Sherry Boschert

SAN FRANCISCO — A majority of patients presenting to emergency departments with pulmonary edema have diastolic heart failure, also known as heart failure with preserved ejection fraction, Dr. William Grossman said.

A recent analysis of data from more than 100,000 hospitalizations in the Acute Decompensated Heart Failure Registry (ADHERE) showed that 51% of patients with heart failure had preserved ejection fractions, and 49% had depressed ejection fractions, also called systolic heart failure (J. Am. Coll. Cardiol. 2006;47:76–84). In-hospital mortality rates were 3% with diastolic heart failure and 4% with systolic heart failure, he said at a meeting sponsored by the California chapter of the American College of Cardiology.

That finding may surprise many people who attribute death from heart failure mainly to systolic dysfunction, said Dr. Grossman, chief of cardiology at the University of California, San Francisco. Many patients have both types of heart failure.

Compared with the systolic heart failure group, patients who had diastolic heart failure were more likely to be women and less likely to have a prior MI or to be taking ACE inhibitors or angiotensin receptor blockers (ARBs).

In a separate recent study, investigators from the Mayo Clinic, Rochester, Minn., followed 556 patients with heart failure in the community for 6 months. The mortality rate was 16% both in the 55% of patients with diastolic heart failure and in the rest of the cohort, who had systolic heart failure, Dr. Grossman noted.

“The prognosis is really not much better than for classic systolic heart failure,” he said at the meeting, also sponsored by the university.

In the Mayo Clinic study, diastolic dysfunction and the patient's ejection fraction independently predicted elevation of brain natriuretic peptide (BNP).

“When patients come to the emergency ward with acute shortness of breath, many of us look to the BNP to tell us, is this pneumonia? Is this asthma? Is this hypertension? BNP is elevated in heart failure whether it's systolic or diastolic,” an important fact to recognize, he said.

If diastolic heart failure is so widespread, what's causing it? It's not all caused by amyloidosis, and is unlikely to be due to untreated hypertension in so many cases, Dr. Grossman believes.

German investigators performed cardiac biopsies and other tests on 70 patients hospitalized with diastolic heart failure and found that 84% were infected with parvovirus B19. Presence of the virus was strongly associated with coronary endothelial dysfunction (Circulation 2005;111:879–86).

“I'm not saying this is what's going on in our emergency wards, but it's certainly something that I would never have thought to look for. We should pay attention. There may be increased information about this in the future,” Dr. Grossman commented.

There are few data from randomized trials to guide treatment of diastolic heart failure. Dr. Grossman approaches management much as he would for patients with systolic heart failure.

SAN FRANCISCO — A majority of patients presenting to emergency departments with pulmonary edema have diastolic heart failure, also known as heart failure with preserved ejection fraction, Dr. William Grossman said.

A recent analysis of data from more than 100,000 hospitalizations in the Acute Decompensated Heart Failure Registry (ADHERE) showed that 51% of patients with heart failure had preserved ejection fractions, and 49% had depressed ejection fractions, also called systolic heart failure (J. Am. Coll. Cardiol. 2006;47:76–84). In-hospital mortality rates were 3% with diastolic heart failure and 4% with systolic heart failure, he said at a meeting sponsored by the California chapter of the American College of Cardiology.

That finding may surprise many people who attribute death from heart failure mainly to systolic dysfunction, said Dr. Grossman, chief of cardiology at the University of California, San Francisco. Many patients have both types of heart failure.

Compared with the systolic heart failure group, patients who had diastolic heart failure were more likely to be women and less likely to have a prior MI or to be taking ACE inhibitors or angiotensin receptor blockers (ARBs).

In a separate recent study, investigators from the Mayo Clinic, Rochester, Minn., followed 556 patients with heart failure in the community for 6 months. The mortality rate was 16% both in the 55% of patients with diastolic heart failure and in the rest of the cohort, who had systolic heart failure, Dr. Grossman noted.

“The prognosis is really not much better than for classic systolic heart failure,” he said at the meeting, also sponsored by the university.

In the Mayo Clinic study, diastolic dysfunction and the patient's ejection fraction independently predicted elevation of brain natriuretic peptide (BNP).

“When patients come to the emergency ward with acute shortness of breath, many of us look to the BNP to tell us, is this pneumonia? Is this asthma? Is this hypertension? BNP is elevated in heart failure whether it's systolic or diastolic,” an important fact to recognize, he said.

If diastolic heart failure is so widespread, what's causing it? It's not all caused by amyloidosis, and is unlikely to be due to untreated hypertension in so many cases, Dr. Grossman believes.

German investigators performed cardiac biopsies and other tests on 70 patients hospitalized with diastolic heart failure and found that 84% were infected with parvovirus B19. Presence of the virus was strongly associated with coronary endothelial dysfunction (Circulation 2005;111:879–86).

“I'm not saying this is what's going on in our emergency wards, but it's certainly something that I would never have thought to look for. We should pay attention. There may be increased information about this in the future,” Dr. Grossman commented.

There are few data from randomized trials to guide treatment of diastolic heart failure. Dr. Grossman approaches management much as he would for patients with systolic heart failure.

SAN FRANCISCO — A majority of patients presenting to emergency departments with pulmonary edema have diastolic heart failure, also known as heart failure with preserved ejection fraction, Dr. William Grossman said.

A recent analysis of data from more than 100,000 hospitalizations in the Acute Decompensated Heart Failure Registry (ADHERE) showed that 51% of patients with heart failure had preserved ejection fractions, and 49% had depressed ejection fractions, also called systolic heart failure (J. Am. Coll. Cardiol. 2006;47:76–84). In-hospital mortality rates were 3% with diastolic heart failure and 4% with systolic heart failure, he said at a meeting sponsored by the California chapter of the American College of Cardiology.

That finding may surprise many people who attribute death from heart failure mainly to systolic dysfunction, said Dr. Grossman, chief of cardiology at the University of California, San Francisco. Many patients have both types of heart failure.

Compared with the systolic heart failure group, patients who had diastolic heart failure were more likely to be women and less likely to have a prior MI or to be taking ACE inhibitors or angiotensin receptor blockers (ARBs).

In a separate recent study, investigators from the Mayo Clinic, Rochester, Minn., followed 556 patients with heart failure in the community for 6 months. The mortality rate was 16% both in the 55% of patients with diastolic heart failure and in the rest of the cohort, who had systolic heart failure, Dr. Grossman noted.

“The prognosis is really not much better than for classic systolic heart failure,” he said at the meeting, also sponsored by the university.

In the Mayo Clinic study, diastolic dysfunction and the patient's ejection fraction independently predicted elevation of brain natriuretic peptide (BNP).

“When patients come to the emergency ward with acute shortness of breath, many of us look to the BNP to tell us, is this pneumonia? Is this asthma? Is this hypertension? BNP is elevated in heart failure whether it's systolic or diastolic,” an important fact to recognize, he said.

