Sherry Boschert

SAN FRANCISCO — Some patients awaiting heart transplantation are as likely to remain alive for 2 years as are those who get transplanted hearts, an outcome that raises the question of whether better risk-stratification methods would keep some patients from being wait-listed in the first place, Dr. Katherine Lietz said at the annual meeting of the International Society for Heart and Lung Transplantation.

In a retrospective study of newly wait-listed patients in the U.S. from 1990 to 2005, Dr. Lietz and her colleague found that the odds of being alive 1 year later or having received a heart transplant jumped from 49% to 69% for patients classified as United Network for Organ Sharing (UNOS) status 1, and improved from 81% to 89% for UNOS status 2 patients.

The probability of wait-listed patients undergoing heart transplantation within 1 year barely changed during that time span. For status 2 patients, the odds of being transplanted within 1 year decreased from 53% in 1990–1994 to 49% in 2000–2005. For status 1 patients, the odds of being transplanted within 1 year crept from 85% to 87%, and the probability of remaining alive on the waiting list for 1 year increased from 17% in 1990–1994 to 40% in 2000–2005.

The improvements seem to be attributable to better medical and device therapies for advanced heart failure, which are keeping patients alive longer on transplant waiting lists, Dr. Lietz said. UNOS status 1 includes the sickest patients who are on device or mechanical support or continuous infusion with IV inotropes. The number of status 1 patients on heart transplant waiting lists increased from 836 in 1990 to 1,159 in 2005, while the number of status 2 patients on a waiting list decreased from 2,612 in 1992 to 1,147 in 2005. Today, the two groups are nearly equally represented on the waiting lists, reported the investigators, of Georgetown University, Washington.

For status 2 patients, the chances of being alive after 2 years on the waiting list increased from 65% in 1990–1994 to 81% in 2000–2005. That 81% survival rate approaches the current 85% survival rate for patients undergoing heart transplantation. Statistical modeling suggests that 2-year survival for patients added to waiting lists today as status 2 would be equivalent to that of patients undergoing heart transplantation, Dr. Lietz observed.

“That raises the question of whether early listing is justified in some of these patients,” she said.

Status 2 patients are a heterogeneous group, however. In the study, 20% died within 2 years of wait-listing, and another 20% were upgraded to status 1. On the other hand, 1,701 status 2 patients were alive more than 5 years after being wait-listed, and 261 patients were alive after 10 years on the list.

“We need better methods of risk-stratifying them, as early listing may not be justified in all these patients,” Dr. Lietz said.

A physician in the audience suggested that what might help more than better risk stratification at the time of wait-listing is better recognition of “triggers” that should prompt reclassification of patients on the list. These might include status 2 patients whose tolerance to β-blocker therapy decreases, or those who develop a creatinine level greater than 1 mg/dL, she said.

Among the wait-listed status 1 patients, 39% died within 2 months. In this very high-risk group, few patients were supported with mechanical devices. The lack of an implantable cardioverter defibrillator (ICD) was significantly associated with poorer outcomes, “perhaps confirming the role of ICD as a bridge to transplantation in these patients,” Dr. Lietz said. “For [status 1] patients who are very sick with signs of severe pump failure, use of mechanical circulatory support should be considered,” especially if the anticipated wait before transplantation exceeds 2 months because of the patient's blood type, body size, or other factors.

SAN FRANCISCO — Some patients awaiting heart transplantation are as likely to remain alive for 2 years as are those who get transplanted hearts, an outcome that raises the question of whether better risk-stratification methods would keep some patients from being wait-listed in the first place, Dr. Katherine Lietz said at the annual meeting of the International Society for Heart and Lung Transplantation.

In a retrospective study of newly wait-listed patients in the U.S. from 1990 to 2005, Dr. Lietz and her colleague found that the odds of being alive 1 year later or having received a heart transplant jumped from 49% to 69% for patients classified as United Network for Organ Sharing (UNOS) status 1, and improved from 81% to 89% for UNOS status 2 patients.

The probability of wait-listed patients undergoing heart transplantation within 1 year barely changed during that time span. For status 2 patients, the odds of being transplanted within 1 year decreased from 53% in 1990–1994 to 49% in 2000–2005. For status 1 patients, the odds of being transplanted within 1 year crept from 85% to 87%, and the probability of remaining alive on the waiting list for 1 year increased from 17% in 1990–1994 to 40% in 2000–2005.

The improvements seem to be attributable to better medical and device therapies for advanced heart failure, which are keeping patients alive longer on transplant waiting lists, Dr. Lietz said. UNOS status 1 includes the sickest patients who are on device or mechanical support or continuous infusion with IV inotropes. The number of status 1 patients on heart transplant waiting lists increased from 836 in 1990 to 1,159 in 2005, while the number of status 2 patients on a waiting list decreased from 2,612 in 1992 to 1,147 in 2005. Today, the two groups are nearly equally represented on the waiting lists, reported the investigators, of Georgetown University, Washington.

For status 2 patients, the chances of being alive after 2 years on the waiting list increased from 65% in 1990–1994 to 81% in 2000–2005. That 81% survival rate approaches the current 85% survival rate for patients undergoing heart transplantation. Statistical modeling suggests that 2-year survival for patients added to waiting lists today as status 2 would be equivalent to that of patients undergoing heart transplantation, Dr. Lietz observed.

“That raises the question of whether early listing is justified in some of these patients,” she said.

Status 2 patients are a heterogeneous group, however. In the study, 20% died within 2 years of wait-listing, and another 20% were upgraded to status 1. On the other hand, 1,701 status 2 patients were alive more than 5 years after being wait-listed, and 261 patients were alive after 10 years on the list.

“We need better methods of risk-stratifying them, as early listing may not be justified in all these patients,” Dr. Lietz said.

A physician in the audience suggested that what might help more than better risk stratification at the time of wait-listing is better recognition of “triggers” that should prompt reclassification of patients on the list. These might include status 2 patients whose tolerance to β-blocker therapy decreases, or those who develop a creatinine level greater than 1 mg/dL, she said.

Among the wait-listed status 1 patients, 39% died within 2 months. In this very high-risk group, few patients were supported with mechanical devices. The lack of an implantable cardioverter defibrillator (ICD) was significantly associated with poorer outcomes, “perhaps confirming the role of ICD as a bridge to transplantation in these patients,” Dr. Lietz said. “For [status 1] patients who are very sick with signs of severe pump failure, use of mechanical circulatory support should be considered,” especially if the anticipated wait before transplantation exceeds 2 months because of the patient's blood type, body size, or other factors.

SAN FRANCISCO — Some patients awaiting heart transplantation are as likely to remain alive for 2 years as are those who get transplanted hearts, an outcome that raises the question of whether better risk-stratification methods would keep some patients from being wait-listed in the first place, Dr. Katherine Lietz said at the annual meeting of the International Society for Heart and Lung Transplantation.

In a retrospective study of newly wait-listed patients in the U.S. from 1990 to 2005, Dr. Lietz and her colleague found that the odds of being alive 1 year later or having received a heart transplant jumped from 49% to 69% for patients classified as United Network for Organ Sharing (UNOS) status 1, and improved from 81% to 89% for UNOS status 2 patients.

The probability of wait-listed patients undergoing heart transplantation within 1 year barely changed during that time span. For status 2 patients, the odds of being transplanted within 1 year decreased from 53% in 1990–1994 to 49% in 2000–2005. For status 1 patients, the odds of being transplanted within 1 year crept from 85% to 87%, and the probability of remaining alive on the waiting list for 1 year increased from 17% in 1990–1994 to 40% in 2000–2005.

The improvements seem to be attributable to better medical and device therapies for advanced heart failure, which are keeping patients alive longer on transplant waiting lists, Dr. Lietz said. UNOS status 1 includes the sickest patients who are on device or mechanical support or continuous infusion with IV inotropes. The number of status 1 patients on heart transplant waiting lists increased from 836 in 1990 to 1,159 in 2005, while the number of status 2 patients on a waiting list decreased from 2,612 in 1992 to 1,147 in 2005. Today, the two groups are nearly equally represented on the waiting lists, reported the investigators, of Georgetown University, Washington.

