Sherry Boschert

SAN FRANCISCO — Multisection CT imaging affected surgical management in 12 of 40 patients undergoing repeat coronary artery bypass grafting and provided helpful information on 30 patients with acute aortic dissection, Dr. Chris Probst said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“In our clinic, we use it routinely for any patient” scheduled for reoperation after a previous coronary artery bypass graft (CABG), said Dr. Probst, of the department of cardiac surgery at the University of Bonn (Germany). “It is an excellent imaging modality for planning the optimal surgical strategy for reoperative patients, as well as for patients with aortic syndromes to prevent injury to the patient.”

In the group referred for repeat CABG, 99% of all grafts could be visualized by multisection CT, including 34 arterial and 69 vein grafts. Of these, multisection CT allowed assessment of the complete anatomical course of 33 arterial grafts (97%) and 67 vein grafts (97%).

The imaging showed that 83 grafts were patent and 20 were occluded, he said. Among the patent grafts, 12 (14%) showed nonstenotic soft plaques.

Adherence of the right ventricle to the sternum was seen in 10 patients. Four patients showed adherence of the left internal mammary artery graft; another four patients showed adherence of the saphenous vein graft. Extensive calcifications of the ascending aorta were seen in three patients.

In the 30 patients with acute Stanford type A dissections, the investigators used multisection CT preoperatively to visualize the aortic valve and coronary tree, achieving good pictures of the aortic valve and the proximal and medium segments of the coronary tree. In one 64-year-old patient, for example, it clearly showed that the aortic valve was not involved in the dissection.

Multisection CT may be an important alternative to catheter angiography, which can delay urgent surgery and may only partially provide the sophisticated preoperative evaluation needed for safe surgery, Dr. Probst said. Evaluation of the thoracic aorta, coronary arteries, and grafts, as well as the anatomical relationships of cardiac structures, informs the surgical management of these two groups of patients.

Dr. Probst has no financial relationships with companies that make multisection CT machines.

ECG-gated CT scans of a 64-year-old patient with type A dissection revealed that neither the aortic valve (left) nor the coronary arteries (right, showing left coronary artery) were involved in the dissection, thereby sparing the patient coronary catheterization that would have delayed surgery. Photos courtesy Dr. Chris Probst

SAN FRANCISCO — Multisection CT imaging affected surgical management in 12 of 40 patients undergoing repeat coronary artery bypass grafting and provided helpful information on 30 patients with acute aortic dissection, Dr. Chris Probst said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“In our clinic, we use it routinely for any patient” scheduled for reoperation after a previous coronary artery bypass graft (CABG), said Dr. Probst, of the department of cardiac surgery at the University of Bonn (Germany). “It is an excellent imaging modality for planning the optimal surgical strategy for reoperative patients, as well as for patients with aortic syndromes to prevent injury to the patient.”

In the group referred for repeat CABG, 99% of all grafts could be visualized by multisection CT, including 34 arterial and 69 vein grafts. Of these, multisection CT allowed assessment of the complete anatomical course of 33 arterial grafts (97%) and 67 vein grafts (97%).

The imaging showed that 83 grafts were patent and 20 were occluded, he said. Among the patent grafts, 12 (14%) showed nonstenotic soft plaques.

Adherence of the right ventricle to the sternum was seen in 10 patients. Four patients showed adherence of the left internal mammary artery graft; another four patients showed adherence of the saphenous vein graft. Extensive calcifications of the ascending aorta were seen in three patients.

In the 30 patients with acute Stanford type A dissections, the investigators used multisection CT preoperatively to visualize the aortic valve and coronary tree, achieving good pictures of the aortic valve and the proximal and medium segments of the coronary tree. In one 64-year-old patient, for example, it clearly showed that the aortic valve was not involved in the dissection.

Multisection CT may be an important alternative to catheter angiography, which can delay urgent surgery and may only partially provide the sophisticated preoperative evaluation needed for safe surgery, Dr. Probst said. Evaluation of the thoracic aorta, coronary arteries, and grafts, as well as the anatomical relationships of cardiac structures, informs the surgical management of these two groups of patients.

Dr. Probst has no financial relationships with companies that make multisection CT machines.