If diastolic heart failure is so widespread, what's causing it? It's not all caused by amyloidosis, and is unlikely to be due to untreated hypertension in so many cases, Dr. Grossman believes.

German investigators performed cardiac biopsies and other tests on 70 patients hospitalized with diastolic heart failure and found that 84% were infected with parvovirus B19. Presence of the virus was strongly associated with coronary endothelial dysfunction (Circulation 2005;111:879–86).

“I'm not saying this is what's going on in our emergency wards, but it's certainly something that I would never have thought to look for. We should pay attention. There may be increased information about this in the future,” Dr. Grossman commented.

There are few data from randomized trials to guide treatment of diastolic heart failure. Dr. Grossman approaches management much as he would for patients with systolic heart failure.

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, she said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts, as well as to protect other aspects of their physical and personal/social well-being.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease.

Heavy drinkers often are malnourished, so treatment should include attention to a healthy diet including thiamine supplementation, Dr. Gray advised. Treat cardiac arrhythmias or systemic hypertension promptly in heavy drinkers, she added.

Most heavy drinkers also are heavy cigarette smokers. Dr. Gray and associates plan to study the interplay between cigarette smoke and alcohol consumption to try to tease out their causal effects in alcoholic cardiomyopathy.

Binge drinking doubled the risk of death in a study of patients being treated for acute MI. ©Boris Kaulin/FOTOLIA

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, she said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts, as well as to protect other aspects of their physical and personal/social well-being.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease.

Heavy drinkers often are malnourished, so treatment should include attention to a healthy diet including thiamine supplementation, Dr. Gray advised. Treat cardiac arrhythmias or systemic hypertension promptly in heavy drinkers, she added.

Most heavy drinkers also are heavy cigarette smokers. Dr. Gray and associates plan to study the interplay between cigarette smoke and alcohol consumption to try to tease out their causal effects in alcoholic cardiomyopathy.

Binge drinking doubled the risk of death in a study of patients being treated for acute MI. ©Boris Kaulin/FOTOLIA

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, she said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts, as well as to protect other aspects of their physical and personal/social well-being.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease.

Heavy drinkers often are malnourished, so treatment should include attention to a healthy diet including thiamine supplementation, Dr. Gray advised. Treat cardiac arrhythmias or systemic hypertension promptly in heavy drinkers, she added.

Most heavy drinkers also are heavy cigarette smokers. Dr. Gray and associates plan to study the interplay between cigarette smoke and alcohol consumption to try to tease out their causal effects in alcoholic cardiomyopathy.

Binge drinking doubled the risk of death in a study of patients being treated for acute MI. ©Boris Kaulin/FOTOLIA

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)–fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives, she said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

Diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms: anger/irritability; depressed mood; moodiness; and anxiety/edginess/nervousness. Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed, headache, breast tenderness, bloating, and joint or muscle pain.

For women with PMDD on oral contraceptives, a pill containing drospirenone and ethinylestradiol improved PMDD symptoms in several studies. Other data suggest shortening the hormone-free interval during oral contraceptive regimens to 3–4 days can improve some symptoms.

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)–fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives, she said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

Diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms: anger/irritability; depressed mood; moodiness; and anxiety/edginess/nervousness. Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed, headache, breast tenderness, bloating, and joint or muscle pain.

For women with PMDD on oral contraceptives, a pill containing drospirenone and ethinylestradiol improved PMDD symptoms in several studies. Other data suggest shortening the hormone-free interval during oral contraceptive regimens to 3–4 days can improve some symptoms.

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)–fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline. OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives, she said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

Diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms: anger/irritability; depressed mood; moodiness; and anxiety/edginess/nervousness. Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed, headache, breast tenderness, bloating, and joint or muscle pain.

For women with PMDD on oral contraceptives, a pill containing drospirenone and ethinylestradiol improved PMDD symptoms in several studies. Other data suggest shortening the hormone-free interval during oral contraceptive regimens to 3–4 days can improve some symptoms.

SCOTTSDALE, ARIZ. — Think of coccidioidomycosis in patients with a rash, fever, and cough, even if they don't live in the southwestern United States where Coccidioides is endemic.

At least two patients have presented to the Mayo Clinic, Rochester, Minn., with cutaneous manifestations of coccidioidomycosis. Both patients were “snowbirds” who traveled to warmer climates in the southwest during the winter, according to physicians from the Mayo Clinic, Scottsdale, Ariz.

Although this mainly is a lung infection, cutaneous manifestations provide a clue to the diagnosis. “In the last 10 years at the Mayo Clinic in Arizona, I've been impressed by how often the dermatologist has a role to play in the diagnosis of coccidioidomycosis,” Dr. David J. DiCaudo said at a dermatology conference sponsored by Skin Disease Education Foundation.

The desert areas of the southwestern United States and northern Mexico are the prime locations of this fungus, which is found in the western United States, Central America, and south to Argentina. Most U.S. infections occur in Arizona and in California's San Joaquin Valley, where a syndrome with the infection was first recognized and dubbed “valley fever,” said Dr. DiCaudo of the Mayo Clinic, Scottsdale.

The incidence of coccidioidomycosis in Arizona more than tripled in the past decade, with a 56% increase in the past year alone. Droughts in recent years and construction activity stirring up soil and dust probably have contributed to the increase, he suggested. The organism lives in soil as filamentous mycelia that break down into arthroconidia, which can be carried on the wind and inhaled. Once inside people or animals, they transform into the spherule form recognized in biopsy specimens.

Most Coccidioides infections cause no symptoms. Around 40% of infected people develop a mild to moderate influenzalike illness with fever, cough, chills, and arthralgias. Even healthy people can be severely affected and laid low for weeks by the symptoms. Fewer than 1% develops severe infection or dissemination to the meninges or bones, with some deaths. People of Filipino heritage are hundreds of times more likely to develop severe infection or dissemination, compared with the general population, and African Americans are at increased risk as well, Dr. DiCaudo said. People with compromised immune systems caused by pregnancy, HIV infection, organ transplant, or those using steroids or other immunocompromising medications also face greater risk with this infection.

The painful red nodules of erythema nodosum are the most common cutaneous manifestation of coccidioidomycosis. They typically appear on the lower extremities 1–3 weeks after the onset of systemic symptoms and suggest a good prognosis. Other cutaneous symptoms appear earlier. Acute exanthem may appear within the first 24–48 hours of illness. “I've seen several patients who had a florid eruption even before the onset of any other symptom. Days later, they developed fever and cough,” he said.

The acute exanthem can resemble a drug reaction. Associated pruritus may be mild to severe. Lesions on the palms are common. It may last days or weeks.