For status 2 patients, the chances of being alive after 2 years on the waiting list increased from 65% in 1990–1994 to 81% in 2000–2005. That 81% survival rate approaches the current 85% survival rate for patients undergoing heart transplantation. Statistical modeling suggests that 2-year survival for patients added to waiting lists today as status 2 would be equivalent to that of patients undergoing heart transplantation, Dr. Lietz observed.

“That raises the question of whether early listing is justified in some of these patients,” she said.

Status 2 patients are a heterogeneous group, however. In the study, 20% died within 2 years of wait-listing, and another 20% were upgraded to status 1. On the other hand, 1,701 status 2 patients were alive more than 5 years after being wait-listed, and 261 patients were alive after 10 years on the list.

“We need better methods of risk-stratifying them, as early listing may not be justified in all these patients,” Dr. Lietz said.

A physician in the audience suggested that what might help more than better risk stratification at the time of wait-listing is better recognition of “triggers” that should prompt reclassification of patients on the list. These might include status 2 patients whose tolerance to β-blocker therapy decreases, or those who develop a creatinine level greater than 1 mg/dL, she said.

Among the wait-listed status 1 patients, 39% died within 2 months. In this very high-risk group, few patients were supported with mechanical devices. The lack of an implantable cardioverter defibrillator (ICD) was significantly associated with poorer outcomes, “perhaps confirming the role of ICD as a bridge to transplantation in these patients,” Dr. Lietz said. “For [status 1] patients who are very sick with signs of severe pump failure, use of mechanical circulatory support should be considered,” especially if the anticipated wait before transplantation exceeds 2 months because of the patient's blood type, body size, or other factors.

LOS ANGELES – It takes a multi-pronged approach to prevent a child from getting sunburned, the results of a randomized trial of sun protection strategies suggest.

An intervention group of children in the sixth to eighth grades–a time when youths usually increase their sun exposure–in 10 New Hampshire towns were matched with grade-equivalent controls and monitored for 2 years, during which time they received sun safety information (Pediatrics 2007;119:e247-56). Study patients randomized to the control group showed a 23% decrease in sun protection during that time, but the level of sun protection decreased by only 8% in towns randomized to a multifaceted intervention.

The children in the intervention group “avoided a majority of the drop-off of sun protection that happens in those middle-school years.” Dr. Martin A. Weinstock noted at the annual meeting of the Society for Investigative Dermatology.

The investigators targeted communities with populations of 6,000-34,000. They observed children at lakes and other recreational areas, noting whether the kids played in the shade and wore protective clothing, and how much of their skin was covered. They asked the children whether they were using sunscreen–if the answer was yes, then they asked to see the container.

Using these elements, the researchers created a measure of the percentage of body surface protected. “It was a fairly objective measure of what sun protection these kids were using,” said Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I. He was not an investigator in the study, but disclosed that he has been a consultant to sunscreen manufacturers. The intervention in the study group reflects a growing understanding that changing behavior requires more than printing a booklet on sun protection or developing a curriculum for teachers, he said.

The investigators went to schools, recreational facilities, primary care practices, and other venues to encourage sun-safe behavior messages from teachers, coaches, lifeguards, clinicians, and others. They trained teen peer counselors to promote the delivery of sun protection messages.

The middle-school students in the intervention group “heard it from their parents, from their teachers, from their doctors–they heard it from everybody,” Dr. Weinstock said. “For long-term benefit, we need to take the type of approach that's informed by these recent results.” The primary change in the children's behavior was in sunscreen use.

Sun protection in childhood is a complex goal that needs to be balanced with the need for physical activity and healthy vitamin D levels. Even if an intervention improves sun exposure, it will take many years to show it reduces melanoma incidence, he said.

LOS ANGELES – It takes a multi-pronged approach to prevent a child from getting sunburned, the results of a randomized trial of sun protection strategies suggest.

An intervention group of children in the sixth to eighth grades–a time when youths usually increase their sun exposure–in 10 New Hampshire towns were matched with grade-equivalent controls and monitored for 2 years, during which time they received sun safety information (Pediatrics 2007;119:e247-56). Study patients randomized to the control group showed a 23% decrease in sun protection during that time, but the level of sun protection decreased by only 8% in towns randomized to a multifaceted intervention.

The children in the intervention group “avoided a majority of the drop-off of sun protection that happens in those middle-school years.” Dr. Martin A. Weinstock noted at the annual meeting of the Society for Investigative Dermatology.

The investigators targeted communities with populations of 6,000-34,000. They observed children at lakes and other recreational areas, noting whether the kids played in the shade and wore protective clothing, and how much of their skin was covered. They asked the children whether they were using sunscreen–if the answer was yes, then they asked to see the container.

Using these elements, the researchers created a measure of the percentage of body surface protected. “It was a fairly objective measure of what sun protection these kids were using,” said Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I. He was not an investigator in the study, but disclosed that he has been a consultant to sunscreen manufacturers. The intervention in the study group reflects a growing understanding that changing behavior requires more than printing a booklet on sun protection or developing a curriculum for teachers, he said.

The investigators went to schools, recreational facilities, primary care practices, and other venues to encourage sun-safe behavior messages from teachers, coaches, lifeguards, clinicians, and others. They trained teen peer counselors to promote the delivery of sun protection messages.

The middle-school students in the intervention group “heard it from their parents, from their teachers, from their doctors–they heard it from everybody,” Dr. Weinstock said. “For long-term benefit, we need to take the type of approach that's informed by these recent results.” The primary change in the children's behavior was in sunscreen use.

Sun protection in childhood is a complex goal that needs to be balanced with the need for physical activity and healthy vitamin D levels. Even if an intervention improves sun exposure, it will take many years to show it reduces melanoma incidence, he said.

LOS ANGELES – It takes a multi-pronged approach to prevent a child from getting sunburned, the results of a randomized trial of sun protection strategies suggest.

An intervention group of children in the sixth to eighth grades–a time when youths usually increase their sun exposure–in 10 New Hampshire towns were matched with grade-equivalent controls and monitored for 2 years, during which time they received sun safety information (Pediatrics 2007;119:e247-56). Study patients randomized to the control group showed a 23% decrease in sun protection during that time, but the level of sun protection decreased by only 8% in towns randomized to a multifaceted intervention.

The children in the intervention group “avoided a majority of the drop-off of sun protection that happens in those middle-school years.” Dr. Martin A. Weinstock noted at the annual meeting of the Society for Investigative Dermatology.

The investigators targeted communities with populations of 6,000-34,000. They observed children at lakes and other recreational areas, noting whether the kids played in the shade and wore protective clothing, and how much of their skin was covered. They asked the children whether they were using sunscreen–if the answer was yes, then they asked to see the container.

Using these elements, the researchers created a measure of the percentage of body surface protected. “It was a fairly objective measure of what sun protection these kids were using,” said Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I. He was not an investigator in the study, but disclosed that he has been a consultant to sunscreen manufacturers. The intervention in the study group reflects a growing understanding that changing behavior requires more than printing a booklet on sun protection or developing a curriculum for teachers, he said.

The investigators went to schools, recreational facilities, primary care practices, and other venues to encourage sun-safe behavior messages from teachers, coaches, lifeguards, clinicians, and others. They trained teen peer counselors to promote the delivery of sun protection messages.

The middle-school students in the intervention group “heard it from their parents, from their teachers, from their doctors–they heard it from everybody,” Dr. Weinstock said. “For long-term benefit, we need to take the type of approach that's informed by these recent results.” The primary change in the children's behavior was in sunscreen use.

