Sherry Boschert

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal can become socially embarrassed by the sound and smell, start shunning social gatherings, or may even develop marital problems, said Dr. Mann of the university.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet.

The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested.

Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics.

For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients and measured the number of times they passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective.

“I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases.

In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans.

Yucca schidigera also has been studied in dogs but may cause bleeding problems.

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal can become socially embarrassed by the sound and smell, start shunning social gatherings, or may even develop marital problems, said Dr. Mann of the university.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet.

The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested.

Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics.

For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients and measured the number of times they passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective.

“I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases.

In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans.

Yucca schidigera also has been studied in dogs but may cause bleeding problems.

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal can become socially embarrassed by the sound and smell, start shunning social gatherings, or may even develop marital problems, said Dr. Mann of the university.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet.

The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested.

Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics.

For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients and measured the number of times they passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective.

“I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases.

In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans.

Yucca schidigera also has been studied in dogs but may cause bleeding problems.

WINNIPEG, MAN. — People who developed their first basal cell carcinoma or squamous cell carcinoma had a higher risk of developing and dying of a second primary cancer, data from a retrospective study of 43,275 patients showed.

A first basal cell carcinoma quadrupled the relative risk for melanoma in men, tripled the risk for melanoma in women, and raised women's risk for lip cancer fivefold. Men with a first primary squamous cell cancer had nine times the risk for salivary gland cancer, compared with men without the first cancer, Dr. Marni C. Wiseman said.

Death from esophageal cancer was seven times more likely in men and five times more likely in women if they'd had a first primary nonmelanoma skin cancer. A first squamous cell cancer increased the risk of death from Hodgkin's lymphoma 14-fold in men. Death from genitourinary cancer was three to four times more common in women after a first primary basal or squamous cell carcinoma, she said at the annual conference of the Canadian Dermatology Association.

The study looked at cancer-free people who developed a first primary nonmelanoma skin cancer between 1956 and 2000. These cancers seldom are treated with systemic therapy or chemotherapy that might alter a patient's chances of getting unrelated second primary cancers, said Dr. Wiseman of the department of dermatology at the University of Manitoba, Winnipeg, and director of cutaneous oncology at CancerCare Manitoba. Patients in the Manitoba Cancer Registry, which recorded other cancers but excluded second nonmelanoma skin cancers, were tracked.

Of the first primary nonmelanoma skin cancers, 21% were squamous cell carcinoma, 74% were basal cell carcinoma, and 5% were other nonmelanoma skin cancers. Of patients in the squamous cell cancer group, 16% developed a second primary nonmelanoma skin cancer, as did 17% of patients in the basal cell carcinoma group.

Compared with people who had no history of nonmelanoma skin cancer, men diagnosed between the ages of 40 and 79 years and women diagnosed between the ages of 40 and 74 years with basal or squamous cell carcinoma had a higher risk for a second primary cancer.

Overall, the risk remained elevated for only 4 years following diagnosis of the primary nonmelanoma skin cancer, except in women originally diagnosed with squamous cell carcinoma, whose risk stayed elevated. For patients diagnosed with a first primary basal or squamous cell carcinoma at a young age (under 60 years), however, the risk of a second primary cancer was permanently elevated, ranging from a relative risk of 1.07 to 1.51 depending on sex and type of first cancer. In general, the lifetime risk of developing a first primary basal cell or squamous cell cancer is common—14% in men and 16% in women.

Dr. Wiseman said it is not known why the risk for a second primary cancer and death is increased, but it is reasonable to think that in some patients, a nonmelanoma skin cancer may be a “first glimpse” of overall cancer-prone status.

WINNIPEG, MAN. — People who developed their first basal cell carcinoma or squamous cell carcinoma had a higher risk of developing and dying of a second primary cancer, data from a retrospective study of 43,275 patients showed.

A first basal cell carcinoma quadrupled the relative risk for melanoma in men, tripled the risk for melanoma in women, and raised women's risk for lip cancer fivefold. Men with a first primary squamous cell cancer had nine times the risk for salivary gland cancer, compared with men without the first cancer, Dr. Marni C. Wiseman said.

Death from esophageal cancer was seven times more likely in men and five times more likely in women if they'd had a first primary nonmelanoma skin cancer. A first squamous cell cancer increased the risk of death from Hodgkin's lymphoma 14-fold in men. Death from genitourinary cancer was three to four times more common in women after a first primary basal or squamous cell carcinoma, she said at the annual conference of the Canadian Dermatology Association.

The study looked at cancer-free people who developed a first primary nonmelanoma skin cancer between 1956 and 2000. These cancers seldom are treated with systemic therapy or chemotherapy that might alter a patient's chances of getting unrelated second primary cancers, said Dr. Wiseman of the department of dermatology at the University of Manitoba, Winnipeg, and director of cutaneous oncology at CancerCare Manitoba. Patients in the Manitoba Cancer Registry, which recorded other cancers but excluded second nonmelanoma skin cancers, were tracked.

Of the first primary nonmelanoma skin cancers, 21% were squamous cell carcinoma, 74% were basal cell carcinoma, and 5% were other nonmelanoma skin cancers. Of patients in the squamous cell cancer group, 16% developed a second primary nonmelanoma skin cancer, as did 17% of patients in the basal cell carcinoma group.

Compared with people who had no history of nonmelanoma skin cancer, men diagnosed between the ages of 40 and 79 years and women diagnosed between the ages of 40 and 74 years with basal or squamous cell carcinoma had a higher risk for a second primary cancer.

Overall, the risk remained elevated for only 4 years following diagnosis of the primary nonmelanoma skin cancer, except in women originally diagnosed with squamous cell carcinoma, whose risk stayed elevated. For patients diagnosed with a first primary basal or squamous cell carcinoma at a young age (under 60 years), however, the risk of a second primary cancer was permanently elevated, ranging from a relative risk of 1.07 to 1.51 depending on sex and type of first cancer. In general, the lifetime risk of developing a first primary basal cell or squamous cell cancer is common—14% in men and 16% in women.

Dr. Wiseman said it is not known why the risk for a second primary cancer and death is increased, but it is reasonable to think that in some patients, a nonmelanoma skin cancer may be a “first glimpse” of overall cancer-prone status.

WINNIPEG, MAN. — People who developed their first basal cell carcinoma or squamous cell carcinoma had a higher risk of developing and dying of a second primary cancer, data from a retrospective study of 43,275 patients showed.

A first basal cell carcinoma quadrupled the relative risk for melanoma in men, tripled the risk for melanoma in women, and raised women's risk for lip cancer fivefold. Men with a first primary squamous cell cancer had nine times the risk for salivary gland cancer, compared with men without the first cancer, Dr. Marni C. Wiseman said.