The infection also can cause Sweet's syndrome, presenting as painful plaques, often but not always on the upper body, associated with fever and peripheral blood leukocytosis. In other settings, Sweet's syndrome commonly is treated with systemic corticosteroids. “It's worth checking to make sure the patient doesn't have coccidioidomycosis first,” because an immunosuppressive drug would increase their risk, Dr. DiCaudo said.

Granulomatous dermatitis can develop early in the course of the disease with widely distributed papules and plaques.

All of these cutaneous symptoms are reactive conditions; no Coccidioides will be found in the skin. The skin symptoms evolve over a period of weeks or months as the patient recovers from the pulmonary infection.

A skin biopsy can be helpful, however, in rare disseminated infection, which typically develops 1–3 months after the onset of illness and can cause nodules, granulomatous plaques, and ulcers on the skin. It can mimic many other diseases including tuberculosis or acne. Even rarer is primary cutaneous infection at the site of inoculation, typically from injury by a laboratory pipette, a splinter, or even a cactus spine.

Serology is the key to diagnosing coccidioidomycosis. Keep in mind that the rash precedes seroconversion, so you may want to retest some patients with negative serologies 2 weeks later, he said. Low titers are common and shouldn't be dismissed.

The IgG antibody test can be positive and the IgM negative during active infection and shouldn't be interpreted as a past infection, he added. The antibodies tend to disappear following recovery, so a positive titer most likely represents acute infection.

The large spherules (10–80 mcm) of Coccidioides are easily seen under microscopy, typically as granulomatous or suppurative inflammatory infiltrate. If needed, an in situ hybridization assay is available to distinguish the organism from Blastomyces or Cryptococcus.

Patients with coccidioidomycosis generally are managed by primary care physicians or infectious disease specialists.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

Sweet's syndrome, presenting as painful plaques, are associated with pulmonary coccidioidomycosis. Courtesy Dr. David J. DiCaudo

SCOTTSDALE, ARIZ. — Think of coccidioidomycosis in patients with a rash, fever, and cough, even if they don't live in the southwestern United States where Coccidioides is endemic.

At least two patients have presented to the Mayo Clinic, Rochester, Minn., with cutaneous manifestations of coccidioidomycosis. Both patients were “snowbirds” who traveled to warmer climates in the southwest during the winter, according to physicians from the Mayo Clinic, Scottsdale, Ariz.

Although this mainly is a lung infection, cutaneous manifestations provide a clue to the diagnosis. “In the last 10 years at the Mayo Clinic in Arizona, I've been impressed by how often the dermatologist has a role to play in the diagnosis of coccidioidomycosis,” Dr. David J. DiCaudo said at a dermatology conference sponsored by Skin Disease Education Foundation.

The desert areas of the southwestern United States and northern Mexico are the prime locations of this fungus, which is found in the western United States, Central America, and south to Argentina. Most U.S. infections occur in Arizona and in California's San Joaquin Valley, where a syndrome with the infection was first recognized and dubbed “valley fever,” said Dr. DiCaudo of the Mayo Clinic, Scottsdale.

The incidence of coccidioidomycosis in Arizona more than tripled in the past decade, with a 56% increase in the past year alone. Droughts in recent years and construction activity stirring up soil and dust probably have contributed to the increase, he suggested. The organism lives in soil as filamentous mycelia that break down into arthroconidia, which can be carried on the wind and inhaled. Once inside people or animals, they transform into the spherule form recognized in biopsy specimens.

Most Coccidioides infections cause no symptoms. Around 40% of infected people develop a mild to moderate influenzalike illness with fever, cough, chills, and arthralgias. Even healthy people can be severely affected and laid low for weeks by the symptoms. Fewer than 1% develops severe infection or dissemination to the meninges or bones, with some deaths. People of Filipino heritage are hundreds of times more likely to develop severe infection or dissemination, compared with the general population, and African Americans are at increased risk as well, Dr. DiCaudo said. People with compromised immune systems caused by pregnancy, HIV infection, organ transplant, or those using steroids or other immunocompromising medications also face greater risk with this infection.

The painful red nodules of erythema nodosum are the most common cutaneous manifestation of coccidioidomycosis. They typically appear on the lower extremities 1–3 weeks after the onset of systemic symptoms and suggest a good prognosis. Other cutaneous symptoms appear earlier. Acute exanthem may appear within the first 24–48 hours of illness. “I've seen several patients who had a florid eruption even before the onset of any other symptom. Days later, they developed fever and cough,” he said.

The acute exanthem can resemble a drug reaction. Associated pruritus may be mild to severe. Lesions on the palms are common. It may last days or weeks.

The infection also can cause Sweet's syndrome, presenting as painful plaques, often but not always on the upper body, associated with fever and peripheral blood leukocytosis. In other settings, Sweet's syndrome commonly is treated with systemic corticosteroids. “It's worth checking to make sure the patient doesn't have coccidioidomycosis first,” because an immunosuppressive drug would increase their risk, Dr. DiCaudo said.

Granulomatous dermatitis can develop early in the course of the disease with widely distributed papules and plaques.

All of these cutaneous symptoms are reactive conditions; no Coccidioides will be found in the skin. The skin symptoms evolve over a period of weeks or months as the patient recovers from the pulmonary infection.

A skin biopsy can be helpful, however, in rare disseminated infection, which typically develops 1–3 months after the onset of illness and can cause nodules, granulomatous plaques, and ulcers on the skin. It can mimic many other diseases including tuberculosis or acne. Even rarer is primary cutaneous infection at the site of inoculation, typically from injury by a laboratory pipette, a splinter, or even a cactus spine.

Serology is the key to diagnosing coccidioidomycosis. Keep in mind that the rash precedes seroconversion, so you may want to retest some patients with negative serologies 2 weeks later, he said. Low titers are common and shouldn't be dismissed.

The IgG antibody test can be positive and the IgM negative during active infection and shouldn't be interpreted as a past infection, he added. The antibodies tend to disappear following recovery, so a positive titer most likely represents acute infection.

The large spherules (10–80 mcm) of Coccidioides are easily seen under microscopy, typically as granulomatous or suppurative inflammatory infiltrate. If needed, an in situ hybridization assay is available to distinguish the organism from Blastomyces or Cryptococcus.

Patients with coccidioidomycosis generally are managed by primary care physicians or infectious disease specialists.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

Sweet's syndrome, presenting as painful plaques, are associated with pulmonary coccidioidomycosis. Courtesy Dr. David J. DiCaudo

SCOTTSDALE, ARIZ. — Think of coccidioidomycosis in patients with a rash, fever, and cough, even if they don't live in the southwestern United States where Coccidioides is endemic.

At least two patients have presented to the Mayo Clinic, Rochester, Minn., with cutaneous manifestations of coccidioidomycosis. Both patients were “snowbirds” who traveled to warmer climates in the southwest during the winter, according to physicians from the Mayo Clinic, Scottsdale, Ariz.