Sun protection in childhood is a complex goal that needs to be balanced with the need for physical activity and healthy vitamin D levels. Even if an intervention improves sun exposure, it will take many years to show it reduces melanoma incidence, he said.

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study 1 year earlier that placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6–43 days. Results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an "impulse buy" to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these "physician extenders."

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. "There is a sweet spot, and if you don't get them, you don't get them," he said.

"Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months," Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists?

A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study 1 year earlier that placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6–43 days. Results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an "impulse buy" to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these "physician extenders."

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. "There is a sweet spot, and if you don't get them, you don't get them," he said.

"Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months," Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists?

A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study 1 year earlier that placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6–43 days. Results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an "impulse buy" to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these "physician extenders."

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. "There is a sweet spot, and if you don't get them, you don't get them," he said.

"Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months," Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists?

A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

SAN FRANCISCO — The number of lung retransplantations is surging, and the wait times for retransplantation is evaporating since adoption of the current lung allocation system in 2005, Dr. Steven M. Kawut said.

A retrospective study also found that survival after lung retransplantation has improved in the modern era but still is not as good as after a first lung transplant. Patients undergoing lung retransplantation within 30 days of the initial transplant are three times more likely to die than patients undergoing retransplantation more than 30 days after the first lung transplant, he and his associates reported at the annual meeting of the International Society for Heart and Lung Transplantation.

“Early retransplantation really should be avoided,” said Dr. Kawut of Columbia University, New York.

In general, only 15% of patients who undergo lung transplant survive to 5 years. Repeating lung transplantation can keep some patients alive but the procedure is more challenging, the patients more vulnerable, and the ethical issues more complex, according to Dr. Kawut.

The investigators compared transplantation registry data on 205 patients who underwent lung retransplantation from 2001 through May of 2006 (the modern-era group) with data on a historical cohort that underwent lung retransplantation from 1990 to 2000, and a third group of patients who underwent primary lung transplantation in the modern era.

The number of lung retransplantations ranged from 25 to 33 per year in 2001–2004 and leaped dramatically to 71 in 2005, when the Organ Procurement and Transplantation Network adopted the new Lung Allocation Score (LAS). The study includes 13 of the 56 retransplantations performed in 2006. The median wait for a lung retransplantation in the modern era was 6 months before introduction of the LAS and 1 month since then.

Pre-LAS, 75% of recipients got lung retransplants within 19 months and the rest waited more than 19 months. Under the LAS system, 25% of recipients underwent lung retransplantation within 3 days of being wait-listed—“unbelievable!” Dr. Kawut remarked. Half of lung retransplantations occurred within 1 month, and 75% of retransplantations were performed within 2 months.

At 1 year after retransplantation, 62% of patients were alive. At 5 years, 45% were alive. Compared with retransplantations done before 2001, patients in the modern era were 40% more likely to survive. Compared with patients undergoing a first lung transplant in the modern era, those getting retransplanted in the same time period were 40% more likely to die after controlling for the potentially confounding effects of age, sex, race, the initial diagnosis, the type of transplant procedure, and the use of mechanical ventilation.

A statistically significant increase in risk for death if the retransplanted lungs came from a male donor should be considered with some skepticism because other studies have not shown this, Dr. Kawut said.

To help physicians advise patients considering lung retransplantation, the investigators analyzed data on a subset of 110 patients who survived at least 1 year after the procedure. They found an “absolutely dismal” survival rate of 14% for those who underwent retransplantation within 30 days of the primary transplant and 1-year survival in 58% who underwent retransplantation more than 30 days after the initial surgery—“still not perfect, but much better than 14%,” he said. “Numbers like these may be more useful for the patient in your office.”

The most difficult part of lung retransplantation is the ethical issues involved in giving one patient two opportunities for transplant when that probably denies other patients of even one transplant, because of donor organ shortages. Attention to this ethical issue “trails far behind our ability to do the procedure,” he said.

SAN FRANCISCO — The number of lung retransplantations is surging, and the wait times for retransplantation is evaporating since adoption of the current lung allocation system in 2005, Dr. Steven M. Kawut said.

A retrospective study also found that survival after lung retransplantation has improved in the modern era but still is not as good as after a first lung transplant. Patients undergoing lung retransplantation within 30 days of the initial transplant are three times more likely to die than patients undergoing retransplantation more than 30 days after the first lung transplant, he and his associates reported at the annual meeting of the International Society for Heart and Lung Transplantation.

“Early retransplantation really should be avoided,” said Dr. Kawut of Columbia University, New York.

In general, only 15% of patients who undergo lung transplant survive to 5 years. Repeating lung transplantation can keep some patients alive but the procedure is more challenging, the patients more vulnerable, and the ethical issues more complex, according to Dr. Kawut.

The investigators compared transplantation registry data on 205 patients who underwent lung retransplantation from 2001 through May of 2006 (the modern-era group) with data on a historical cohort that underwent lung retransplantation from 1990 to 2000, and a third group of patients who underwent primary lung transplantation in the modern era.

The number of lung retransplantations ranged from 25 to 33 per year in 2001–2004 and leaped dramatically to 71 in 2005, when the Organ Procurement and Transplantation Network adopted the new Lung Allocation Score (LAS). The study includes 13 of the 56 retransplantations performed in 2006. The median wait for a lung retransplantation in the modern era was 6 months before introduction of the LAS and 1 month since then.

Pre-LAS, 75% of recipients got lung retransplants within 19 months and the rest waited more than 19 months. Under the LAS system, 25% of recipients underwent lung retransplantation within 3 days of being wait-listed—“unbelievable!” Dr. Kawut remarked. Half of lung retransplantations occurred within 1 month, and 75% of retransplantations were performed within 2 months.

At 1 year after retransplantation, 62% of patients were alive. At 5 years, 45% were alive. Compared with retransplantations done before 2001, patients in the modern era were 40% more likely to survive. Compared with patients undergoing a first lung transplant in the modern era, those getting retransplanted in the same time period were 40% more likely to die after controlling for the potentially confounding effects of age, sex, race, the initial diagnosis, the type of transplant procedure, and the use of mechanical ventilation.

A statistically significant increase in risk for death if the retransplanted lungs came from a male donor should be considered with some skepticism because other studies have not shown this, Dr. Kawut said.

To help physicians advise patients considering lung retransplantation, the investigators analyzed data on a subset of 110 patients who survived at least 1 year after the procedure. They found an “absolutely dismal” survival rate of 14% for those who underwent retransplantation within 30 days of the primary transplant and 1-year survival in 58% who underwent retransplantation more than 30 days after the initial surgery—“still not perfect, but much better than 14%,” he said. “Numbers like these may be more useful for the patient in your office.”

The most difficult part of lung retransplantation is the ethical issues involved in giving one patient two opportunities for transplant when that probably denies other patients of even one transplant, because of donor organ shortages. Attention to this ethical issue “trails far behind our ability to do the procedure,” he said.

SAN FRANCISCO — The number of lung retransplantations is surging, and the wait times for retransplantation is evaporating since adoption of the current lung allocation system in 2005, Dr. Steven M. Kawut said.

A retrospective study also found that survival after lung retransplantation has improved in the modern era but still is not as good as after a first lung transplant. Patients undergoing lung retransplantation within 30 days of the initial transplant are three times more likely to die than patients undergoing retransplantation more than 30 days after the first lung transplant, he and his associates reported at the annual meeting of the International Society for Heart and Lung Transplantation.

“Early retransplantation really should be avoided,” said Dr. Kawut of Columbia University, New York.

In general, only 15% of patients who undergo lung transplant survive to 5 years. Repeating lung transplantation can keep some patients alive but the procedure is more challenging, the patients more vulnerable, and the ethical issues more complex, according to Dr. Kawut.

The investigators compared transplantation registry data on 205 patients who underwent lung retransplantation from 2001 through May of 2006 (the modern-era group) with data on a historical cohort that underwent lung retransplantation from 1990 to 2000, and a third group of patients who underwent primary lung transplantation in the modern era.