Death from esophageal cancer was seven times more likely in men and five times more likely in women if they'd had a first primary nonmelanoma skin cancer. A first squamous cell cancer increased the risk of death from Hodgkin's lymphoma 14-fold in men. Death from genitourinary cancer was three to four times more common in women after a first primary basal or squamous cell carcinoma, she said at the annual conference of the Canadian Dermatology Association.

The study looked at cancer-free people who developed a first primary nonmelanoma skin cancer between 1956 and 2000. These cancers seldom are treated with systemic therapy or chemotherapy that might alter a patient's chances of getting unrelated second primary cancers, said Dr. Wiseman of the department of dermatology at the University of Manitoba, Winnipeg, and director of cutaneous oncology at CancerCare Manitoba. Patients in the Manitoba Cancer Registry, which recorded other cancers but excluded second nonmelanoma skin cancers, were tracked.

Of the first primary nonmelanoma skin cancers, 21% were squamous cell carcinoma, 74% were basal cell carcinoma, and 5% were other nonmelanoma skin cancers. Of patients in the squamous cell cancer group, 16% developed a second primary nonmelanoma skin cancer, as did 17% of patients in the basal cell carcinoma group.

Compared with people who had no history of nonmelanoma skin cancer, men diagnosed between the ages of 40 and 79 years and women diagnosed between the ages of 40 and 74 years with basal or squamous cell carcinoma had a higher risk for a second primary cancer.

Overall, the risk remained elevated for only 4 years following diagnosis of the primary nonmelanoma skin cancer, except in women originally diagnosed with squamous cell carcinoma, whose risk stayed elevated. For patients diagnosed with a first primary basal or squamous cell carcinoma at a young age (under 60 years), however, the risk of a second primary cancer was permanently elevated, ranging from a relative risk of 1.07 to 1.51 depending on sex and type of first cancer. In general, the lifetime risk of developing a first primary basal cell or squamous cell cancer is common—14% in men and 16% in women.

Dr. Wiseman said it is not known why the risk for a second primary cancer and death is increased, but it is reasonable to think that in some patients, a nonmelanoma skin cancer may be a “first glimpse” of overall cancer-prone status.

LAKE TAHOE, CALIF. — An implanted device that delivers gastric electrical stimulation can relieve chronic gastroparesis in patients who do not respond to drug therapy, Dr. Amar Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Called Enterra therapy, the device is approved for humanitarian use in fewer than 4,000 patients per year who have intractable nausea and vomiting from idiopathic or diabetic gastroparesis and whose symptoms cannot be controlled by medications.

Gastric electrical stimulation is “a new tool that has really changed the management of gastroparesis,” said Dr. Al-Juburi, of the division of gastroenterology at the university.

He has no relationship with Medtronic Inc., the company that makes the device.

Although institutional review board approval is required before a hospital begins using the device, many medical centers in the United States now offer Enterra therapy, and more than 1,000 of these electrical stimulators have been implanted, he estimated.

A randomized, double-blind, placebo-controlled, crossover trial involving 33 patients helped win approval of the device for humanitarian use. The Worldwide Anti-Vomiting Electrical Stimulation Study began with the device turned on in one group of patients and turned off in a second group.

One month later, the groups switched device status, and were followed for another month. Then all patients were followed with the device turned on for another 10 months for a total of 12 months.

In the first 2 months, gastric electrical stimulation significantly decreased nausea and vomiting, compared with no stimulation; and most patients preferred the time span when the device was turned on (Gastroenterology 2003;125:421–8).

Among the 23 patients followed for 12 months—with the device turned on during 11 of those months—52% showed a greater than 80% reduction in the frequency of vomiting, and 79% had at least a 50% reduction in vomiting.

A summary of scores for nausea, vomiting, anorexia, abdominal pain, and distention in each patient improved significantly at 6 and 12 months, compared with baseline.

Hospitalizations dropped significantly. “That's very important,” Dr. Al-Juburi noted. Patients with moderate to severe gastroparesis often show up in emergency rooms and get admitted, and it can be difficult to improve symptoms enough to discharge them.

In the study, the mean number of days spent in the hospital by 24 patients decreased from 49 in the year before Enterra therapy to 28 days in the year after implantation of the device.

“For drug-refractory gastroparesis, this is the way to go,” said Dr. Al-Juburi, whose institution just started using the device.

The treatment works through high-frequency stimulation of the autonomic nervous system via a neurostimulator device that's about 2 inches in length by 1 inch in width and 0.5 inch thick.

Surgeons create three or four abdominal 5-mm ports laparoscopically to implant the device; the upper right port is used as a subcutaneous pocket to house the stimulator near the stomach's greater curvature.

Leads from the device are sutured 10 cm from the stomach's pylorus, in the area thought to be responsible for gastric pacing, Dr. Al-Juburi said. An external programmer that's turned on after stimulator implantation can be adjusted to the stimulation parameter that produces the best response.

Implantation of the device takes about 1 hour to perform. In the current study, patients spent a mean of 6 days in the hospital related to the implantation surgery.

“Gastric stimulation is, so far, really a good option for drug-refractory gastroparesis,” he said.

LAKE TAHOE, CALIF. — An implanted device that delivers gastric electrical stimulation can relieve chronic gastroparesis in patients who do not respond to drug therapy, Dr. Amar Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Called Enterra therapy, the device is approved for humanitarian use in fewer than 4,000 patients per year who have intractable nausea and vomiting from idiopathic or diabetic gastroparesis and whose symptoms cannot be controlled by medications.

Gastric electrical stimulation is “a new tool that has really changed the management of gastroparesis,” said Dr. Al-Juburi, of the division of gastroenterology at the university.

He has no relationship with Medtronic Inc., the company that makes the device.

Although institutional review board approval is required before a hospital begins using the device, many medical centers in the United States now offer Enterra therapy, and more than 1,000 of these electrical stimulators have been implanted, he estimated.

A randomized, double-blind, placebo-controlled, crossover trial involving 33 patients helped win approval of the device for humanitarian use. The Worldwide Anti-Vomiting Electrical Stimulation Study began with the device turned on in one group of patients and turned off in a second group.

One month later, the groups switched device status, and were followed for another month. Then all patients were followed with the device turned on for another 10 months for a total of 12 months.

In the first 2 months, gastric electrical stimulation significantly decreased nausea and vomiting, compared with no stimulation; and most patients preferred the time span when the device was turned on (Gastroenterology 2003;125:421–8).

Among the 23 patients followed for 12 months—with the device turned on during 11 of those months—52% showed a greater than 80% reduction in the frequency of vomiting, and 79% had at least a 50% reduction in vomiting.