Although this mainly is a lung infection, cutaneous manifestations provide a clue to the diagnosis. “In the last 10 years at the Mayo Clinic in Arizona, I've been impressed by how often the dermatologist has a role to play in the diagnosis of coccidioidomycosis,” Dr. David J. DiCaudo said at a dermatology conference sponsored by Skin Disease Education Foundation.

The desert areas of the southwestern United States and northern Mexico are the prime locations of this fungus, which is found in the western United States, Central America, and south to Argentina. Most U.S. infections occur in Arizona and in California's San Joaquin Valley, where a syndrome with the infection was first recognized and dubbed “valley fever,” said Dr. DiCaudo of the Mayo Clinic, Scottsdale.

The incidence of coccidioidomycosis in Arizona more than tripled in the past decade, with a 56% increase in the past year alone. Droughts in recent years and construction activity stirring up soil and dust probably have contributed to the increase, he suggested. The organism lives in soil as filamentous mycelia that break down into arthroconidia, which can be carried on the wind and inhaled. Once inside people or animals, they transform into the spherule form recognized in biopsy specimens.

Most Coccidioides infections cause no symptoms. Around 40% of infected people develop a mild to moderate influenzalike illness with fever, cough, chills, and arthralgias. Even healthy people can be severely affected and laid low for weeks by the symptoms. Fewer than 1% develops severe infection or dissemination to the meninges or bones, with some deaths. People of Filipino heritage are hundreds of times more likely to develop severe infection or dissemination, compared with the general population, and African Americans are at increased risk as well, Dr. DiCaudo said. People with compromised immune systems caused by pregnancy, HIV infection, organ transplant, or those using steroids or other immunocompromising medications also face greater risk with this infection.

The painful red nodules of erythema nodosum are the most common cutaneous manifestation of coccidioidomycosis. They typically appear on the lower extremities 1–3 weeks after the onset of systemic symptoms and suggest a good prognosis. Other cutaneous symptoms appear earlier. Acute exanthem may appear within the first 24–48 hours of illness. “I've seen several patients who had a florid eruption even before the onset of any other symptom. Days later, they developed fever and cough,” he said.

The acute exanthem can resemble a drug reaction. Associated pruritus may be mild to severe. Lesions on the palms are common. It may last days or weeks.

The infection also can cause Sweet's syndrome, presenting as painful plaques, often but not always on the upper body, associated with fever and peripheral blood leukocytosis. In other settings, Sweet's syndrome commonly is treated with systemic corticosteroids. “It's worth checking to make sure the patient doesn't have coccidioidomycosis first,” because an immunosuppressive drug would increase their risk, Dr. DiCaudo said.

Granulomatous dermatitis can develop early in the course of the disease with widely distributed papules and plaques.

All of these cutaneous symptoms are reactive conditions; no Coccidioides will be found in the skin. The skin symptoms evolve over a period of weeks or months as the patient recovers from the pulmonary infection.

A skin biopsy can be helpful, however, in rare disseminated infection, which typically develops 1–3 months after the onset of illness and can cause nodules, granulomatous plaques, and ulcers on the skin. It can mimic many other diseases including tuberculosis or acne. Even rarer is primary cutaneous infection at the site of inoculation, typically from injury by a laboratory pipette, a splinter, or even a cactus spine.

Serology is the key to diagnosing coccidioidomycosis. Keep in mind that the rash precedes seroconversion, so you may want to retest some patients with negative serologies 2 weeks later, he said. Low titers are common and shouldn't be dismissed.

The IgG antibody test can be positive and the IgM negative during active infection and shouldn't be interpreted as a past infection, he added. The antibodies tend to disappear following recovery, so a positive titer most likely represents acute infection.

The large spherules (10–80 mcm) of Coccidioides are easily seen under microscopy, typically as granulomatous or suppurative inflammatory infiltrate. If needed, an in situ hybridization assay is available to distinguish the organism from Blastomyces or Cryptococcus.

Patients with coccidioidomycosis generally are managed by primary care physicians or infectious disease specialists.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

Sweet's syndrome, presenting as painful plaques, are associated with pulmonary coccidioidomycosis. Courtesy Dr. David J. DiCaudo

SAN FRANCISCO— Treatment of asymptomatic thyroid disease is controversial but probably worthwhile, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroid-stimulating hormone (TSH) tests are very sensitive and frequently pick up subclinical thyroid disease. The frequency of referrals for subclinical disease seems to be increasing, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minn. “We get a lot of consultations coming our way because of this.”

When free T4 hormone levels are normal, a TSH level below 0.5 mIU/L indicates subclinical hyperthyroidism, and a TSH level greater than 5.0 mIU/L indicates subclinical hypothyroid disease. If both the TSH and free T4 levels are abnormal, the patient has clinical thyroid disease, he said.

Make sure you have the right diagnosis before considering treatment, Dr. Gharib cautioned. A low TSH may be seen in patients who are hospitalized, have pituitary disease, or are being treated with thyroxin or amiodarone. An elevated TSH may be due to thyroid hormone resistance, rare forms of hyperthyroidism, or other causes.

He argued for treatment of subclinical hyperthyroidism because of potential cardiac, bone, and mortality benefits. The Framingham heart study showed that a TSH level below 0.1 mIU/L was associated with a 28% incidence of atrial fibrillation, triple the relative risk for atrial fibrillation seen in people with normal TSH levels during the 10-year study (N. Engl. J. Med. 1994;331:1249–52).

It is well established that accelerated bone loss seen with either clinical or subclinical hyperthyroidism (especially in menopausal women) can be arrested or reversed with treatment of thyroid disease, he added. Another long-term study shows that people with low TSH levels have an increased risk of dying, probably from cardiovascular causes (Lancet 2001;358:861–5).

He argued for treatment of subclinical hypothyroid disease to prevent progression to overt hypothyroidism, reduce symptoms, and reduce risks from increases in total cholesterol or cardiovascular problems that may accompany frank hypothyroidism. Treatment of subclinical hypothyroidism is controversial especially because it is not a life-threatening problem and usually is asymptomatic.

One study found that people with subclinical hypothyroidism who were TSH antibody positive had a 55% chance of progressing to clinical hypothyroid disease over 20 years compared with a 27% cumulative incidence of frank hypothyroidism in people with normal TSH levels who were TSH antibody positive (Clin. Endocrinol. 1995;43:55–68).

“I think that the evidence is compelling enough that we should tell the patient, 'Let's treat today so you won't become clinically hypothyroid,'” he said.

The presence of other factors should influence the decision to treat, he added. A physician may choose not to treat a healthy 35-year-old with subclinical hypothyroidism, but should strongly consider treatment in the presence of thyroid peroxidase antibodies, goiter, elevated total cholesterol, infertility, or symptoms of hyperthyroidism.

Any woman with subclinical hypothyroidism who is pregnant or thinking of becoming pregnant should be treated because even a mildly abnormal TSH level in the early stages of pregnancy can cause adverse pregnancy outcomes, Dr. Gharib said.