ECG-gated CT scans of a 64-year-old patient with type A dissection revealed that neither the aortic valve (left) nor the coronary arteries (right, showing left coronary artery) were involved in the dissection, thereby sparing the patient coronary catheterization that would have delayed surgery. Photos courtesy Dr. Chris Probst

SAN FRANCISCO — Multisection CT imaging affected surgical management in 12 of 40 patients undergoing repeat coronary artery bypass grafting and provided helpful information on 30 patients with acute aortic dissection, Dr. Chris Probst said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“In our clinic, we use it routinely for any patient” scheduled for reoperation after a previous coronary artery bypass graft (CABG), said Dr. Probst, of the department of cardiac surgery at the University of Bonn (Germany). “It is an excellent imaging modality for planning the optimal surgical strategy for reoperative patients, as well as for patients with aortic syndromes to prevent injury to the patient.”

In the group referred for repeat CABG, 99% of all grafts could be visualized by multisection CT, including 34 arterial and 69 vein grafts. Of these, multisection CT allowed assessment of the complete anatomical course of 33 arterial grafts (97%) and 67 vein grafts (97%).

The imaging showed that 83 grafts were patent and 20 were occluded, he said. Among the patent grafts, 12 (14%) showed nonstenotic soft plaques.

Adherence of the right ventricle to the sternum was seen in 10 patients. Four patients showed adherence of the left internal mammary artery graft; another four patients showed adherence of the saphenous vein graft. Extensive calcifications of the ascending aorta were seen in three patients.

In the 30 patients with acute Stanford type A dissections, the investigators used multisection CT preoperatively to visualize the aortic valve and coronary tree, achieving good pictures of the aortic valve and the proximal and medium segments of the coronary tree. In one 64-year-old patient, for example, it clearly showed that the aortic valve was not involved in the dissection.

Multisection CT may be an important alternative to catheter angiography, which can delay urgent surgery and may only partially provide the sophisticated preoperative evaluation needed for safe surgery, Dr. Probst said. Evaluation of the thoracic aorta, coronary arteries, and grafts, as well as the anatomical relationships of cardiac structures, informs the surgical management of these two groups of patients.

Dr. Probst has no financial relationships with companies that make multisection CT machines.

ECG-gated CT scans of a 64-year-old patient with type A dissection revealed that neither the aortic valve (left) nor the coronary arteries (right, showing left coronary artery) were involved in the dissection, thereby sparing the patient coronary catheterization that would have delayed surgery. Photos courtesy Dr. Chris Probst

LAS VEGAS — A simple survey can provide physicians with a sense of patient satisfaction after cosmetic procedures, Dr. Jarl Bunæs said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

As the operator of the oldest facial plastic surgery clinic in Norway (Klinikk Bunæs in Sandvika), each year he performs approximately 1,500 surgical procedures. He sent a questionnaire that he designed to 100 consecutive patients who had undergone cosmetic procedures at least 1 year earlier. Of the 84 patients who responded, 62 (74%) were women; the mean age was 42 years (ranging from 18 to 68), said Dr. Bunæs.

Asked to rate their satisfaction with the procedure's results on a visual analog scale of 1–10 (with 10 being the best), patients reported a mean score of 8. They also rated their overall quality of life after the procedure as 8.

Seventy-one patients (84%) said the cosmetic problem that was treated had lowered their self-esteem before the procedure, and 71 patients said their self-esteem improved after treatment.

LAS VEGAS — A simple survey can provide physicians with a sense of patient satisfaction after cosmetic procedures, Dr. Jarl Bunæs said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

As the operator of the oldest facial plastic surgery clinic in Norway (Klinikk Bunæs in Sandvika), each year he performs approximately 1,500 surgical procedures. He sent a questionnaire that he designed to 100 consecutive patients who had undergone cosmetic procedures at least 1 year earlier. Of the 84 patients who responded, 62 (74%) were women; the mean age was 42 years (ranging from 18 to 68), said Dr. Bunæs.

Asked to rate their satisfaction with the procedure's results on a visual analog scale of 1–10 (with 10 being the best), patients reported a mean score of 8. They also rated their overall quality of life after the procedure as 8.

Seventy-one patients (84%) said the cosmetic problem that was treated had lowered their self-esteem before the procedure, and 71 patients said their self-esteem improved after treatment.