A summary of scores for nausea, vomiting, anorexia, abdominal pain, and distention in each patient improved significantly at 6 and 12 months, compared with baseline.

Hospitalizations dropped significantly. “That's very important,” Dr. Al-Juburi noted. Patients with moderate to severe gastroparesis often show up in emergency rooms and get admitted, and it can be difficult to improve symptoms enough to discharge them.

In the study, the mean number of days spent in the hospital by 24 patients decreased from 49 in the year before Enterra therapy to 28 days in the year after implantation of the device.

“For drug-refractory gastroparesis, this is the way to go,” said Dr. Al-Juburi, whose institution just started using the device.

The treatment works through high-frequency stimulation of the autonomic nervous system via a neurostimulator device that's about 2 inches in length by 1 inch in width and 0.5 inch thick.

Surgeons create three or four abdominal 5-mm ports laparoscopically to implant the device; the upper right port is used as a subcutaneous pocket to house the stimulator near the stomach's greater curvature.

Leads from the device are sutured 10 cm from the stomach's pylorus, in the area thought to be responsible for gastric pacing, Dr. Al-Juburi said. An external programmer that's turned on after stimulator implantation can be adjusted to the stimulation parameter that produces the best response.

Implantation of the device takes about 1 hour to perform. In the current study, patients spent a mean of 6 days in the hospital related to the implantation surgery.

“Gastric stimulation is, so far, really a good option for drug-refractory gastroparesis,” he said.

LAKE TAHOE, CALIF. — An implanted device that delivers gastric electrical stimulation can relieve chronic gastroparesis in patients who do not respond to drug therapy, Dr. Amar Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Called Enterra therapy, the device is approved for humanitarian use in fewer than 4,000 patients per year who have intractable nausea and vomiting from idiopathic or diabetic gastroparesis and whose symptoms cannot be controlled by medications.

Gastric electrical stimulation is “a new tool that has really changed the management of gastroparesis,” said Dr. Al-Juburi, of the division of gastroenterology at the university.

He has no relationship with Medtronic Inc., the company that makes the device.

Although institutional review board approval is required before a hospital begins using the device, many medical centers in the United States now offer Enterra therapy, and more than 1,000 of these electrical stimulators have been implanted, he estimated.

A randomized, double-blind, placebo-controlled, crossover trial involving 33 patients helped win approval of the device for humanitarian use. The Worldwide Anti-Vomiting Electrical Stimulation Study began with the device turned on in one group of patients and turned off in a second group.

One month later, the groups switched device status, and were followed for another month. Then all patients were followed with the device turned on for another 10 months for a total of 12 months.

In the first 2 months, gastric electrical stimulation significantly decreased nausea and vomiting, compared with no stimulation; and most patients preferred the time span when the device was turned on (Gastroenterology 2003;125:421–8).

Among the 23 patients followed for 12 months—with the device turned on during 11 of those months—52% showed a greater than 80% reduction in the frequency of vomiting, and 79% had at least a 50% reduction in vomiting.

A summary of scores for nausea, vomiting, anorexia, abdominal pain, and distention in each patient improved significantly at 6 and 12 months, compared with baseline.

Hospitalizations dropped significantly. “That's very important,” Dr. Al-Juburi noted. Patients with moderate to severe gastroparesis often show up in emergency rooms and get admitted, and it can be difficult to improve symptoms enough to discharge them.

In the study, the mean number of days spent in the hospital by 24 patients decreased from 49 in the year before Enterra therapy to 28 days in the year after implantation of the device.

“For drug-refractory gastroparesis, this is the way to go,” said Dr. Al-Juburi, whose institution just started using the device.

The treatment works through high-frequency stimulation of the autonomic nervous system via a neurostimulator device that's about 2 inches in length by 1 inch in width and 0.5 inch thick.

Surgeons create three or four abdominal 5-mm ports laparoscopically to implant the device; the upper right port is used as a subcutaneous pocket to house the stimulator near the stomach's greater curvature.

Leads from the device are sutured 10 cm from the stomach's pylorus, in the area thought to be responsible for gastric pacing, Dr. Al-Juburi said. An external programmer that's turned on after stimulator implantation can be adjusted to the stimulation parameter that produces the best response.

Implantation of the device takes about 1 hour to perform. In the current study, patients spent a mean of 6 days in the hospital related to the implantation surgery.

“Gastric stimulation is, so far, really a good option for drug-refractory gastroparesis,” he said.

SOUTH LAKE TAHOE, CALIF. — Treating refractory gastroparesis aggressively with a combination of prokinetic medications in high doses and then slowly reducing the doses over time works much better than does a stepped-up dosing strategy, Dr. Amar Al-Juburi said.

Gastroparesis is a challenging problem that greatly decreases the quality of life, often in young patients. Most commonly it develops as an idiopathic disorder, or after surgery, or in association with diabetes.

Slow movement of food out of the stomach leads to nausea, vomiting, regurgitation, fullness, and bloating, Dr. Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Dietary modification may help by reducing intake of fat and fiber, avoiding alcohol and smoking, and offering a liquid diet supplemented with vitamins and minerals if the patient can't tolerate solid foods, said Dr. Al-Juburi of the division of gastroenterology at the university.

Drug therapy can include antiemetics, prokinetic agents, and proton pump inhibitors to limit acid, which slows gastric emptying. Dr. Al-Juburi said he has no relationships with the companies that manufacture the drugs and devices that he discussed.

Among antiemetics, Dr. Al-Juburi may start with a dopamine receptor antagonist such as promethazine (Phenergan) with or without a serotonin receptor antagonist. Benzodiazepines can be helpful as short-term antiemetics for gastroparesis associated with chemotherapy or surgery but shouldn't be used long term.

The main prokinetic agent, metoclopramide, works much better in liquid form than in pill form, he said. “Providers forget that it comes in many formulations—pill, liquid, [intravenous, intramuscular], and subcutaneous,” he said. Subcutaneous metoclopramide is useful to treat some patients at home who otherwise would be hospitalized, and the intravenous form may be useful for some inpatients.

Domperidone is an excellent alternative to metoclopramide and is being used but is an experimental agent that's not yet approved for use in the United States, he added.

The drug has fewer CNS side effects because it does not cross the blood-brain barrier, as metoclopramide does.

Intravenous erythromycin—but not oral erythromycin—is a prokinetic agent that's helpful in acute situations for hospitalized patients, at a dosage of 250 mg every 8 hours. “It kick-starts the gastric motility,” he said. Side effects from chronic therapy keep this a short-term treatment.

Data are scarce on the best strategy for treating refractory gastroparesis, but Dr. Al-Juburi advised using an aggressive step-down approach with a combination of prokinetics.