The number of lung retransplantations ranged from 25 to 33 per year in 2001–2004 and leaped dramatically to 71 in 2005, when the Organ Procurement and Transplantation Network adopted the new Lung Allocation Score (LAS). The study includes 13 of the 56 retransplantations performed in 2006. The median wait for a lung retransplantation in the modern era was 6 months before introduction of the LAS and 1 month since then.

Pre-LAS, 75% of recipients got lung retransplants within 19 months and the rest waited more than 19 months. Under the LAS system, 25% of recipients underwent lung retransplantation within 3 days of being wait-listed—“unbelievable!” Dr. Kawut remarked. Half of lung retransplantations occurred within 1 month, and 75% of retransplantations were performed within 2 months.

At 1 year after retransplantation, 62% of patients were alive. At 5 years, 45% were alive. Compared with retransplantations done before 2001, patients in the modern era were 40% more likely to survive. Compared with patients undergoing a first lung transplant in the modern era, those getting retransplanted in the same time period were 40% more likely to die after controlling for the potentially confounding effects of age, sex, race, the initial diagnosis, the type of transplant procedure, and the use of mechanical ventilation.

A statistically significant increase in risk for death if the retransplanted lungs came from a male donor should be considered with some skepticism because other studies have not shown this, Dr. Kawut said.

To help physicians advise patients considering lung retransplantation, the investigators analyzed data on a subset of 110 patients who survived at least 1 year after the procedure. They found an “absolutely dismal” survival rate of 14% for those who underwent retransplantation within 30 days of the primary transplant and 1-year survival in 58% who underwent retransplantation more than 30 days after the initial surgery—“still not perfect, but much better than 14%,” he said. “Numbers like these may be more useful for the patient in your office.”

The most difficult part of lung retransplantation is the ethical issues involved in giving one patient two opportunities for transplant when that probably denies other patients of even one transplant, because of donor organ shortages. Attention to this ethical issue “trails far behind our ability to do the procedure,” he said.

LOS ANGELES — Asking patients to perform thorough skin self-examinations and to bring a diagram of moles they observe to their appointment will improve the rates and the accuracy of self-examinations, Dr. Martin A. Weinstock said at the annual meeting of the Society for Investigational Dermatology.

In a randomized study of 88 patients being seen in primary care clinics for routine visits, all were asked to perform skin self-examinations at home for melanoma prevention, of which half were asked to make a diagram of the lesions they observed before their next visit. Dr. Weinstock and his associates photographed the patients' backs, but patients did not see the photos at that time (J.A.A.D. 2006;55:245–50).

When the patients returned 2 weeks later for a follow-up visit, they were shown two photos of their backs and told that one or both photos might contain a phony 5-mm pigmented lesion that had been added using Adobe Photoshop software.

Patients who had been asked to diagram their lesions were better able to detect the “new” lesion on their back photos, reported Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I., and his associates.

“It's a very simple intervention, and something that I now do routinely because it works,” he said. Making the lesion diagram improved the accuracy of skin self-examinations probably because patients had to really look at their back and do a more thorough job of examining the skin in order to diagram the lesions.

In a separate randomized study that has been accepted for publication, Dr. Weinstock and associates compared a multicomponent intervention designed to get people to do thorough skin self-examinations monthly with a control group of people placed on dietary interventions who also were asked to do monthly skin self-examinations.

At baseline there was no difference between groups in the proportion doing thorough skin self-examinations, but at 2, 6, and 12 months after the intervention, significantly more people in the multicomponent intervention group were doing thorough skin self-exams, compared with the control group. Participants were recruited from primary care offices.

Significantly more people in the intervention group went out and bought wall mirrors. “As research funding gets tight, I assure you that for my next grant I will figure out who manufactures these mirrors and see if they have some spare cash,” he said. The National Institutes of Health funded the study.

The proportion of people who underwent some kind of skin surgery was similar between groups in the 6 months prior to the study. Six months after the intervention, significantly more people in the intervention group had skin surgery, compared with the control group, but that difference disappeared by 12 months after the intervention.

“When you get people to look at their skin, they see all sorts of stuff that they never really noticed before, and they ask their doctor about it,” Dr. Weinstock said. That may explain the higher surgery rate after 6 months. Over time, as people become more familiar with what's on their skin, new surgery is less likely, he speculated.

A 1996 study showed that people who do skin self-examinations are about one third less likely to develop melanoma over a 5-year period and two thirds less likely to develop lethal or advanced melanomas, compared with people who don't perform skin self-exams. In general, 80%–90% of people don't do thorough skin self-examinations, he said.

Factors that increase the likelihood of people examining their skin include having a wall mirror, having a partner help with the exam, learning how to do a skin exam with a partner (instead of learning alone), and being advised by a physician to examine one's skin.

“Just tell them,” Dr. Weinstock urged.

“There's a general view among physicians who do a lot of this that patients don't pay attention to you, but in fact many of them do.”

LOS ANGELES — Asking patients to perform thorough skin self-examinations and to bring a diagram of moles they observe to their appointment will improve the rates and the accuracy of self-examinations, Dr. Martin A. Weinstock said at the annual meeting of the Society for Investigational Dermatology.

In a randomized study of 88 patients being seen in primary care clinics for routine visits, all were asked to perform skin self-examinations at home for melanoma prevention, of which half were asked to make a diagram of the lesions they observed before their next visit. Dr. Weinstock and his associates photographed the patients' backs, but patients did not see the photos at that time (J.A.A.D. 2006;55:245–50).

When the patients returned 2 weeks later for a follow-up visit, they were shown two photos of their backs and told that one or both photos might contain a phony 5-mm pigmented lesion that had been added using Adobe Photoshop software.

Patients who had been asked to diagram their lesions were better able to detect the “new” lesion on their back photos, reported Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I., and his associates.

“It's a very simple intervention, and something that I now do routinely because it works,” he said. Making the lesion diagram improved the accuracy of skin self-examinations probably because patients had to really look at their back and do a more thorough job of examining the skin in order to diagram the lesions.

In a separate randomized study that has been accepted for publication, Dr. Weinstock and associates compared a multicomponent intervention designed to get people to do thorough skin self-examinations monthly with a control group of people placed on dietary interventions who also were asked to do monthly skin self-examinations.

At baseline there was no difference between groups in the proportion doing thorough skin self-examinations, but at 2, 6, and 12 months after the intervention, significantly more people in the multicomponent intervention group were doing thorough skin self-exams, compared with the control group. Participants were recruited from primary care offices.

Significantly more people in the intervention group went out and bought wall mirrors. “As research funding gets tight, I assure you that for my next grant I will figure out who manufactures these mirrors and see if they have some spare cash,” he said. The National Institutes of Health funded the study.

The proportion of people who underwent some kind of skin surgery was similar between groups in the 6 months prior to the study. Six months after the intervention, significantly more people in the intervention group had skin surgery, compared with the control group, but that difference disappeared by 12 months after the intervention.

“When you get people to look at their skin, they see all sorts of stuff that they never really noticed before, and they ask their doctor about it,” Dr. Weinstock said. That may explain the higher surgery rate after 6 months. Over time, as people become more familiar with what's on their skin, new surgery is less likely, he speculated.

A 1996 study showed that people who do skin self-examinations are about one third less likely to develop melanoma over a 5-year period and two thirds less likely to develop lethal or advanced melanomas, compared with people who don't perform skin self-exams. In general, 80%–90% of people don't do thorough skin self-examinations, he said.

Factors that increase the likelihood of people examining their skin include having a wall mirror, having a partner help with the exam, learning how to do a skin exam with a partner (instead of learning alone), and being advised by a physician to examine one's skin.

“Just tell them,” Dr. Weinstock urged.

“There's a general view among physicians who do a lot of this that patients don't pay attention to you, but in fact many of them do.”