He suggested that women older than 30 years should get a TSH test periodically. The American Thyroid Association recommends a TSH test for women at age 35 years, to be repeated every 5 years.

Endocrine Society guidelines advise observing patients if the TSH level is 0.1–0.5 mIU/L, treating most patients with a TSH between 5 mIU/L and 10 mIU/L, and treating all patients with TSH levels that are below 0.1 mIU/L or above 10 mIU/L.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Make sure you have the right diagnosis before you begin treatment. DR. GHARIB

SAN FRANCISCO— Treatment of asymptomatic thyroid disease is controversial but probably worthwhile, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroid-stimulating hormone (TSH) tests are very sensitive and frequently pick up subclinical thyroid disease. The frequency of referrals for subclinical disease seems to be increasing, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minn. “We get a lot of consultations coming our way because of this.”

When free T4 hormone levels are normal, a TSH level below 0.5 mIU/L indicates subclinical hyperthyroidism, and a TSH level greater than 5.0 mIU/L indicates subclinical hypothyroid disease. If both the TSH and free T4 levels are abnormal, the patient has clinical thyroid disease, he said.

Make sure you have the right diagnosis before considering treatment, Dr. Gharib cautioned. A low TSH may be seen in patients who are hospitalized, have pituitary disease, or are being treated with thyroxin or amiodarone. An elevated TSH may be due to thyroid hormone resistance, rare forms of hyperthyroidism, or other causes.

He argued for treatment of subclinical hyperthyroidism because of potential cardiac, bone, and mortality benefits. The Framingham heart study showed that a TSH level below 0.1 mIU/L was associated with a 28% incidence of atrial fibrillation, triple the relative risk for atrial fibrillation seen in people with normal TSH levels during the 10-year study (N. Engl. J. Med. 1994;331:1249–52).

It is well established that accelerated bone loss seen with either clinical or subclinical hyperthyroidism (especially in menopausal women) can be arrested or reversed with treatment of thyroid disease, he added. Another long-term study shows that people with low TSH levels have an increased risk of dying, probably from cardiovascular causes (Lancet 2001;358:861–5).

He argued for treatment of subclinical hypothyroid disease to prevent progression to overt hypothyroidism, reduce symptoms, and reduce risks from increases in total cholesterol or cardiovascular problems that may accompany frank hypothyroidism. Treatment of subclinical hypothyroidism is controversial especially because it is not a life-threatening problem and usually is asymptomatic.

One study found that people with subclinical hypothyroidism who were TSH antibody positive had a 55% chance of progressing to clinical hypothyroid disease over 20 years compared with a 27% cumulative incidence of frank hypothyroidism in people with normal TSH levels who were TSH antibody positive (Clin. Endocrinol. 1995;43:55–68).

“I think that the evidence is compelling enough that we should tell the patient, 'Let's treat today so you won't become clinically hypothyroid,'” he said.

The presence of other factors should influence the decision to treat, he added. A physician may choose not to treat a healthy 35-year-old with subclinical hypothyroidism, but should strongly consider treatment in the presence of thyroid peroxidase antibodies, goiter, elevated total cholesterol, infertility, or symptoms of hyperthyroidism.

Any woman with subclinical hypothyroidism who is pregnant or thinking of becoming pregnant should be treated because even a mildly abnormal TSH level in the early stages of pregnancy can cause adverse pregnancy outcomes, Dr. Gharib said.

He suggested that women older than 30 years should get a TSH test periodically. The American Thyroid Association recommends a TSH test for women at age 35 years, to be repeated every 5 years.

Endocrine Society guidelines advise observing patients if the TSH level is 0.1–0.5 mIU/L, treating most patients with a TSH between 5 mIU/L and 10 mIU/L, and treating all patients with TSH levels that are below 0.1 mIU/L or above 10 mIU/L.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Make sure you have the right diagnosis before you begin treatment. DR. GHARIB

SAN FRANCISCO— Treatment of asymptomatic thyroid disease is controversial but probably worthwhile, Dr. Hossein Gharib said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

Thyroid-stimulating hormone (TSH) tests are very sensitive and frequently pick up subclinical thyroid disease. The frequency of referrals for subclinical disease seems to be increasing, said Dr. Gharib, professor of medicine at the Mayo Clinic College of Medicine in Rochester, Minn. “We get a lot of consultations coming our way because of this.”

When free T4 hormone levels are normal, a TSH level below 0.5 mIU/L indicates subclinical hyperthyroidism, and a TSH level greater than 5.0 mIU/L indicates subclinical hypothyroid disease. If both the TSH and free T4 levels are abnormal, the patient has clinical thyroid disease, he said.

Make sure you have the right diagnosis before considering treatment, Dr. Gharib cautioned. A low TSH may be seen in patients who are hospitalized, have pituitary disease, or are being treated with thyroxin or amiodarone. An elevated TSH may be due to thyroid hormone resistance, rare forms of hyperthyroidism, or other causes.

He argued for treatment of subclinical hyperthyroidism because of potential cardiac, bone, and mortality benefits. The Framingham heart study showed that a TSH level below 0.1 mIU/L was associated with a 28% incidence of atrial fibrillation, triple the relative risk for atrial fibrillation seen in people with normal TSH levels during the 10-year study (N. Engl. J. Med. 1994;331:1249–52).

It is well established that accelerated bone loss seen with either clinical or subclinical hyperthyroidism (especially in menopausal women) can be arrested or reversed with treatment of thyroid disease, he added. Another long-term study shows that people with low TSH levels have an increased risk of dying, probably from cardiovascular causes (Lancet 2001;358:861–5).

He argued for treatment of subclinical hypothyroid disease to prevent progression to overt hypothyroidism, reduce symptoms, and reduce risks from increases in total cholesterol or cardiovascular problems that may accompany frank hypothyroidism. Treatment of subclinical hypothyroidism is controversial especially because it is not a life-threatening problem and usually is asymptomatic.

One study found that people with subclinical hypothyroidism who were TSH antibody positive had a 55% chance of progressing to clinical hypothyroid disease over 20 years compared with a 27% cumulative incidence of frank hypothyroidism in people with normal TSH levels who were TSH antibody positive (Clin. Endocrinol. 1995;43:55–68).

“I think that the evidence is compelling enough that we should tell the patient, 'Let's treat today so you won't become clinically hypothyroid,'” he said.

The presence of other factors should influence the decision to treat, he added. A physician may choose not to treat a healthy 35-year-old with subclinical hypothyroidism, but should strongly consider treatment in the presence of thyroid peroxidase antibodies, goiter, elevated total cholesterol, infertility, or symptoms of hyperthyroidism.

Any woman with subclinical hypothyroidism who is pregnant or thinking of becoming pregnant should be treated because even a mildly abnormal TSH level in the early stages of pregnancy can cause adverse pregnancy outcomes, Dr. Gharib said.