LAS VEGAS — A simple survey can provide physicians with a sense of patient satisfaction after cosmetic procedures, Dr. Jarl Bunæs said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

As the operator of the oldest facial plastic surgery clinic in Norway (Klinikk Bunæs in Sandvika), each year he performs approximately 1,500 surgical procedures. He sent a questionnaire that he designed to 100 consecutive patients who had undergone cosmetic procedures at least 1 year earlier. Of the 84 patients who responded, 62 (74%) were women; the mean age was 42 years (ranging from 18 to 68), said Dr. Bunæs.

Asked to rate their satisfaction with the procedure's results on a visual analog scale of 1–10 (with 10 being the best), patients reported a mean score of 8. They also rated their overall quality of life after the procedure as 8.

Seventy-one patients (84%) said the cosmetic problem that was treated had lowered their self-esteem before the procedure, and 71 patients said their self-esteem improved after treatment.

SAN FRANCISCO — A double decidual sign on ultrasound can rule out ectopic pregnancy in women seeking emergency care for first-trimester pain or bleeding, Dr. Bon S. Ku said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

In a retrospective study of 1,339 patients with indeterminate ultrasounds, 4% of ultrasounds showed a double decidual sign without definitive signs of intrauterine pregnancy. Only 1 (2%) of these 57 patients with the double decidual sign ultimately was diagnosed with ectopic pregnancy. The other 56 had a live intrauterine pregnancy (29 patients) or an abnormal intrauterine pregnancy (27 patients), said Dr. Ku of the University of Pennsylvania, Philadelphia.

Put another way, 18% of the 1,339 patients had a final diagnosis of ectopic pregnancy, and only 1 (0.4%) of these 245 patients with ectopic pregnancy had a double decidual sign on ultrasound.

In women with first-trimester pain or bleeding and an indeterminate ultrasound, the presence of a double decidual sign makes ectopic pregnancy “extremely unlikely,” said Dr. Ku and his associates.

A double decidual sign shows a gestational sac surrounded by two echogenic rings of endometrial tissue (decidua), the decidual capsularis (inner ring) and decidual parietalis (outer ring). It is the only ultrasound finding consistently related to serum quantitative β-human chorionic gonadotropin (β-HCG) levels, and some previous studies report that a double decidual sign is a reliable indicator of intrauterine pregnancy.

Dr. Ku's institution and many other medical centers do not consider the double decidual sign to be definitive of intrauterine pregnancy, however, because its recognition is somewhat subjective, he said. A sonogram must show a yolk sac, fetal pole, or fetal heart tones to diagnose definitive intrauterine pregnancy. Clinically stable women with “indeterminate” ultrasounds that lack these definitive signs are diagnosed as “possible early intrauterine pregnancy/cannot exclude ectopic pregnancy” and asked to return in 2 days for a repeat evaluation and β-HCG measurement. Patients who fail to return are contacted by staff.

The study correlated the presence of the double decidual sign with the final diagnosis, which was determined by sonographic evidence of intrauterine pregnancy, β-HCG measurements that declined to zero, evidence of trophoblastic tissue after spontaneous abortion, or D&C for ectopic pregnancy.

The findings are limited by the small number of ultrasounds with a double decidual sign and because the study relied on ultrasound reports rather than images, Dr. Ku noted.

SAN FRANCISCO — A double decidual sign on ultrasound can rule out ectopic pregnancy in women seeking emergency care for first-trimester pain or bleeding, Dr. Bon S. Ku said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

In a retrospective study of 1,339 patients with indeterminate ultrasounds, 4% of ultrasounds showed a double decidual sign without definitive signs of intrauterine pregnancy. Only 1 (2%) of these 57 patients with the double decidual sign ultimately was diagnosed with ectopic pregnancy. The other 56 had a live intrauterine pregnancy (29 patients) or an abnormal intrauterine pregnancy (27 patients), said Dr. Ku of the University of Pennsylvania, Philadelphia.

Put another way, 18% of the 1,339 patients had a final diagnosis of ectopic pregnancy, and only 1 (0.4%) of these 245 patients with ectopic pregnancy had a double decidual sign on ultrasound.

In women with first-trimester pain or bleeding and an indeterminate ultrasound, the presence of a double decidual sign makes ectopic pregnancy “extremely unlikely,” said Dr. Ku and his associates.

A double decidual sign shows a gestational sac surrounded by two echogenic rings of endometrial tissue (decidua), the decidual capsularis (inner ring) and decidual parietalis (outer ring). It is the only ultrasound finding consistently related to serum quantitative β-human chorionic gonadotropin (β-HCG) levels, and some previous studies report that a double decidual sign is a reliable indicator of intrauterine pregnancy.

