 days in 86 of 133 (64.7%) patients, although 46 (34.6%) did not respond. Among patients with chronic pruritus of unknown origin, 15 of 19 (79%) responded to the therapy.

With the exception of 28 patients, itching usually recurred when the therapy was interrupted, she said.

Dr. Ständer stressed that patients should be informed before treatment with naltrexone of potential side effects, such as nausea and vomiting. Such side effects are common, but are limited to the first few days of treatment.

Finally, single case reports suggest that selective serotonin reuptake inhibitors (SSRIs) also may relieve chronic itching.

An ongoing study of 80 patients with chronic pruritus has shown that itching can be relieved after 4 days of treatment with either paroxetine (Paxil) or fluvoxamine (Luvox) applied in low therapeutic dosages.

This approach isn't recommended for elderly patients because of cardiovascular side effects, such as arrhythmias and increased bleeding, associated with SSRIs, she said.