“You have to break the cycle of the exacerbation of the nausea and vomiting,” he said. Don't limit patients to small doses p.r.n., he advised. “We've had people use a Phenergan pump,” perhaps in combination with intravenous erythromycin and oral tegaserod.

The dose of tegaserod is higher than that used for chronic constipation. Refractory gastroparesis usually requires about 18 mg (6 mg t.i.d.) of tegaserod. Keep in mind that tegaserod does not have antiemetic effects, and consider adding an antiemetic agent as well, he said.

For patients who fail these strategies, injections of pyloric botulinum toxin (Botox) may help, pilot studies suggest, but the drug is expensive and effects last for only a few months.

Clinicians may resort to enteral feeding for patients who require intensive nutritional rehabilitation, but this may not alleviate the symptoms of gastroparesis.

Dr. Al-Juburi said he would choose jejunostomy over gastrostomy.

Jejunostomy frequently causes complications and impairs quality of life, but itcan usually maintain patients for months or years.

SOUTH LAKE TAHOE, CALIF. — Treating refractory gastroparesis aggressively with a combination of prokinetic medications in high doses and then slowly reducing the doses over time works much better than does a stepped-up dosing strategy, Dr. Amar Al-Juburi said.

Gastroparesis is a challenging problem that greatly decreases the quality of life, often in young patients. Most commonly it develops as an idiopathic disorder, or after surgery, or in association with diabetes.

Slow movement of food out of the stomach leads to nausea, vomiting, regurgitation, fullness, and bloating, Dr. Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Dietary modification may help by reducing intake of fat and fiber, avoiding alcohol and smoking, and offering a liquid diet supplemented with vitamins and minerals if the patient can't tolerate solid foods, said Dr. Al-Juburi of the division of gastroenterology at the university.

Drug therapy can include antiemetics, prokinetic agents, and proton pump inhibitors to limit acid, which slows gastric emptying. Dr. Al-Juburi said he has no relationships with the companies that manufacture the drugs and devices that he discussed.

Among antiemetics, Dr. Al-Juburi may start with a dopamine receptor antagonist such as promethazine (Phenergan) with or without a serotonin receptor antagonist. Benzodiazepines can be helpful as short-term antiemetics for gastroparesis associated with chemotherapy or surgery but shouldn't be used long term.

The main prokinetic agent, metoclopramide, works much better in liquid form than in pill form, he said. “Providers forget that it comes in many formulations—pill, liquid, [intravenous, intramuscular], and subcutaneous,” he said. Subcutaneous metoclopramide is useful to treat some patients at home who otherwise would be hospitalized, and the intravenous form may be useful for some inpatients.

Domperidone is an excellent alternative to metoclopramide and is being used but is an experimental agent that's not yet approved for use in the United States, he added.

The drug has fewer CNS side effects because it does not cross the blood-brain barrier, as metoclopramide does.

Intravenous erythromycin—but not oral erythromycin—is a prokinetic agent that's helpful in acute situations for hospitalized patients, at a dosage of 250 mg every 8 hours. “It kick-starts the gastric motility,” he said. Side effects from chronic therapy keep this a short-term treatment.

Data are scarce on the best strategy for treating refractory gastroparesis, but Dr. Al-Juburi advised using an aggressive step-down approach with a combination of prokinetics.

“You have to break the cycle of the exacerbation of the nausea and vomiting,” he said. Don't limit patients to small doses p.r.n., he advised. “We've had people use a Phenergan pump,” perhaps in combination with intravenous erythromycin and oral tegaserod.

The dose of tegaserod is higher than that used for chronic constipation. Refractory gastroparesis usually requires about 18 mg (6 mg t.i.d.) of tegaserod. Keep in mind that tegaserod does not have antiemetic effects, and consider adding an antiemetic agent as well, he said.

For patients who fail these strategies, injections of pyloric botulinum toxin (Botox) may help, pilot studies suggest, but the drug is expensive and effects last for only a few months.

Clinicians may resort to enteral feeding for patients who require intensive nutritional rehabilitation, but this may not alleviate the symptoms of gastroparesis.

Dr. Al-Juburi said he would choose jejunostomy over gastrostomy.

Jejunostomy frequently causes complications and impairs quality of life, but itcan usually maintain patients for months or years.

SOUTH LAKE TAHOE, CALIF. — Treating refractory gastroparesis aggressively with a combination of prokinetic medications in high doses and then slowly reducing the doses over time works much better than does a stepped-up dosing strategy, Dr. Amar Al-Juburi said.

Gastroparesis is a challenging problem that greatly decreases the quality of life, often in young patients. Most commonly it develops as an idiopathic disorder, or after surgery, or in association with diabetes.

Slow movement of food out of the stomach leads to nausea, vomiting, regurgitation, fullness, and bloating, Dr. Al-Juburi said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Dietary modification may help by reducing intake of fat and fiber, avoiding alcohol and smoking, and offering a liquid diet supplemented with vitamins and minerals if the patient can't tolerate solid foods, said Dr. Al-Juburi of the division of gastroenterology at the university.

Drug therapy can include antiemetics, prokinetic agents, and proton pump inhibitors to limit acid, which slows gastric emptying. Dr. Al-Juburi said he has no relationships with the companies that manufacture the drugs and devices that he discussed.

Among antiemetics, Dr. Al-Juburi may start with a dopamine receptor antagonist such as promethazine (Phenergan) with or without a serotonin receptor antagonist. Benzodiazepines can be helpful as short-term antiemetics for gastroparesis associated with chemotherapy or surgery but shouldn't be used long term.

The main prokinetic agent, metoclopramide, works much better in liquid form than in pill form, he said. “Providers forget that it comes in many formulations—pill, liquid, [intravenous, intramuscular], and subcutaneous,” he said. Subcutaneous metoclopramide is useful to treat some patients at home who otherwise would be hospitalized, and the intravenous form may be useful for some inpatients.

Domperidone is an excellent alternative to metoclopramide and is being used but is an experimental agent that's not yet approved for use in the United States, he added.

The drug has fewer CNS side effects because it does not cross the blood-brain barrier, as metoclopramide does.

Intravenous erythromycin—but not oral erythromycin—is a prokinetic agent that's helpful in acute situations for hospitalized patients, at a dosage of 250 mg every 8 hours. “It kick-starts the gastric motility,” he said. Side effects from chronic therapy keep this a short-term treatment.

Data are scarce on the best strategy for treating refractory gastroparesis, but Dr. Al-Juburi advised using an aggressive step-down approach with a combination of prokinetics.

“You have to break the cycle of the exacerbation of the nausea and vomiting,” he said. Don't limit patients to small doses p.r.n., he advised. “We've had people use a Phenergan pump,” perhaps in combination with intravenous erythromycin and oral tegaserod.