LOS ANGELES — Asking patients to perform thorough skin self-examinations and to bring a diagram of moles they observe to their appointment will improve the rates and the accuracy of self-examinations, Dr. Martin A. Weinstock said at the annual meeting of the Society for Investigational Dermatology.

In a randomized study of 88 patients being seen in primary care clinics for routine visits, all were asked to perform skin self-examinations at home for melanoma prevention, of which half were asked to make a diagram of the lesions they observed before their next visit. Dr. Weinstock and his associates photographed the patients' backs, but patients did not see the photos at that time (J.A.A.D. 2006;55:245–50).

When the patients returned 2 weeks later for a follow-up visit, they were shown two photos of their backs and told that one or both photos might contain a phony 5-mm pigmented lesion that had been added using Adobe Photoshop software.

Patients who had been asked to diagram their lesions were better able to detect the “new” lesion on their back photos, reported Dr. Weinstock, professor of dermatology and community health at Brown University, Providence, R.I., and his associates.

“It's a very simple intervention, and something that I now do routinely because it works,” he said. Making the lesion diagram improved the accuracy of skin self-examinations probably because patients had to really look at their back and do a more thorough job of examining the skin in order to diagram the lesions.

In a separate randomized study that has been accepted for publication, Dr. Weinstock and associates compared a multicomponent intervention designed to get people to do thorough skin self-examinations monthly with a control group of people placed on dietary interventions who also were asked to do monthly skin self-examinations.

At baseline there was no difference between groups in the proportion doing thorough skin self-examinations, but at 2, 6, and 12 months after the intervention, significantly more people in the multicomponent intervention group were doing thorough skin self-exams, compared with the control group. Participants were recruited from primary care offices.

Significantly more people in the intervention group went out and bought wall mirrors. “As research funding gets tight, I assure you that for my next grant I will figure out who manufactures these mirrors and see if they have some spare cash,” he said. The National Institutes of Health funded the study.

The proportion of people who underwent some kind of skin surgery was similar between groups in the 6 months prior to the study. Six months after the intervention, significantly more people in the intervention group had skin surgery, compared with the control group, but that difference disappeared by 12 months after the intervention.

“When you get people to look at their skin, they see all sorts of stuff that they never really noticed before, and they ask their doctor about it,” Dr. Weinstock said. That may explain the higher surgery rate after 6 months. Over time, as people become more familiar with what's on their skin, new surgery is less likely, he speculated.

A 1996 study showed that people who do skin self-examinations are about one third less likely to develop melanoma over a 5-year period and two thirds less likely to develop lethal or advanced melanomas, compared with people who don't perform skin self-exams. In general, 80%–90% of people don't do thorough skin self-examinations, he said.

Factors that increase the likelihood of people examining their skin include having a wall mirror, having a partner help with the exam, learning how to do a skin exam with a partner (instead of learning alone), and being advised by a physician to examine one's skin.

“Just tell them,” Dr. Weinstock urged.

“There's a general view among physicians who do a lot of this that patients don't pay attention to you, but in fact many of them do.”

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, as well as an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients.

No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, according to Dr. Wayne P. Gulliver.

Dr. Gulliver and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population.

The study's findings should “lead to early diagnosis and improved outcomes for the patients,” Dr. Gulliver suggested.

The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, as well as an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients.

No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, according to Dr. Wayne P. Gulliver.

Dr. Gulliver and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population.

The study's findings should “lead to early diagnosis and improved outcomes for the patients,” Dr. Gulliver suggested.

The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

LOS ANGELES — Two studies on psoriasis presented at the annual meeting of the Society for Investigative Dermatology show an association between the disease and increased mortality, as well as an increased risk for hypertension, heart disease, and diabetes.

In the first study, severe psoriasis was an independent predictor of death and increased patients' mortality risk by 50%, compared with normal control patients' risk, in a cohort study of more than 713,000 patients.

No increased risk for death was seen in patients with mild psoriasis, however, compared with controls, Shanu Kohli Kurd said at the meeting. Ms. Kurd and her associates derived the 50% greater mortality risk for severe psoriasis after adjusting for the effects of age and gender.

Patients with severe psoriasis should receive comprehensive health assessments to try to reduce their risk of death, suggested Ms. Kurd, a clinical research fellow in dermatology at the University of Pennsylvania, Philadelphia, and her associates. Multiple comorbidities that have been associated with psoriasis may increase mortality, but even after adjusting for the effects of major comorbidities, the risk of death was 40% higher in patients with severe psoriasis, compared with controls.

Severe psoriasis was defined as disease requiring systemic therapy; mild psoriasis did not require such therapy. Data drawn from the General Practice Research Database, compiled in the United Kingdom from 1987 to 2002, accounted for 3,951 patients with severe psoriasis, 133,568 patients with mild psoriasis, and up to 5 control patients for each psoriasis patient, seen in the same practices in the same time periods.

The overall incidence of death was 12 patients per 1,000 patient-years in each of three other groups: the mild psoriasis group, the 560,358 controls for the mild psoriasis group, and the 15,075 controls for the severe psoriasis group. In patients with severe psoriasis, however, overall incidence of death was 21 patients per 1,000 patient-years, Ms. Kurd reported.

The relative risk of death was greatest for younger patients with severe psoriasis, and was not affected by gender. At age 35 years, patients with severe psoriasis were 2.5 times more likely to die, compared with control patients. By age 95 years, severe psoriasis incurred only a 10% increased relative risk of death. The increased relative risk of death persisted in analyses that excluded patients with concomitant psoriatic arthritis or rheumatologic disease.

The median age of death for patients with severe psoriasis was 74 years in males and 75 years in females, compared with 77 years in males and 81 years in females in the control group.

The study was funded in part by Centocor Inc., which markets infliximab.

The second study found increased rates of hypertension, heart disease, and diabetes in patients with psoriasis, compared with the general population, according to Dr. Wayne P. Gulliver.

Dr. Gulliver and his associate at a medical research organization in St. John's, Nfld., analyzed data from the province of Newfoundland and Labrador, where the population has a high prevalence of psoriasis linked to two genetic markers for psoriasis (HLA-Cw6 and tumor necrosis factor-α238).

Surveys of 100 patients with mild to moderate psoriasis and 100 patients with severe psoriasis—all older than age 50 years—found hypertension in 25% of the mild to moderate group and 21% of the severe psoriasis group, compared with 14% of the general population aged 30–64 years.

Heart disease had been diagnosed in 14% of the mild to moderate group, 10% of the severe psoriasis group, and 4% of the general population. Diabetes was present in 10% of the mild to moderate group, 12% of the severe psoriasis group, and 4% of the general population.

Records on 169 separate patients with psoriasis who had died showed that they lived 10 years fewer, on average, compared with the average life span in Canada. Cardiovascular or genitourinary disease was more likely to be the immediate cause of death in the psoriasis group, compared with death statistics in Newfoundland and Labrador.

In the psoriasis deaths, 44% were caused by cardiovascular disease, compared with 36% in the general population. Genitourinary disease was the cause of 3% of deaths in the psoriasis group and none in the general population.

The study's findings should “lead to early diagnosis and improved outcomes for the patients,” Dr. Gulliver suggested.

The study was funded in part by Merck Serono S.A., which markets efalizumab in Europe.

SAN FRANCISCO — A plateau in bone mineral density improvement while on antiresorptive therapy for osteoporosis does not mean the treatment has stopped working, Dr. Steven T. Harris said at a diabetes update sponsored by the University of California, San Francisco.

Explain this to patients at the start of therapy to avoid disappointment or worse when their T scores stop rising, suggested Dr. Harris, of the university.

The most important clinical objective is to prevent fractures, not to produce changes in surrogate markers like bone mineral density or biochemical markers of bone turnover, he emphasized.

The risk of fracture declines significantly despite a slight improvement in T score or even no change in T score in the first year on antiresorptive medication because of improvements in bone quality. The fracture protection continues while the patient is on therapy, despite no further changes in bone mineral density.