He suggested that women older than 30 years should get a TSH test periodically. The American Thyroid Association recommends a TSH test for women at age 35 years, to be repeated every 5 years.

Endocrine Society guidelines advise observing patients if the TSH level is 0.1–0.5 mIU/L, treating most patients with a TSH between 5 mIU/L and 10 mIU/L, and treating all patients with TSH levels that are below 0.1 mIU/L or above 10 mIU/L.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

Make sure you have the right diagnosis before you begin treatment. DR. GHARIB

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, Dr. Grey said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease. An older patient who also uses cocaine or has coronary disease or diabetes is much less likely to recover cardiac function with abstinence, she said.

Heavy drinkers often are malnourished, so treatment should include focus on a healthy diet with thiamine supplementation, Dr. Gray advised. The investigators also plan to study the interplay between cigarette smoke and alcohol consumption.

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, Dr. Grey said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease. An older patient who also uses cocaine or has coronary disease or diabetes is much less likely to recover cardiac function with abstinence, she said.

Heavy drinkers often are malnourished, so treatment should include focus on a healthy diet with thiamine supplementation, Dr. Gray advised. The investigators also plan to study the interplay between cigarette smoke and alcohol consumption.

SAN FRANCISCO — Moderate consumption of alcohol can be part of a healthy lifestyle to prevent cardiac disease, but not if you drink too fast, Dr. Mary O. Gray said at a meeting sponsored by the California chapter of the American College of Cardiology.

The cardioprotective benefits of alcohol appear to be limited to one drink per day for women or two drinks per day for men (with a “drink” consisting of one glass of wine, one shot of liquor, or one bottle or can of beer). Beyond that, alcohol is cardiotoxic, said Dr. Gray of San Francisco General Hospital.

Binge drinking—defined as consuming three or more drinks in 1 or 2 hours—doubled the risk of death from any cause in a recent study of patients treated for acute MI (Circulation 2005;112:3839–45). Investigators interviewed 2,000 patients a median of 4 days after a confirmed MI and found that regular consumption of alcohol reduced their risk of death, but binge drinking blocked or attenuated this benefit.

The negative effects of binge drinking applied regardless of whether a person was a light or heavy drinker overall. The study also asked about other factors that might affect cardiovascular risk, such as vigorous activity or vigorous sexual activity, but found no correlation with mortality, Dr. Grey said at the meeting, also sponsored by the University of California, San Francisco.

Heavy drinking for a long time can cause alcoholic cardiomyopathy, a diagnosis made clinically through history and elimination of other etiologies. Heavy drinkers with hypertension or heart failure should be advised to stop drinking to preserve their hearts.

Data on very heavy drinkers suggest that those who develop heart failure may recover cardiovascular function if they stop drinking. Recovery is more likely if the patient is relatively young and has no other risk factors for cardiovascular disease. An older patient who also uses cocaine or has coronary disease or diabetes is much less likely to recover cardiac function with abstinence, she said.

Heavy drinkers often are malnourished, so treatment should include focus on a healthy diet with thiamine supplementation, Dr. Gray advised. The investigators also plan to study the interplay between cigarette smoke and alcohol consumption.

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at a meeting on women's health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)—fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives—from 576 to 672 days, approximately. “That's a lot of days to feel lousy or be incapacitated,” Dr. Singer said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

A diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms—anger or irritability; depressed mood; moodiness; and anxiety/edginess/nervousness.

Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed or out of control, and physical symptoms such as headache, breast tenderness, bloating, and joint or muscle pain.

For women on oral contraceptives with PMDD, using a pill containing the novel progestin drospirenone and ethinylestradiol improved symptoms of PMDD in several studies. Other studies suggest that shortening the hormone-free interval during oral contraceptive regimens from the standard 7 days to 3–4 days can improve some PMDD symptoms, Dr. Singer said.

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at a meeting on women's health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)—fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives—from 576 to 672 days, approximately. “That's a lot of days to feel lousy or be incapacitated,” Dr. Singer said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

A diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms—anger or irritability; depressed mood; moodiness; and anxiety/edginess/nervousness.

Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed or out of control, and physical symptoms such as headache, breast tenderness, bloating, and joint or muscle pain.

For women on oral contraceptives with PMDD, using a pill containing the novel progestin drospirenone and ethinylestradiol improved symptoms of PMDD in several studies. Other studies suggest that shortening the hormone-free interval during oral contraceptive regimens from the standard 7 days to 3–4 days can improve some PMDD symptoms, Dr. Singer said.

SAN FRANCISCO — Women with premenstrual dysphoric disorder usually respond rapidly to the first treatment cycle of an antidepressant, allowing intermittent dosing that follows the menstrual cycle, Dr. Andrea J. Singer said at a meeting on women's health sponsored by OB.GYN. NEWS.

Three selective serotonin reuptake inhibitors (SSRIs) are approved for the treatment of premenstrual dysphoric disorder (PMDD)—fluoxetine, sertraline, and paroxetine. “You don't necessarily have to have people on these long term to see a benefit,” said Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington.

Dr. Singer is on the speakers' bureau of Pfizer Inc., which makes sertraline.

PMDD causes severe premenstrual symptoms that result in significant impairment of normal function, usually during the last 6–7 days of the menstrual cycle. American women with PMDD experience the symptoms on average for 8 years during their reproductive lives—from 576 to 672 days, approximately. “That's a lot of days to feel lousy or be incapacitated,” Dr. Singer said.

Because the disorder is intermittent and treatment with an SSRI brings rapid onset of improvement, intermittent therapy is sufficient, which lowers medication costs and limits side effects, compared with treatment of overt depression. In addition, low doses typically are effective for PMDD.

A diagnosis of PMDD requires the exclusion of underlying overt depression and the presence of at least five symptoms, including at least one of four core symptoms—anger or irritability; depressed mood; moodiness; and anxiety/edginess/nervousness.

Other symptoms include fatigue or lethargy, decreased interest in usual activities, insomnia or hypersomnia, difficulty concentrating, food cravings or appetite changes, feeling overwhelmed or out of control, and physical symptoms such as headache, breast tenderness, bloating, and joint or muscle pain.

For women on oral contraceptives with PMDD, using a pill containing the novel progestin drospirenone and ethinylestradiol improved symptoms of PMDD in several studies. Other studies suggest that shortening the hormone-free interval during oral contraceptive regimens from the standard 7 days to 3–4 days can improve some PMDD symptoms, Dr. Singer said.

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy can mimic the heart disease symptoms, said Dr. Crawford, professor of medicine at the University of California, San Francisco,

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment for cardiomyopathy differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery.

ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia.

“You get by with diuretics, digoxin, and hydralazine during pregnancy” for peripartum cardiomyopathy, Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. “That's encouraging,” he noted.