The dose of tegaserod is higher than that used for chronic constipation. Refractory gastroparesis usually requires about 18 mg (6 mg t.i.d.) of tegaserod. Keep in mind that tegaserod does not have antiemetic effects, and consider adding an antiemetic agent as well, he said.

For patients who fail these strategies, injections of pyloric botulinum toxin (Botox) may help, pilot studies suggest, but the drug is expensive and effects last for only a few months.

Clinicians may resort to enteral feeding for patients who require intensive nutritional rehabilitation, but this may not alleviate the symptoms of gastroparesis.

Dr. Al-Juburi said he would choose jejunostomy over gastrostomy.

Jejunostomy frequently causes complications and impairs quality of life, but itcan usually maintain patients for months or years.

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal may become socially embarrassed by the sound and smell, start shunning social gatherings, or even develop marital problems, said Dr. Mann, of UC-Davis.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet. The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested. Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics. For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients; they measured the number of times the patients passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective. “I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases. In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans. Yucca schidigera also has been studied in dogs but may cause bleeding problems.

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal may become socially embarrassed by the sound and smell, start shunning social gatherings, or even develop marital problems, said Dr. Mann, of UC-Davis.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet. The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested. Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics. For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients; they measured the number of times the patients passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective. “I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases. In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans. Yucca schidigera also has been studied in dogs but may cause bleeding problems.

LAKE TAHOE, CALIF. — Ingesting six capsules of activated charcoal twice a day is the best treatment option for patients with excessive flatus not caused by an underlying treatable condition, Dr. Nirmal S. Mann said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

People normally pass flatus a mean of 15 times per day. Those whose bowels release gas more often or in larger quantities than normal may become socially embarrassed by the sound and smell, start shunning social gatherings, or even develop marital problems, said Dr. Mann, of UC-Davis.

Dietary modifications may help, such as avoiding excessive ingestion of beans, cabbage, starch, or complex carbohydrates, which are more likely to cause gas. The over-the-counter product Beano, containing α-galactosidase derived from Aspergillus niger, claims to reduce flatus but does not help, he said.

Lactase-deficient patients should avoid ingesting lactose. One lactose-intolerant patient who passed flatus 134 times in 24 hours solved the problem by restricting lactose in the diet. The small intestine has a limited capacity to absorb fructose, so patients with excessive gas should avoid high-fructose tropical fruits, such as dates and mangoes, in favor of such low-fructose fruits as cantaloupe.

Artificial sweeteners used in some chewing gum and soft drinks generate more gas, including sorbitol, mannitol, and xylitol. Advise diabetic patients, who are more likely to use these products, to look at product labels if they're complaining of flatus, he suggested. Sucrose deficiency, a congenital disease, may be the cause of excessive flatus. Consider this diagnosis, especially in children, and treat it with sacrosidase, Dr. Mann added.

Another underlying cause of excessive flatus—small bowel bacterial overgrowth—occurs in about 35% of patients with inflammatory bowel disease. Hydrogen breath tests can detect this problem, which can be treated with antibiotics. For patients who do not fit into any of the categories above, oral activated charcoal is the best short-term treatment option, Dr. Mann said. He and his associates gave activated charcoal to six patients with excessive flatus and six control patients; they measured the number of times the patients passed flatus in 8 hours, the amount of gas with each release, and bloating scores. All parameters decreased in both groups with treatment.

“Five out of six patients came back thanking me profusely” for reducing flatus, he said. The sixth patient had only a marginal response, so activated charcoal doesn't work every time.

Airtight undergarments containing a charcoal-lined cushion also have been marketed. A recent study found that the cushion made no difference, but the airtight construction contained the smell, if not the sound, of flatus.

“These may not be comfortable [for] sleeping, but if you're trying to avoid a divorce, I think it is a small price to pay,” Dr. Mann said.

Another purported treatment, simethicone, is an organopolysiloxane that produced contradictory results in trials and probably is ineffective. “I think it just breaks up the bubbles and has no value at all” for reducing flatus, he said.

In the long term, ingesting probiotics may be the most promising strategy for the average patient with excessive flatus. Probiotics may replace bacteria in the gut with bacteria that produce less-odiferous gases. In patients with lactose malabsorption, prolonged use of lactulose changes the growth of bacteria and reduces malodorous flatus.

Bismuth compounds have been used to control odor from flatus but lead to black-colored stool. “This causes confusion, so I don't recommend that,” he said.

Studies in dogs suggest that zinc acetate might be helpful, but there are no data in humans. Yucca schidigera also has been studied in dogs but may cause bleeding problems.

MONTEREY, CALIF. — The first in vivo study of the pharmacokinetics of IV vancomycin in pregnant women found that it crosses the placental barrier, and that the dose recommended for prophylaxis against neonatal group B streptococcus infection may be too high, Dr. Joann Laiprasert said.

Penicillin is the first-line choice for prophylactic treatment of pregnant women colonized with group B streptococcus (GBS) at 35–37 weeks' gestation. For women with penicillin allergy who have a high risk for anaphylaxis, clindamycin is the preferred drug, but 15%–30% of GBS isolates are resistant to clindamycin. Erythromycin should not be used in this situation because it has a similar resistance pattern and its passage through the placenta is incomplete.

Vancomycin is recommended for pregnant women at high risk of anaphylaxis from penicillin who have clindamycin-resistant GBS, she explained at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the study, 13 healthy pregnant women with no indications for antibiotics volunteered to receive 1 g of intravenous vancomycin. Seven women (54%) did not get the full dose because they developed symptoms of Red Man's syndrome, and the drug was stopped. Despite not getting the full dose, all women and fetuses had serum levels of vancomycin above the 1 mcg/mL breakpoint for effective prophylaxis against neonatal GBS, reported Dr. Laiprasert of the University of Michigan, Ann Arbor, and her associates.

The investigators extrapolated the data to model the effects if all women had received 1-g doses and calculated that this would produce supertherapeutic serum levels of the drug in the mother and the fetus. A second model in which all women received only 500 mg of vancomycin still would have resulted in therapeutic levels in maternal and fetal compartments.

The first four women in the study received the drug in 60-minute infusions, and an interim analysis found that three of them (75%) developed symptoms of Red Man's syndrome: pruritus, shortness of breath, rash, or hypotension. For the following nine patients, the infusion duration was lengthened to 90 minutes, and four of them (44%) developed symptoms of Red Man's syndrome.