Antiresorptive agents such as bisphosphonates, selective estrogen receptor modifiers, calcitonin, and estrogen decrease bone resorption and bone formation. This typically produces an increase in bone mineral density in the first year of therapy and a smaller increase the second year, followed by a plateau. Despite the plateau, fracture protection continues.

“It is the rule, not the exception, that bone density goes up a little, then stabilizes. That is not nonresponse. That does not mean you have to change the therapy. That does not mean your patients are not taking their medications. This is physiology in action,” Dr. Harris commented.

Explain this concept early to patients, because many of them logically assume that if a T score of −3.2 won them a diagnosis of osteoporosis, for example, then the goal of therapy is to get the T score back to zero. “As much as we'd all like to have the bone density of the average 19-year-old … it ain't happening, and it doesn't have to happen,” he said.

Studies of the bisphosphonates risedronate and alendronate, for example, show that therapy increases spinal bone density 5%–8% and hip bone density by 3%–5% after 3 years in osteoporotic women.

“Not terribly impressive” numbers until you look at the fracture protection, he noted.

The drugs reduced the incidence of vertebral fractures by 40%–65% and the incidence of hip fractures by 40%–60%. “If you had asked me 4 years ago what I thought a 4% increase in bone density could accomplish,” these benefits wouldn't have been guessed, Dr. Harris said.

SAN FRANCISCO — A plateau in bone mineral density improvement while on antiresorptive therapy for osteoporosis does not mean the treatment has stopped working, Dr. Steven T. Harris said at a diabetes update sponsored by the University of California, San Francisco.

Explain this to patients at the start of therapy to avoid disappointment or worse when their T scores stop rising, suggested Dr. Harris, of the university.

The most important clinical objective is to prevent fractures, not to produce changes in surrogate markers like bone mineral density or biochemical markers of bone turnover, he emphasized.

The risk of fracture declines significantly despite a slight improvement in T score or even no change in T score in the first year on antiresorptive medication because of improvements in bone quality. The fracture protection continues while the patient is on therapy, despite no further changes in bone mineral density.

Antiresorptive agents such as bisphosphonates, selective estrogen receptor modifiers, calcitonin, and estrogen decrease bone resorption and bone formation. This typically produces an increase in bone mineral density in the first year of therapy and a smaller increase the second year, followed by a plateau. Despite the plateau, fracture protection continues.

“It is the rule, not the exception, that bone density goes up a little, then stabilizes. That is not nonresponse. That does not mean you have to change the therapy. That does not mean your patients are not taking their medications. This is physiology in action,” Dr. Harris commented.

Explain this concept early to patients, because many of them logically assume that if a T score of −3.2 won them a diagnosis of osteoporosis, for example, then the goal of therapy is to get the T score back to zero. “As much as we'd all like to have the bone density of the average 19-year-old … it ain't happening, and it doesn't have to happen,” he said.

Studies of the bisphosphonates risedronate and alendronate, for example, show that therapy increases spinal bone density 5%–8% and hip bone density by 3%–5% after 3 years in osteoporotic women.

“Not terribly impressive” numbers until you look at the fracture protection, he noted.

The drugs reduced the incidence of vertebral fractures by 40%–65% and the incidence of hip fractures by 40%–60%. “If you had asked me 4 years ago what I thought a 4% increase in bone density could accomplish,” these benefits wouldn't have been guessed, Dr. Harris said.

SAN FRANCISCO — A plateau in bone mineral density improvement while on antiresorptive therapy for osteoporosis does not mean the treatment has stopped working, Dr. Steven T. Harris said at a diabetes update sponsored by the University of California, San Francisco.

Explain this to patients at the start of therapy to avoid disappointment or worse when their T scores stop rising, suggested Dr. Harris, of the university.

The most important clinical objective is to prevent fractures, not to produce changes in surrogate markers like bone mineral density or biochemical markers of bone turnover, he emphasized.

The risk of fracture declines significantly despite a slight improvement in T score or even no change in T score in the first year on antiresorptive medication because of improvements in bone quality. The fracture protection continues while the patient is on therapy, despite no further changes in bone mineral density.

Antiresorptive agents such as bisphosphonates, selective estrogen receptor modifiers, calcitonin, and estrogen decrease bone resorption and bone formation. This typically produces an increase in bone mineral density in the first year of therapy and a smaller increase the second year, followed by a plateau. Despite the plateau, fracture protection continues.

“It is the rule, not the exception, that bone density goes up a little, then stabilizes. That is not nonresponse. That does not mean you have to change the therapy. That does not mean your patients are not taking their medications. This is physiology in action,” Dr. Harris commented.

Explain this concept early to patients, because many of them logically assume that if a T score of −3.2 won them a diagnosis of osteoporosis, for example, then the goal of therapy is to get the T score back to zero. “As much as we'd all like to have the bone density of the average 19-year-old … it ain't happening, and it doesn't have to happen,” he said.

Studies of the bisphosphonates risedronate and alendronate, for example, show that therapy increases spinal bone density 5%–8% and hip bone density by 3%–5% after 3 years in osteoporotic women.

“Not terribly impressive” numbers until you look at the fracture protection, he noted.

The drugs reduced the incidence of vertebral fractures by 40%–65% and the incidence of hip fractures by 40%–60%. “If you had asked me 4 years ago what I thought a 4% increase in bone density could accomplish,” these benefits wouldn't have been guessed, Dr. Harris said.

LOS ANGELES — Only 6% of patients with melanoma present with the disease on the scalp or neck, but these patients account for 10% of melanoma deaths, Anne M. Lachiewicz reported in a poster presentation at the annual meeting of the Society for Investigational Dermatology.

Patients with scalp/neck melanomas died at nearly twice the rate of patients with melanomas on extremities, the face, or the ears in a retrospective study of 51,704 melanoma cases, said Ms. Lachiewicz, a medical student at the University of North Carolina, Chapel Hill.

Full-skin examinations should include a careful look at the scalp. Five-year survival for the patients in the study with scalp/neck melanomas was 83%, compared with 92% for patients with melanomas at other sites. Ten-year survival rates were 76% with scalp-neck melanomas and 89% with other melanomas.

Compared with other melanomas, scalp/neck melanomas increased the risk for death by 92% after controlling for the effects of age, sex, melanoma thickness, ulceration, lymph node status, and extent of ultraviolet light exposure.

The data came from 13 Surveillance Epidemiology and End Results (SEER) Registries that cover 14% of the U.S. population in 11 states. Ms. Lachiewicz and her associates looked at cases of first invasive melanoma among non-Hispanic white adults during 1992–2003.

Patients with scalp/neck melanomas generally were older (mean age 59 years) than patients with other melanomas (mean age 55 years), and they were more likely to be male (74% vs. 54%, respectively). At diagnosis, melanomas of the scalp/neck were thicker (0.7 mm) than melanomas at other sites (0.6 mm) and more likely to be ulcerated, nodular, or lentigo maligna subtypes. Lymph-node involvement was more common in patients with scalp/neck melanoma.

“They're clearly presenting later” in the scalp/neck group, Ms. Lachiewicz said.

Melanomas on the extremities or on the face or ears had the best prognosis after controlling for factors other than anatomic location. Melanomas on the trunk carried an intermediate risk, with a 26% greater risk of death compared with melanomas on extremities.

Besides location on the scalp/neck or trunk, other independent predictors of poor prognosis included older age, greater lesion thickness, male sex, ulceration, and positive lymph nodes.

The age-adjusted incidence rate for melanoma using the SEER data was 25 per 100,000 people. The mean age at diagnosis was 56 years, and the median lesion thickness was 0.64 mm. Males comprised 56% of patients.