Dr. Ku's institution and many other medical centers do not consider the double decidual sign to be definitive of intrauterine pregnancy, however, because its recognition is somewhat subjective, he said. A sonogram must show a yolk sac, fetal pole, or fetal heart tones to diagnose definitive intrauterine pregnancy. Clinically stable women with “indeterminate” ultrasounds that lack these definitive signs are diagnosed as “possible early intrauterine pregnancy/cannot exclude ectopic pregnancy” and asked to return in 2 days for a repeat evaluation and β-HCG measurement. Patients who fail to return are contacted by staff.

The study correlated the presence of the double decidual sign with the final diagnosis, which was determined by sonographic evidence of intrauterine pregnancy, β-HCG measurements that declined to zero, evidence of trophoblastic tissue after spontaneous abortion, or D&C for ectopic pregnancy.

The findings are limited by the small number of ultrasounds with a double decidual sign and because the study relied on ultrasound reports rather than images, Dr. Ku noted.

SAN FRANCISCO — A double decidual sign on ultrasound can rule out ectopic pregnancy in women seeking emergency care for first-trimester pain or bleeding, Dr. Bon S. Ku said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

In a retrospective study of 1,339 patients with indeterminate ultrasounds, 4% of ultrasounds showed a double decidual sign without definitive signs of intrauterine pregnancy. Only 1 (2%) of these 57 patients with the double decidual sign ultimately was diagnosed with ectopic pregnancy. The other 56 had a live intrauterine pregnancy (29 patients) or an abnormal intrauterine pregnancy (27 patients), said Dr. Ku of the University of Pennsylvania, Philadelphia.

Put another way, 18% of the 1,339 patients had a final diagnosis of ectopic pregnancy, and only 1 (0.4%) of these 245 patients with ectopic pregnancy had a double decidual sign on ultrasound.

In women with first-trimester pain or bleeding and an indeterminate ultrasound, the presence of a double decidual sign makes ectopic pregnancy “extremely unlikely,” said Dr. Ku and his associates.

A double decidual sign shows a gestational sac surrounded by two echogenic rings of endometrial tissue (decidua), the decidual capsularis (inner ring) and decidual parietalis (outer ring). It is the only ultrasound finding consistently related to serum quantitative β-human chorionic gonadotropin (β-HCG) levels, and some previous studies report that a double decidual sign is a reliable indicator of intrauterine pregnancy.

Dr. Ku's institution and many other medical centers do not consider the double decidual sign to be definitive of intrauterine pregnancy, however, because its recognition is somewhat subjective, he said. A sonogram must show a yolk sac, fetal pole, or fetal heart tones to diagnose definitive intrauterine pregnancy. Clinically stable women with “indeterminate” ultrasounds that lack these definitive signs are diagnosed as “possible early intrauterine pregnancy/cannot exclude ectopic pregnancy” and asked to return in 2 days for a repeat evaluation and β-HCG measurement. Patients who fail to return are contacted by staff.

The study correlated the presence of the double decidual sign with the final diagnosis, which was determined by sonographic evidence of intrauterine pregnancy, β-HCG measurements that declined to zero, evidence of trophoblastic tissue after spontaneous abortion, or D&C for ectopic pregnancy.

The findings are limited by the small number of ultrasounds with a double decidual sign and because the study relied on ultrasound reports rather than images, Dr. Ku noted.

SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“We all know that transmyocardial revascularization is a palliative treatment. It is not a first-line treatment of coronary artery disease,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. “There is a small group of patients with diffuse coronary artery disease with severe, refractory angina. We have a therapy that relieves angina in those patients.”

The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.

They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.

Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.

The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).

The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.

The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.

Compared with maximal medical therapy, transmyocardial revascularization reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality of life scores at 1 year.

The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.

The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). “I leave it to you to decide if that's clinically significant or not,” but the difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.

SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“We all know that transmyocardial revascularization is a palliative treatment. It is not a first-line treatment of coronary artery disease,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. “There is a small group of patients with diffuse coronary artery disease with severe, refractory angina. We have a therapy that relieves angina in those patients.”

The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.

They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.

Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.

The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).

The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.

The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.

Compared with maximal medical therapy, transmyocardial revascularization reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality of life scores at 1 year.