One woman required treatment with saturated oxygen after developing a moderately severe reaction with symptoms of hypotension, shortness of breath, and oxygen desaturation. Investigators stopped the study after that, with enough data to draw conclusions about vancomycin's pharmacokinetics. Therapeutic drug levels were seen in fetal serum within 30 minutes after completing the 90-minute infusion (120 minutes after starting the infusion) and persisted for 8 hours.

Because less than the recommended 1-g dose of vancomycin produced therapeutic serum levels and because Red Man's syndrome was so common, a 500-mg dose should be considered adequate, Dr. Laiprasert suggested. A slower infusion rate also may be important for safe administration of vancomycin during pregnancy. Redosing vancomycin at 12-hour intervals seems reasonable if needed, she added.

The investigators collected amniotic fluid samples and plan to study them to improve understanding of the metabolism of vancomycin in the fetal circulation.

Dr. Mark D. Pearlman, one of Dr. Laiprasert's associates in the study, commented after her talk that using a lower dose of vancomycin in these patients makes sense. Other treatment options also need to be studied for women with clindamycin-resistant GBS who are at high risk for anaphylaxis from penicillin, added Dr. Pearlman of the university.

“We really need to pressure the FDA and others to start to look at other non-β-lactams that are active against GBS, to have alternatives to vancomycin,” he said. “There are a whole host of newer, extended-spectrum, gram-positive drugs that have great activity against clindamycin-resistant GBS.”

MONTEREY, CALIF. — The first in vivo study of the pharmacokinetics of IV vancomycin in pregnant women found that it crosses the placental barrier, and that the dose recommended for prophylaxis against neonatal group B streptococcus infection may be too high, Dr. Joann Laiprasert said.

Penicillin is the first-line choice for prophylactic treatment of pregnant women colonized with group B streptococcus (GBS) at 35–37 weeks' gestation. For women with penicillin allergy who have a high risk for anaphylaxis, clindamycin is the preferred drug, but 15%–30% of GBS isolates are resistant to clindamycin. Erythromycin should not be used in this situation because it has a similar resistance pattern and its passage through the placenta is incomplete.

Vancomycin is recommended for pregnant women at high risk of anaphylaxis from penicillin who have clindamycin-resistant GBS, she explained at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the study, 13 healthy pregnant women with no indications for antibiotics volunteered to receive 1 g of intravenous vancomycin. Seven women (54%) did not get the full dose because they developed symptoms of Red Man's syndrome, and the drug was stopped. Despite not getting the full dose, all women and fetuses had serum levels of vancomycin above the 1 mcg/mL breakpoint for effective prophylaxis against neonatal GBS, reported Dr. Laiprasert of the University of Michigan, Ann Arbor, and her associates.

The investigators extrapolated the data to model the effects if all women had received 1-g doses and calculated that this would produce supertherapeutic serum levels of the drug in the mother and the fetus. A second model in which all women received only 500 mg of vancomycin still would have resulted in therapeutic levels in maternal and fetal compartments.

The first four women in the study received the drug in 60-minute infusions, and an interim analysis found that three of them (75%) developed symptoms of Red Man's syndrome: pruritus, shortness of breath, rash, or hypotension. For the following nine patients, the infusion duration was lengthened to 90 minutes, and four of them (44%) developed symptoms of Red Man's syndrome.

One woman required treatment with saturated oxygen after developing a moderately severe reaction with symptoms of hypotension, shortness of breath, and oxygen desaturation. Investigators stopped the study after that, with enough data to draw conclusions about vancomycin's pharmacokinetics. Therapeutic drug levels were seen in fetal serum within 30 minutes after completing the 90-minute infusion (120 minutes after starting the infusion) and persisted for 8 hours.

Because less than the recommended 1-g dose of vancomycin produced therapeutic serum levels and because Red Man's syndrome was so common, a 500-mg dose should be considered adequate, Dr. Laiprasert suggested. A slower infusion rate also may be important for safe administration of vancomycin during pregnancy. Redosing vancomycin at 12-hour intervals seems reasonable if needed, she added.

The investigators collected amniotic fluid samples and plan to study them to improve understanding of the metabolism of vancomycin in the fetal circulation.

Dr. Mark D. Pearlman, one of Dr. Laiprasert's associates in the study, commented after her talk that using a lower dose of vancomycin in these patients makes sense. Other treatment options also need to be studied for women with clindamycin-resistant GBS who are at high risk for anaphylaxis from penicillin, added Dr. Pearlman of the university.

“We really need to pressure the FDA and others to start to look at other non-β-lactams that are active against GBS, to have alternatives to vancomycin,” he said. “There are a whole host of newer, extended-spectrum, gram-positive drugs that have great activity against clindamycin-resistant GBS.”

MONTEREY, CALIF. — The first in vivo study of the pharmacokinetics of IV vancomycin in pregnant women found that it crosses the placental barrier, and that the dose recommended for prophylaxis against neonatal group B streptococcus infection may be too high, Dr. Joann Laiprasert said.

Penicillin is the first-line choice for prophylactic treatment of pregnant women colonized with group B streptococcus (GBS) at 35–37 weeks' gestation. For women with penicillin allergy who have a high risk for anaphylaxis, clindamycin is the preferred drug, but 15%–30% of GBS isolates are resistant to clindamycin. Erythromycin should not be used in this situation because it has a similar resistance pattern and its passage through the placenta is incomplete.

Vancomycin is recommended for pregnant women at high risk of anaphylaxis from penicillin who have clindamycin-resistant GBS, she explained at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the study, 13 healthy pregnant women with no indications for antibiotics volunteered to receive 1 g of intravenous vancomycin. Seven women (54%) did not get the full dose because they developed symptoms of Red Man's syndrome, and the drug was stopped. Despite not getting the full dose, all women and fetuses had serum levels of vancomycin above the 1 mcg/mL breakpoint for effective prophylaxis against neonatal GBS, reported Dr. Laiprasert of the University of Michigan, Ann Arbor, and her associates.

The investigators extrapolated the data to model the effects if all women had received 1-g doses and calculated that this would produce supertherapeutic serum levels of the drug in the mother and the fetus. A second model in which all women received only 500 mg of vancomycin still would have resulted in therapeutic levels in maternal and fetal compartments.

The first four women in the study received the drug in 60-minute infusions, and an interim analysis found that three of them (75%) developed symptoms of Red Man's syndrome: pruritus, shortness of breath, rash, or hypotension. For the following nine patients, the infusion duration was lengthened to 90 minutes, and four of them (44%) developed symptoms of Red Man's syndrome.

One woman required treatment with saturated oxygen after developing a moderately severe reaction with symptoms of hypotension, shortness of breath, and oxygen desaturation. Investigators stopped the study after that, with enough data to draw conclusions about vancomycin's pharmacokinetics. Therapeutic drug levels were seen in fetal serum within 30 minutes after completing the 90-minute infusion (120 minutes after starting the infusion) and persisted for 8 hours.