The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity, which are symptoms of cardiomyopathy, also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, also are normal symptoms of pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left.

Physical findings in normal pregnancies may include jugular venous distension, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

“It can be confusing,” Dr. Crawford said.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added.

Consider prophylactic medication in women with risk factors (thrombophilia, history of thrombosis, antiphospholipid syndrome, lupus erythematosus, sickle cell anemia, or any kind of heart disease that would lead to thrombus formation).

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added.

Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy can mimic the heart disease symptoms, said Dr. Crawford, professor of medicine at the University of California, San Francisco,

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment for cardiomyopathy differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery.

ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia.

“You get by with diuretics, digoxin, and hydralazine during pregnancy” for peripartum cardiomyopathy, Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. “That's encouraging,” he noted.

The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity, which are symptoms of cardiomyopathy, also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, also are normal symptoms of pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left.

Physical findings in normal pregnancies may include jugular venous distension, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

“It can be confusing,” Dr. Crawford said.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added.

Consider prophylactic medication in women with risk factors (thrombophilia, history of thrombosis, antiphospholipid syndrome, lupus erythematosus, sickle cell anemia, or any kind of heart disease that would lead to thrombus formation).

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added.

Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

SAN FRANCISCO — Maternal peripartum cardiomyopathy, seen in 1 in 3,000 live births, generally carries a good prognosis, Dr. Michael Crawford said at a meeting sponsored by the California chapter of the American College of Cardiology.

Diagnosis of peripartum cardiomyopathy—or of other heart diseases during pregnancy—often is delayed because the symptoms of pregnancy can mimic the heart disease symptoms, said Dr. Crawford, professor of medicine at the University of California, San Francisco,

A majority of women with peripartum cardiomyopathy recover after delivery, but 10%–20% require heart transplantation and 1%–2% die, data suggest. The patient's ejection fraction 2 months after diagnosis appears to be the best prognostic factor, he said at the meeting, also sponsored by the university.

Treatment for cardiomyopathy differs for pregnant women compared with nonpregnant patients because some drugs shouldn't be used until after delivery.

ACE inhibitors and warfarin are teratogenic, and β-blockers can lead to fetal bradycardia.

“You get by with diuretics, digoxin, and hydralazine during pregnancy” for peripartum cardiomyopathy, Dr. Crawford said.

In a recent study at a large medical center, ejection fractions improved at least 15% in 62% of women with peripartum cardiomyopathy, remained unchanged in 25%, and declined in 13% (Am. Heart J. 2006;152:509–13).

Ejection fractions returned to normal in 45%. Ten percent of patients required transplantation. No patients died during an average 43-month follow-up. “That's encouraging,” he noted.

The initial echocardiogram, obtained between 1 month prepartum and 5 months post partum, did not predict which patients required transplantation, nor which had final ejection fractions below or above 50%. “Don't get discouraged with the first echo,” Dr. Crawford said. Echocardiograms 2 months later predicted outcomes in that study.

Patients with ejection fractions below 20% probably are headed for transplant. Those with ejection fractions between 20% and 50% should see some improvement but are unlikely to return to normal. If the 2-month ejection fraction is above 40%, the patient is likely to recover fully (defined as an ejection fraction greater than 50%), he said.

Shortness of breath and decreased exercise capacity, which are symptoms of cardiomyopathy, also are symptoms of a normal pregnancy. Fatigue, orthopnea, and dizziness or syncope, which might be symptoms of other heart disease, also are normal symptoms of pregnancy.

Electrocardiograms in normal pregnancies often detect sinus tachycardia, and may show nonspecific ST-T changes. As the pregnancy advances, the heart's axis shifts more to the left.

Physical findings in normal pregnancies may include jugular venous distension, an enlarged left ventricle apex, right ventricle heave, a palpable pulmonary artery pulse, third heart sounds, systolic ejection murmurs, venous hums, or a mammary souffle noise if you listen over the breast.

“It can be confusing,” Dr. Crawford said.

The most common peripartum cardiovascular problem is venous thromboembolism, which is the leading cause of death in pregnancy, he added.

Consider prophylactic medication in women with risk factors (thrombophilia, history of thrombosis, antiphospholipid syndrome, lupus erythematosus, sickle cell anemia, or any kind of heart disease that would lead to thrombus formation).

Coronary artery disease during pregnancy is more common than one might think, perhaps because more women are having children later in life, he added.

Maternal MI occurs in 6 out of 100,000 deliveries, three to four times more common than is expected in age-matched nonpregnant women.

SAN FRANCISCO — Consider not only the risks of antidepressant drugs but also the risks of not treating depression during pregnancy, Dr. Andrea J. Singer recommended.

Approximately 1 in 10 women become depressed at some point during pregnancy. In addition to nonpharmacologic therapies such as increased social support, cognitive-behavioral therapy, or counseling as first-line treatments, many depressed women need supplemental antidepressant medication, she said at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

“How we treat depends on the severity of depression. There are clear data that a significantly depressed mother is at more risk than a mother on antidepressant medication,” Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington, said at the meeting.

Because the effectiveness of antidepressant medications generally is comparable between classes and within classes of drugs, the choice of pharmacotherapy—and which medication—rests on questions of safety and tolerability for both the mother and fetus, patient preference, cost, and the quantity and quality of data available on the drug.

If depression is not adequately treated, the woman will have a higher risk for suicide, poor maternal and fetal nutrition, adverse neonatal outcomes, continued depression into the postpartum period, and impaired mother-child bonding, said Dr. Singer.

Depression during pregnancy is associated with an increased likelihood of using drugs, alcohol, or nicotine and a decreased likelihood of getting early prenatal care.

Depressed pregnant women often don't report depression but more often complain of physical health problems, compared with nondepressed pregnant women, she added.

The incidence of premature births is higher in depressed than in nondepressed women. Compared with term deliveries, children born prematurely tend to perform less well in school, are less likely to graduate from high school, and have higher rates of neurosensory impairments, bipolar disorder, and subnormal height.

Antidepressants probably are the best-studied class of drugs used during pregnancy, though the amount of data from controlled clinical trials still is small, said Dr. Singer. She is on the speakers' bureau of Pfizer, which makes the SSRI sertraline.

Two studies in the past decade encompassing a total of 1,089 women found no causal relationship between use of tricyclic and noncyclic antidepressants and adverse pregnancy outcomes, Dr. Singer said.

In general, no increase in teratogenic risk has been found with use of the SSRIs fluvoxamine or sertraline, which are the antidepressants most commonly prescribed for pregnant women.

One recent study suggests that paroxetine use during the first trimester might be associated with an increased risk of cardiovascular birth defects, particularly ventricular septal defects, she said.

In addition, there have been several reports of possible withdrawal symptoms in babies who were exposed to SSRIs during or at the end of the third trimester. The reports describe neonatal jitteriness, irritability, or respiratory difficulties.