The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.

The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). “I leave it to you to decide if that's clinically significant or not,” but the difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.

SAN FRANCISCO — A consensus committee of 10 experts recommended transmyocardial revascularization to provide relief for some patients with severe refractory angina, Dr. Anno Diegeler reported at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

“We all know that transmyocardial revascularization is a palliative treatment. It is not a first-line treatment of coronary artery disease,” said Dr. Diegeler, of the University of Leipzig, Bad Neustadt, Germany. “There is a small group of patients with diffuse coronary artery disease with severe, refractory angina. We have a therapy that relieves angina in those patients.”

The committee reviewed the data on transmyocardial revascularization and formulated recommendations that will be published in the society's journal, Innovations.

They analyzed results from six randomized, controlled trials involving a total of 967 patients that compared transmyocardial revascularization with maximal medical therapy. In addition, they looked at studies that compared coronary artery bypass grafting (CABG) with CABG plus adjunctive transmyocardial revascularization, drawing on three randomized, controlled trials involving 327 patients and an additional three nonrandomized trials.

Dr. Diegeler, chair of the committee, outlined the recommendations at the meeting, dividing them according to two groups of patients.

The first group is stable patients with refractory, severe angina who are not amenable to conventional revascularization and who can be treated solely with transmyocardial revascularization or maximal medical therapy. For such patients, the committee recommended transmyocardial revascularization to provide sustained angina relief, reduce major adverse cardiac events, and improve exercise performance, on the basis of results of randomized, controlled trials (level A evidence); and to reduce readmissions and reinterventions, on the basis of one randomized, controlled trial and nonrandomized data (level B evidence).

The second group is patients with diffuse coronary artery disease and chronic angina who cannot be completely revascularized by CABG alone. For them the committee recommended adding transmyocardial revascularization to improve the likelihood of long-term angina relief (up to 5 years), reduce 30-day mortality and major adverse cardiac events, and improve 1-year exercise performance.

The recommendations for CABG plus transmyocardial revascularization rather than CABG alone were based on levels A and B evidence and were all class II recommendations encompassing conflicting evidence or diverging opinions. The recommendations regarding sole transmyocardial revascularization versus maximal medical therapy were all class I recommendations with solid evidence and general agreement, said Dr. Davy Cheng of the University of Western Ontario, London, who was also a member of the consensus committee.

Compared with maximal medical therapy, transmyocardial revascularization reduced angina by at least two New York Heart Association classes and left more patients free of class III or IV angina at 1–5 years. The procedure also improved quality of life scores at 1 year.

The improvements in mortality and major adverse cardiac events seen at 30 days and in exercise performance at 1 year after CABG plus transmyocardial revascularization, compared with CABG alone, did not hold up at 5 years after treatment, Dr. Diegeler noted.

The difference between groups in exercise treatment test results at 1 year was a mean of 88 seconds favoring CABG plus transmyocardial revascularization (with a range of 52–123 seconds). “I leave it to you to decide if that's clinically significant or not,” but the difference was statistically significant and was incorporated into the recommendations, Dr. Diegeler said.

SAN FRANCISCO — Infants with intractable seizures and normal imaging results may have focal cortical dysplasia that can be detected by serial high-resolution MRI, Dr. Herman Tse said in a poster presentation at the annual meeting of the American Association of Neurological Surgeons.

Identifying and resecting focal cortical dysplasia can significantly decrease seizures in patients who do not respond to other therapies, said Dr. Tse, of Oregon Health and Science University, Portland, and his associates.

He described the case of a 12-month-old boy with multiple episodes of partial seizures whose EEG results showed the seizure onset to be focused in the brain's right hemisphere but whose CT and MRI results were normal. Treatment with multiple anticonvulsant medications failed to improve the patient's seizures.

Repeat MRI studies at 13, 23, and 30 months of age revealed progression of a right posterior frontal lesion with increased signals on T2-weighted images and fluid-attenuated inversion recovery (FLAIR) MRI. These findings and disruption of the gray-white junction were consistent with focal cortical dysplasia, said Dr. Tse.

At age 30 months, the infant underwent staged cortical mapping and resection of the lesion with the aid of subdural grid placement and stereotactic navigation, he said. Pathology showed large, bizarrely shaped dyslaminated neurons with nodules of cortical dysplasia. The surgical resection caused no complications and reduced the frequency of seizures by more than 90%.