The anatomic sites at diagnosis included 18% on the neck or head (of which 6% were scalp or neck and 12% were face or ears). Another 34% of lesions were on the trunk, 43% on an extremity, and 4% were unclassified or on overlapping sites. Five percent of patients had ulcerated melanomas, and 6% had melanoma in their lymph nodes.

These results could inform public health messages concerning melanoma. Emphasizing partner skin exams and educating hairdressers may help catch scalp melanomas earlier, she suggested.

Five-year survival associated with scalp/neck melanomas was 83%, compared with 92% for those at other sites. MS. LACHIEWICZ

If hairdressers were trained, it could help catch scalp melanomas earlier. Courtesy Anne M. Lachiewicz/UNC Dermatology

LOS ANGELES — Only 6% of patients with melanoma present with the disease on the scalp or neck, but these patients account for 10% of melanoma deaths, Anne M. Lachiewicz reported in a poster presentation at the annual meeting of the Society for Investigational Dermatology.

Patients with scalp/neck melanomas died at nearly twice the rate of patients with melanomas on extremities, the face, or the ears in a retrospective study of 51,704 melanoma cases, said Ms. Lachiewicz, a medical student at the University of North Carolina, Chapel Hill.

Full-skin examinations should include a careful look at the scalp. Five-year survival for the patients in the study with scalp/neck melanomas was 83%, compared with 92% for patients with melanomas at other sites. Ten-year survival rates were 76% with scalp-neck melanomas and 89% with other melanomas.

Compared with other melanomas, scalp/neck melanomas increased the risk for death by 92% after controlling for the effects of age, sex, melanoma thickness, ulceration, lymph node status, and extent of ultraviolet light exposure.

The data came from 13 Surveillance Epidemiology and End Results (SEER) Registries that cover 14% of the U.S. population in 11 states. Ms. Lachiewicz and her associates looked at cases of first invasive melanoma among non-Hispanic white adults during 1992–2003.

Patients with scalp/neck melanomas generally were older (mean age 59 years) than patients with other melanomas (mean age 55 years), and they were more likely to be male (74% vs. 54%, respectively). At diagnosis, melanomas of the scalp/neck were thicker (0.7 mm) than melanomas at other sites (0.6 mm) and more likely to be ulcerated, nodular, or lentigo maligna subtypes. Lymph-node involvement was more common in patients with scalp/neck melanoma.

“They're clearly presenting later” in the scalp/neck group, Ms. Lachiewicz said.

Melanomas on the extremities or on the face or ears had the best prognosis after controlling for factors other than anatomic location. Melanomas on the trunk carried an intermediate risk, with a 26% greater risk of death compared with melanomas on extremities.

Besides location on the scalp/neck or trunk, other independent predictors of poor prognosis included older age, greater lesion thickness, male sex, ulceration, and positive lymph nodes.

The age-adjusted incidence rate for melanoma using the SEER data was 25 per 100,000 people. The mean age at diagnosis was 56 years, and the median lesion thickness was 0.64 mm. Males comprised 56% of patients.

The anatomic sites at diagnosis included 18% on the neck or head (of which 6% were scalp or neck and 12% were face or ears). Another 34% of lesions were on the trunk, 43% on an extremity, and 4% were unclassified or on overlapping sites. Five percent of patients had ulcerated melanomas, and 6% had melanoma in their lymph nodes.

These results could inform public health messages concerning melanoma. Emphasizing partner skin exams and educating hairdressers may help catch scalp melanomas earlier, she suggested.

Five-year survival associated with scalp/neck melanomas was 83%, compared with 92% for those at other sites. MS. LACHIEWICZ

If hairdressers were trained, it could help catch scalp melanomas earlier. Courtesy Anne M. Lachiewicz/UNC Dermatology

LOS ANGELES — Only 6% of patients with melanoma present with the disease on the scalp or neck, but these patients account for 10% of melanoma deaths, Anne M. Lachiewicz reported in a poster presentation at the annual meeting of the Society for Investigational Dermatology.

Patients with scalp/neck melanomas died at nearly twice the rate of patients with melanomas on extremities, the face, or the ears in a retrospective study of 51,704 melanoma cases, said Ms. Lachiewicz, a medical student at the University of North Carolina, Chapel Hill.

Full-skin examinations should include a careful look at the scalp. Five-year survival for the patients in the study with scalp/neck melanomas was 83%, compared with 92% for patients with melanomas at other sites. Ten-year survival rates were 76% with scalp-neck melanomas and 89% with other melanomas.

Compared with other melanomas, scalp/neck melanomas increased the risk for death by 92% after controlling for the effects of age, sex, melanoma thickness, ulceration, lymph node status, and extent of ultraviolet light exposure.

The data came from 13 Surveillance Epidemiology and End Results (SEER) Registries that cover 14% of the U.S. population in 11 states. Ms. Lachiewicz and her associates looked at cases of first invasive melanoma among non-Hispanic white adults during 1992–2003.

Patients with scalp/neck melanomas generally were older (mean age 59 years) than patients with other melanomas (mean age 55 years), and they were more likely to be male (74% vs. 54%, respectively). At diagnosis, melanomas of the scalp/neck were thicker (0.7 mm) than melanomas at other sites (0.6 mm) and more likely to be ulcerated, nodular, or lentigo maligna subtypes. Lymph-node involvement was more common in patients with scalp/neck melanoma.

“They're clearly presenting later” in the scalp/neck group, Ms. Lachiewicz said.

Melanomas on the extremities or on the face or ears had the best prognosis after controlling for factors other than anatomic location. Melanomas on the trunk carried an intermediate risk, with a 26% greater risk of death compared with melanomas on extremities.

Besides location on the scalp/neck or trunk, other independent predictors of poor prognosis included older age, greater lesion thickness, male sex, ulceration, and positive lymph nodes.

The age-adjusted incidence rate for melanoma using the SEER data was 25 per 100,000 people. The mean age at diagnosis was 56 years, and the median lesion thickness was 0.64 mm. Males comprised 56% of patients.

The anatomic sites at diagnosis included 18% on the neck or head (of which 6% were scalp or neck and 12% were face or ears). Another 34% of lesions were on the trunk, 43% on an extremity, and 4% were unclassified or on overlapping sites. Five percent of patients had ulcerated melanomas, and 6% had melanoma in their lymph nodes.

These results could inform public health messages concerning melanoma. Emphasizing partner skin exams and educating hairdressers may help catch scalp melanomas earlier, she suggested.

Five-year survival associated with scalp/neck melanomas was 83%, compared with 92% for those at other sites. MS. LACHIEWICZ

If hairdressers were trained, it could help catch scalp melanomas earlier. Courtesy Anne M. Lachiewicz/UNC Dermatology

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study a year earlier in which researchers placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6 to 43 days. The results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an “impulse buy” to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these “physician extenders.”

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. “There is a sweet spot, and if you don't get them, you don't get them,” he said.

“Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months,” Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists? A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study a year earlier in which researchers placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6 to 43 days. The results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an “impulse buy” to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these “physician extenders.”

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. “There is a sweet spot, and if you don't get them, you don't get them,” he said.

“Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months,” Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists? A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

LOS ANGELES — New patients requesting cosmetic botulinum toxin injections get appointments with dermatologists in less than half the time it takes patients seeking evaluations of rapidly changing moles, a new study found.

Sham phone calls to all 898 practicing dermatologists in 12 metropolitan areas (containing about 10% of U.S. dermatologists) found that 51% offered cosmetic botulinum toxin (Botox) services. Among these, the average wait time for an appointment was 16 days, and the median wait was 8 days for patients willing to pay cash to get Botox injections for forehead wrinkles, Dr. Jack S. Resneck Jr. reported at the annual meeting of the Society for Investigative Dermatology.

A separate study a year earlier in which researchers placed sham phone calls in the same medical service areas found that 89% of dermatologists offered evaluations of rapidly changing moles. The average wait time for a new patient appointment for this potentially cancerous problem was 38 days, and the median wait was 26 days, said Dr. Resneck, a dermatologist at the University of California, San Francisco.