Because less than the recommended 1-g dose of vancomycin produced therapeutic serum levels and because Red Man's syndrome was so common, a 500-mg dose should be considered adequate, Dr. Laiprasert suggested. A slower infusion rate also may be important for safe administration of vancomycin during pregnancy. Redosing vancomycin at 12-hour intervals seems reasonable if needed, she added.

The investigators collected amniotic fluid samples and plan to study them to improve understanding of the metabolism of vancomycin in the fetal circulation.

Dr. Mark D. Pearlman, one of Dr. Laiprasert's associates in the study, commented after her talk that using a lower dose of vancomycin in these patients makes sense. Other treatment options also need to be studied for women with clindamycin-resistant GBS who are at high risk for anaphylaxis from penicillin, added Dr. Pearlman of the university.

“We really need to pressure the FDA and others to start to look at other non-β-lactams that are active against GBS, to have alternatives to vancomycin,” he said. “There are a whole host of newer, extended-spectrum, gram-positive drugs that have great activity against clindamycin-resistant GBS.”

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

SAN FRANCISCO — Cryothermia ablation of atrial fibrillation restored sinus rhythm in more than 80% of 114 consecutive patients undergoing concomitant mitral valve surgery, Dr. Sacha P. Salzberg said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

The investigators retrospectively reviewed patient charts and prospectively mailed a follow-up questionnaire to the referring doctors.

Patients were treated between January 2003 and June 2005 for paroxysmal atrial fibrillation in 55% and chronic atrial fibrillation in 45%. Degenerative mitral valve disease made up the bulk of valvular problems treated; 77% of patients underwent valve repair, and 23% had valve replacement, said Dr. Salzberg, whose research was performed at Mount Sinai Medical Center, New York.

Patients had a mean age of 66 years and had atrial fibrillation for a mean of almost 3 years before the cryosurgery. A total of 4% of patients died during surgery; 85% were discharged from the hospital with their sinus rhythm restored, said Dr. Salzberg and his associates.

Several lesion sets for ablation have been described for the left or right atria; the current study primarily created lesions on the left atria and included endocardial pulmonary vein isolation with a connecting lesion to the posterior aspect of the mitral valve annulus. In 8% of patients with documented atrial flutter, the physicians also made a right atrial set of lesions, said Dr. Salzberg, now of the University of Zurich.

A new pacemaker was needed in 8% of patients: six patients with sick sinus syndrome and three with third-degree heart block.

At 1-year follow-up, approximately 80% of patients remained in sinus rhythm. Use of anticoagulants and antiarrhythmic medications declined. There were no strokes and no complications related directly to the cryothermia ablation.

Cryothermia is a relatively new alternative to surgical ablation of atrial fibrillation, a well-accepted adjunct therapy in patients undergoing valvular surgery.

Although the Cox-Maze III procedure is considered the standard for surgical treatment of atrial fibrillation because of its high cure rate and long-term patency, the surgery is technically challenging, carries a high risk for renal problems, and is seldom performed, with only about 1,000 cases done in the past decade, said Dr. Salzberg.

Cryothermia should be applied routinely to patients undergoing mitral valve surgery with a history of atrial fibrillation, the investigators suggested.

The study's lead author was Dr. Farzan Filsoufi of Mount Sinai. Dr. Filsoufi and Dr. Salzberg have no financial association with the company that makes the cryothermia instrument, which applied a temperature of −160° C to create the atrial lesions.

SAN FRANCISCO — Cryothermia ablation of atrial fibrillation restored sinus rhythm in more than 80% of 114 consecutive patients undergoing concomitant mitral valve surgery, Dr. Sacha P. Salzberg said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

The investigators retrospectively reviewed patient charts and prospectively mailed a follow-up questionnaire to the referring doctors.

Patients were treated between January 2003 and June 2005 for paroxysmal atrial fibrillation in 55% and chronic atrial fibrillation in 45%. Degenerative mitral valve disease made up the bulk of valvular problems treated; 77% of patients underwent valve repair, and 23% had valve replacement, said Dr. Salzberg, whose research was performed at Mount Sinai Medical Center, New York.

Patients had a mean age of 66 years and had atrial fibrillation for a mean of almost 3 years before the cryosurgery. A total of 4% of patients died during surgery; 85% were discharged from the hospital with their sinus rhythm restored, said Dr. Salzberg and his associates.

Several lesion sets for ablation have been described for the left or right atria; the current study primarily created lesions on the left atria and included endocardial pulmonary vein isolation with a connecting lesion to the posterior aspect of the mitral valve annulus. In 8% of patients with documented atrial flutter, the physicians also made a right atrial set of lesions, said Dr. Salzberg, now of the University of Zurich.

A new pacemaker was needed in 8% of patients: six patients with sick sinus syndrome and three with third-degree heart block.

At 1-year follow-up, approximately 80% of patients remained in sinus rhythm. Use of anticoagulants and antiarrhythmic medications declined. There were no strokes and no complications related directly to the cryothermia ablation.

Cryothermia is a relatively new alternative to surgical ablation of atrial fibrillation, a well-accepted adjunct therapy in patients undergoing valvular surgery.

Although the Cox-Maze III procedure is considered the standard for surgical treatment of atrial fibrillation because of its high cure rate and long-term patency, the surgery is technically challenging, carries a high risk for renal problems, and is seldom performed, with only about 1,000 cases done in the past decade, said Dr. Salzberg.

Cryothermia should be applied routinely to patients undergoing mitral valve surgery with a history of atrial fibrillation, the investigators suggested.

The study's lead author was Dr. Farzan Filsoufi of Mount Sinai. Dr. Filsoufi and Dr. Salzberg have no financial association with the company that makes the cryothermia instrument, which applied a temperature of −160° C to create the atrial lesions.

SAN FRANCISCO — Cryothermia ablation of atrial fibrillation restored sinus rhythm in more than 80% of 114 consecutive patients undergoing concomitant mitral valve surgery, Dr. Sacha P. Salzberg said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

The investigators retrospectively reviewed patient charts and prospectively mailed a follow-up questionnaire to the referring doctors.

Patients were treated between January 2003 and June 2005 for paroxysmal atrial fibrillation in 55% and chronic atrial fibrillation in 45%. Degenerative mitral valve disease made up the bulk of valvular problems treated; 77% of patients underwent valve repair, and 23% had valve replacement, said Dr. Salzberg, whose research was performed at Mount Sinai Medical Center, New York.

Patients had a mean age of 66 years and had atrial fibrillation for a mean of almost 3 years before the cryosurgery. A total of 4% of patients died during surgery; 85% were discharged from the hospital with their sinus rhythm restored, said Dr. Salzberg and his associates.