Physicians may want to consider temporarily halting maternal SSRI therapy near the end of the third trimester in some patients who can tolerate an interruption in therapy and restarting the medication in the postpartum period, Dr. Singer suggested. Watch neonates born to women who took SSRIs late in pregnancy for potential withdrawal signs, she added.

The women at greatest risk for developing depression during pregnancy are those with a history of depression before pregnancy. “That's a red flag to follow the patient closely during pregnancy,” she said.

Other risk factors for depression during pregnancy include a history of premenstrual dysphoric disorder, younger maternal age, living alone or with limited social support, ambivalence about the pregnancy, conflict with her spouse or significant other, and having multiple other children.

SAN FRANCISCO — Consider not only the risks of antidepressant drugs but also the risks of not treating depression during pregnancy, Dr. Andrea J. Singer recommended.

Approximately 1 in 10 women become depressed at some point during pregnancy. In addition to nonpharmacologic therapies such as increased social support, cognitive-behavioral therapy, or counseling as first-line treatments, many depressed women need supplemental antidepressant medication, she said at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

“How we treat depends on the severity of depression. There are clear data that a significantly depressed mother is at more risk than a mother on antidepressant medication,” Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington, said at the meeting.

Because the effectiveness of antidepressant medications generally is comparable between classes and within classes of drugs, the choice of pharmacotherapy—and which medication—rests on questions of safety and tolerability for both the mother and fetus, patient preference, cost, and the quantity and quality of data available on the drug.

If depression is not adequately treated, the woman will have a higher risk for suicide, poor maternal and fetal nutrition, adverse neonatal outcomes, continued depression into the postpartum period, and impaired mother-child bonding, said Dr. Singer.

Depression during pregnancy is associated with an increased likelihood of using drugs, alcohol, or nicotine and a decreased likelihood of getting early prenatal care.

Depressed pregnant women often don't report depression but more often complain of physical health problems, compared with nondepressed pregnant women, she added.

The incidence of premature births is higher in depressed than in nondepressed women. Compared with term deliveries, children born prematurely tend to perform less well in school, are less likely to graduate from high school, and have higher rates of neurosensory impairments, bipolar disorder, and subnormal height.

Antidepressants probably are the best-studied class of drugs used during pregnancy, though the amount of data from controlled clinical trials still is small, said Dr. Singer. She is on the speakers' bureau of Pfizer, which makes the SSRI sertraline.

Two studies in the past decade encompassing a total of 1,089 women found no causal relationship between use of tricyclic and noncyclic antidepressants and adverse pregnancy outcomes, Dr. Singer said.

In general, no increase in teratogenic risk has been found with use of the SSRIs fluvoxamine or sertraline, which are the antidepressants most commonly prescribed for pregnant women.

One recent study suggests that paroxetine use during the first trimester might be associated with an increased risk of cardiovascular birth defects, particularly ventricular septal defects, she said.

In addition, there have been several reports of possible withdrawal symptoms in babies who were exposed to SSRIs during or at the end of the third trimester. The reports describe neonatal jitteriness, irritability, or respiratory difficulties.

Physicians may want to consider temporarily halting maternal SSRI therapy near the end of the third trimester in some patients who can tolerate an interruption in therapy and restarting the medication in the postpartum period, Dr. Singer suggested. Watch neonates born to women who took SSRIs late in pregnancy for potential withdrawal signs, she added.

The women at greatest risk for developing depression during pregnancy are those with a history of depression before pregnancy. “That's a red flag to follow the patient closely during pregnancy,” she said.

Other risk factors for depression during pregnancy include a history of premenstrual dysphoric disorder, younger maternal age, living alone or with limited social support, ambivalence about the pregnancy, conflict with her spouse or significant other, and having multiple other children.

SAN FRANCISCO — Consider not only the risks of antidepressant drugs but also the risks of not treating depression during pregnancy, Dr. Andrea J. Singer recommended.

Approximately 1 in 10 women become depressed at some point during pregnancy. In addition to nonpharmacologic therapies such as increased social support, cognitive-behavioral therapy, or counseling as first-line treatments, many depressed women need supplemental antidepressant medication, she said at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

“How we treat depends on the severity of depression. There are clear data that a significantly depressed mother is at more risk than a mother on antidepressant medication,” Dr. Singer, director of women's primary care at Georgetown University Medical Center, Washington, said at the meeting.

Because the effectiveness of antidepressant medications generally is comparable between classes and within classes of drugs, the choice of pharmacotherapy—and which medication—rests on questions of safety and tolerability for both the mother and fetus, patient preference, cost, and the quantity and quality of data available on the drug.

If depression is not adequately treated, the woman will have a higher risk for suicide, poor maternal and fetal nutrition, adverse neonatal outcomes, continued depression into the postpartum period, and impaired mother-child bonding, said Dr. Singer.

Depression during pregnancy is associated with an increased likelihood of using drugs, alcohol, or nicotine and a decreased likelihood of getting early prenatal care.

Depressed pregnant women often don't report depression but more often complain of physical health problems, compared with nondepressed pregnant women, she added.

The incidence of premature births is higher in depressed than in nondepressed women. Compared with term deliveries, children born prematurely tend to perform less well in school, are less likely to graduate from high school, and have higher rates of neurosensory impairments, bipolar disorder, and subnormal height.

Antidepressants probably are the best-studied class of drugs used during pregnancy, though the amount of data from controlled clinical trials still is small, said Dr. Singer. She is on the speakers' bureau of Pfizer, which makes the SSRI sertraline.

Two studies in the past decade encompassing a total of 1,089 women found no causal relationship between use of tricyclic and noncyclic antidepressants and adverse pregnancy outcomes, Dr. Singer said.

In general, no increase in teratogenic risk has been found with use of the SSRIs fluvoxamine or sertraline, which are the antidepressants most commonly prescribed for pregnant women.

One recent study suggests that paroxetine use during the first trimester might be associated with an increased risk of cardiovascular birth defects, particularly ventricular septal defects, she said.

In addition, there have been several reports of possible withdrawal symptoms in babies who were exposed to SSRIs during or at the end of the third trimester. The reports describe neonatal jitteriness, irritability, or respiratory difficulties.

Physicians may want to consider temporarily halting maternal SSRI therapy near the end of the third trimester in some patients who can tolerate an interruption in therapy and restarting the medication in the postpartum period, Dr. Singer suggested. Watch neonates born to women who took SSRIs late in pregnancy for potential withdrawal signs, she added.

The women at greatest risk for developing depression during pregnancy are those with a history of depression before pregnancy. “That's a red flag to follow the patient closely during pregnancy,” she said.

Other risk factors for depression during pregnancy include a history of premenstrual dysphoric disorder, younger maternal age, living alone or with limited social support, ambivalence about the pregnancy, conflict with her spouse or significant other, and having multiple other children.