Wait times for Botox appointments ranged from 6 to 43 days. The results varied by geographic region. Comparing the same geographic areas surveyed in both studies, the difference in wait times for Botox or changing moles was statistically significant in 8 of the 12 areas.

Dr. Resneck said dermatologists may be giving preferential treatment to patients seeking cosmetic services. Allergan Inc., the company that markets Botox, has been showing dermatologists slide presentations that cast Botox as an “impulse buy” to be accommodated quickly lest the dermatologist risk losing the sale, he said.

There may be more benign reasons for these differences in wait times, he added. Dermatologists may block out chunks of time for Botox patients so that they use a whole vial rather than part of a vial.

Previous studies suggest that the proportion of dermatology practices with wait times longer than 30 days for appointments increased from 18% in 1996 to 48% in 2002, and was 45% in 2005. Wait times are long despite a huge influx of physician assistants and nurse practitioners into dermatologists' practices in recent years. Approximately 28% of U.S. dermatology practices now employ these “physician extenders.”

The sham calls in the current study also asked if the offices employed physician extenders who offered Botox services, and when appointments with them might be available. The median wait in practices where physician extenders provided Botox was 6 days for an appointment with a physician extender or 10 days to get Botox from the dermatologist, reported the investigators.

The use of physician extenders varied by region. In Phoenix, 40% of practices employed physician extenders, compared with 10% of practices in Little Rock, Ark.

In the Botox services study, 46% of all appointments were within 1 week of the request, compared with 24% of appointments in the changing mole study.

A physician in the audience at the meeting said some patients seek urgent appointments for Botox because of an impending wedding or other event. “There is a sweet spot, and if you don't get them, you don't get them,” he said.

“Nobody would argue with that, if we weren't in a situation where patients with a changing mole and possible malignancy are waiting 38 days for their appointments, and in a number of communities waiting 2 or 3 months,” Dr. Resneck said.

One potential weakness of the study is the question of whether the practices offering Botox are representative of all dermatologists. Might the dermatologists who offer shorter wait times for Botox appointments also offer shorter wait times for mole evaluations, compared with other dermatologists? A Kaplan-Meier analysis of this question strongly suggests that's not the case, Dr. Resneck said.

CHICAGO — Adding clonidine to a local anesthetic hastens the onset of a peripheral nerve block, prolongs the nerve block's effects, and reduces postoperative pain, Dr. Ahmad Elsharydah reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His conclusions came from a metaanalysis of data on 601 adults in 16 randomized, controlled studies that compared the addition of either clonidine or placebo to a single injection of local anesthetic for peripheral nerve block.

Dr. Elsharydah and his associates undertook the meta-analysis because previous studies presented conflicting conclusions about the benefits of adding clonidine to local anesthetics in peripheral and central nerve blocks.

Each of the studies in the meta-analysis was reviewed by three investigators.

The studies did not provide enough data to draw a firm conclusion about the safety of combining clonidine with local anesthetic, but most investigators reported minimal or no adverse reactions, said Dr. Elsharydah of the anesthesia and surgery departments at Louisiana State University, Shreveport.

Dr. Elsharydah has no association with the company that makes clonidine.

Most patients in the 16 studies received peripheral nerve blocks in their upper extremities. The most common local anesthetics used were ropivacaine or mepivacaine; from 0.1 to 3.8 mcg/kg of clonidine was added to the anesthetics.

Pain assessed by visual analog scale scores was significantly lower at multiple points in time after surgery in patients who received clonidine. The clonidine group also needed less postoperative morphine, especially in the first 24 hours, he said.

The time from administration of the peripheral nerve block to the onset of effects was shorter in the clonidine group, and the effects of the block lasted significantly longer than in the placebo group.

Nine of the 16 studies found no difference between groups in the odds of developing hypotension, bradycardia, or sedation, although these findings were not published, Dr. Elsharydah said. Meta-analyses showed that clonidine use was associated with an increased risk of sedation in three studies, a higher risk of hypotension in three studies, and greater odds of bradycardia in three studies.

More well-designed, controlled trials are needed to confirm the findings of this meta-analysis, he said.

CHICAGO — Adding clonidine to a local anesthetic hastens the onset of a peripheral nerve block, prolongs the nerve block's effects, and reduces postoperative pain, Dr. Ahmad Elsharydah reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His conclusions came from a metaanalysis of data on 601 adults in 16 randomized, controlled studies that compared the addition of either clonidine or placebo to a single injection of local anesthetic for peripheral nerve block.

Dr. Elsharydah and his associates undertook the meta-analysis because previous studies presented conflicting conclusions about the benefits of adding clonidine to local anesthetics in peripheral and central nerve blocks.

Each of the studies in the meta-analysis was reviewed by three investigators.

The studies did not provide enough data to draw a firm conclusion about the safety of combining clonidine with local anesthetic, but most investigators reported minimal or no adverse reactions, said Dr. Elsharydah of the anesthesia and surgery departments at Louisiana State University, Shreveport.

Dr. Elsharydah has no association with the company that makes clonidine.

Most patients in the 16 studies received peripheral nerve blocks in their upper extremities. The most common local anesthetics used were ropivacaine or mepivacaine; from 0.1 to 3.8 mcg/kg of clonidine was added to the anesthetics.

Pain assessed by visual analog scale scores was significantly lower at multiple points in time after surgery in patients who received clonidine. The clonidine group also needed less postoperative morphine, especially in the first 24 hours, he said.

The time from administration of the peripheral nerve block to the onset of effects was shorter in the clonidine group, and the effects of the block lasted significantly longer than in the placebo group.

Nine of the 16 studies found no difference between groups in the odds of developing hypotension, bradycardia, or sedation, although these findings were not published, Dr. Elsharydah said. Meta-analyses showed that clonidine use was associated with an increased risk of sedation in three studies, a higher risk of hypotension in three studies, and greater odds of bradycardia in three studies.

More well-designed, controlled trials are needed to confirm the findings of this meta-analysis, he said.

CHICAGO — Adding clonidine to a local anesthetic hastens the onset of a peripheral nerve block, prolongs the nerve block's effects, and reduces postoperative pain, Dr. Ahmad Elsharydah reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

His conclusions came from a metaanalysis of data on 601 adults in 16 randomized, controlled studies that compared the addition of either clonidine or placebo to a single injection of local anesthetic for peripheral nerve block.

Dr. Elsharydah and his associates undertook the meta-analysis because previous studies presented conflicting conclusions about the benefits of adding clonidine to local anesthetics in peripheral and central nerve blocks.

Each of the studies in the meta-analysis was reviewed by three investigators.

The studies did not provide enough data to draw a firm conclusion about the safety of combining clonidine with local anesthetic, but most investigators reported minimal or no adverse reactions, said Dr. Elsharydah of the anesthesia and surgery departments at Louisiana State University, Shreveport.

Dr. Elsharydah has no association with the company that makes clonidine.

Most patients in the 16 studies received peripheral nerve blocks in their upper extremities. The most common local anesthetics used were ropivacaine or mepivacaine; from 0.1 to 3.8 mcg/kg of clonidine was added to the anesthetics.

Pain assessed by visual analog scale scores was significantly lower at multiple points in time after surgery in patients who received clonidine. The clonidine group also needed less postoperative morphine, especially in the first 24 hours, he said.

The time from administration of the peripheral nerve block to the onset of effects was shorter in the clonidine group, and the effects of the block lasted significantly longer than in the placebo group.

Nine of the 16 studies found no difference between groups in the odds of developing hypotension, bradycardia, or sedation, although these findings were not published, Dr. Elsharydah said. Meta-analyses showed that clonidine use was associated with an increased risk of sedation in three studies, a higher risk of hypotension in three studies, and greater odds of bradycardia in three studies.

More well-designed, controlled trials are needed to confirm the findings of this meta-analysis, he said.