Several lesion sets for ablation have been described for the left or right atria; the current study primarily created lesions on the left atria and included endocardial pulmonary vein isolation with a connecting lesion to the posterior aspect of the mitral valve annulus. In 8% of patients with documented atrial flutter, the physicians also made a right atrial set of lesions, said Dr. Salzberg, now of the University of Zurich.

A new pacemaker was needed in 8% of patients: six patients with sick sinus syndrome and three with third-degree heart block.

At 1-year follow-up, approximately 80% of patients remained in sinus rhythm. Use of anticoagulants and antiarrhythmic medications declined. There were no strokes and no complications related directly to the cryothermia ablation.

Cryothermia is a relatively new alternative to surgical ablation of atrial fibrillation, a well-accepted adjunct therapy in patients undergoing valvular surgery.

Although the Cox-Maze III procedure is considered the standard for surgical treatment of atrial fibrillation because of its high cure rate and long-term patency, the surgery is technically challenging, carries a high risk for renal problems, and is seldom performed, with only about 1,000 cases done in the past decade, said Dr. Salzberg.

Cryothermia should be applied routinely to patients undergoing mitral valve surgery with a history of atrial fibrillation, the investigators suggested.

The study's lead author was Dr. Farzan Filsoufi of Mount Sinai. Dr. Filsoufi and Dr. Salzberg have no financial association with the company that makes the cryothermia instrument, which applied a temperature of −160° C to create the atrial lesions.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days. By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups. Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, though they lacked supportive data. Others have suggested the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (less complicated flora) were more likely to be cured than were those scores of 9–10, the intent-to-treat analysis found.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days. By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups. Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, though they lacked supportive data. Others have suggested the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (less complicated flora) were more likely to be cured than were those scores of 9–10, the intent-to-treat analysis found.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days. By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups. Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, though they lacked supportive data. Others have suggested the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (less complicated flora) were more likely to be cured than were those scores of 9–10, the intent-to-treat analysis found.

WINNIPEG, MAN. — Chronic paronychia is a variety of contact dermatitis that affects the proximal nail fold, so treating it with systemic antifungals is not useful, Dr. Antonella Tosti said at the annual conference of the Canadian Dermatology Association.

“Most people still believe that chronic paronychia is a candida infection. It is not,” said Dr. Tosti, professor of dermatology at the University of Bologna, Italy.

Instead, it starts with loss of the cuticle due to trauma or other causes, followed by irritation, immediate or delayed allergic reaction, or immediate hypersensitivity to food ingredients handled by the patient. Chronic paronychia is a common occupational problem among food workers, she said.

With the cuticle gone, environmental agents penetrate the proximal nail fold, causing inflammation in the nail matrix. Yeast and bacteria also may penetrate the proximal nail fold, leading to secondary colonization that may produce self-limited episodes of painful acute inflammation with pus. A green discoloration of the nail develops with colonization by Pseudomonas aeruginosa.

That's why clinicians may be able to culture bacteria or yeast, but treating with systemic antifungals will not cure the patient because it manages only the secondary problem, not the primary inflammation, Dr. Tosti said.

Chronic paronychia should be managed like contact dermatitis is treated, with hand protection and topical steroids, she advised. For patients with secondary candida colonization, recommend a high-potency topical steroid at bedtime and a topical antifungal in the morning. “I may use systemic steroids in severe cases” to provide fast relief of inflammation and pain, she added.

Chronic paronychia is shown before treatment with topical steroids.

The same patient is shown following treatment. Photos courtesy Dr. Antonella Tosti

WINNIPEG, MAN. — Chronic paronychia is a variety of contact dermatitis that affects the proximal nail fold, so treating it with systemic antifungals is not useful, Dr. Antonella Tosti said at the annual conference of the Canadian Dermatology Association.

“Most people still believe that chronic paronychia is a candida infection. It is not,” said Dr. Tosti, professor of dermatology at the University of Bologna, Italy.

Instead, it starts with loss of the cuticle due to trauma or other causes, followed by irritation, immediate or delayed allergic reaction, or immediate hypersensitivity to food ingredients handled by the patient. Chronic paronychia is a common occupational problem among food workers, she said.

With the cuticle gone, environmental agents penetrate the proximal nail fold, causing inflammation in the nail matrix. Yeast and bacteria also may penetrate the proximal nail fold, leading to secondary colonization that may produce self-limited episodes of painful acute inflammation with pus. A green discoloration of the nail develops with colonization by Pseudomonas aeruginosa.

That's why clinicians may be able to culture bacteria or yeast, but treating with systemic antifungals will not cure the patient because it manages only the secondary problem, not the primary inflammation, Dr. Tosti said.

Chronic paronychia should be managed like contact dermatitis is treated, with hand protection and topical steroids, she advised. For patients with secondary candida colonization, recommend a high-potency topical steroid at bedtime and a topical antifungal in the morning. “I may use systemic steroids in severe cases” to provide fast relief of inflammation and pain, she added.

Chronic paronychia is shown before treatment with topical steroids.

The same patient is shown following treatment. Photos courtesy Dr. Antonella Tosti

WINNIPEG, MAN. — Chronic paronychia is a variety of contact dermatitis that affects the proximal nail fold, so treating it with systemic antifungals is not useful, Dr. Antonella Tosti said at the annual conference of the Canadian Dermatology Association.

“Most people still believe that chronic paronychia is a candida infection. It is not,” said Dr. Tosti, professor of dermatology at the University of Bologna, Italy.

Instead, it starts with loss of the cuticle due to trauma or other causes, followed by irritation, immediate or delayed allergic reaction, or immediate hypersensitivity to food ingredients handled by the patient. Chronic paronychia is a common occupational problem among food workers, she said.

With the cuticle gone, environmental agents penetrate the proximal nail fold, causing inflammation in the nail matrix. Yeast and bacteria also may penetrate the proximal nail fold, leading to secondary colonization that may produce self-limited episodes of painful acute inflammation with pus. A green discoloration of the nail develops with colonization by Pseudomonas aeruginosa.

That's why clinicians may be able to culture bacteria or yeast, but treating with systemic antifungals will not cure the patient because it manages only the secondary problem, not the primary inflammation, Dr. Tosti said.

Chronic paronychia should be managed like contact dermatitis is treated, with hand protection and topical steroids, she advised. For patients with secondary candida colonization, recommend a high-potency topical steroid at bedtime and a topical antifungal in the morning. “I may use systemic steroids in severe cases” to provide fast relief of inflammation and pain, she added.

Chronic paronychia is shown before treatment with topical steroids.

The same patient is shown following treatment. Photos courtesy Dr. Antonella Tosti