Focal cortical dysplasia, a type of cortical development malformation first described in 1971, is a common cause of pediatric intractable epilepsy. During infancy, as the cerebral cortex undergoes significant development, MRI may be normal initially in infants with intractable partial epilepsy, especially if the focus of seizures is located in areas of late myelination.

Therefore, serial imaging, especially with high-resolution MRI, may be helpful, particularly in infants under 18 months of age with intractable seizures, said Dr. Tse.

SAN FRANCISCO — Infants with intractable seizures and normal imaging results may have focal cortical dysplasia that can be detected by serial high-resolution MRI, Dr. Herman Tse said in a poster presentation at the annual meeting of the American Association of Neurological Surgeons.

Identifying and resecting focal cortical dysplasia can significantly decrease seizures in patients who do not respond to other therapies, said Dr. Tse, of Oregon Health and Science University, Portland, and his associates.

He described the case of a 12-month-old boy with multiple episodes of partial seizures whose EEG results showed the seizure onset to be focused in the brain's right hemisphere but whose CT and MRI results were normal. Treatment with multiple anticonvulsant medications failed to improve the patient's seizures.

Repeat MRI studies at 13, 23, and 30 months of age revealed progression of a right posterior frontal lesion with increased signals on T2-weighted images and fluid-attenuated inversion recovery (FLAIR) MRI. These findings and disruption of the gray-white junction were consistent with focal cortical dysplasia, said Dr. Tse.

At age 30 months, the infant underwent staged cortical mapping and resection of the lesion with the aid of subdural grid placement and stereotactic navigation, he said. Pathology showed large, bizarrely shaped dyslaminated neurons with nodules of cortical dysplasia. The surgical resection caused no complications and reduced the frequency of seizures by more than 90%.

Focal cortical dysplasia, a type of cortical development malformation first described in 1971, is a common cause of pediatric intractable epilepsy. During infancy, as the cerebral cortex undergoes significant development, MRI may be normal initially in infants with intractable partial epilepsy, especially if the focus of seizures is located in areas of late myelination.

Therefore, serial imaging, especially with high-resolution MRI, may be helpful, particularly in infants under 18 months of age with intractable seizures, said Dr. Tse.

SAN FRANCISCO — Infants with intractable seizures and normal imaging results may have focal cortical dysplasia that can be detected by serial high-resolution MRI, Dr. Herman Tse said in a poster presentation at the annual meeting of the American Association of Neurological Surgeons.

Identifying and resecting focal cortical dysplasia can significantly decrease seizures in patients who do not respond to other therapies, said Dr. Tse, of Oregon Health and Science University, Portland, and his associates.

He described the case of a 12-month-old boy with multiple episodes of partial seizures whose EEG results showed the seizure onset to be focused in the brain's right hemisphere but whose CT and MRI results were normal. Treatment with multiple anticonvulsant medications failed to improve the patient's seizures.

Repeat MRI studies at 13, 23, and 30 months of age revealed progression of a right posterior frontal lesion with increased signals on T2-weighted images and fluid-attenuated inversion recovery (FLAIR) MRI. These findings and disruption of the gray-white junction were consistent with focal cortical dysplasia, said Dr. Tse.

At age 30 months, the infant underwent staged cortical mapping and resection of the lesion with the aid of subdural grid placement and stereotactic navigation, he said. Pathology showed large, bizarrely shaped dyslaminated neurons with nodules of cortical dysplasia. The surgical resection caused no complications and reduced the frequency of seizures by more than 90%.

Focal cortical dysplasia, a type of cortical development malformation first described in 1971, is a common cause of pediatric intractable epilepsy. During infancy, as the cerebral cortex undergoes significant development, MRI may be normal initially in infants with intractable partial epilepsy, especially if the focus of seizures is located in areas of late myelination.

Therefore, serial imaging, especially with high-resolution MRI, may be helpful, particularly in infants under 18 months of age with intractable seizures, said Dr. Tse.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined “acceptable” cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant (“early”) involution before age 5, 38% had “imperfect” cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant (“late”) involution by 5 years of age, 80% had imperfect cosmetic outcomes, he noted. Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion.

All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

Lesion Myths And Realities

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. “This is very low-tech surgery,” Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that although these myths don't apply to hemangiomas, they may sometimes apply to malformations like port wine stains.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined “acceptable” cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant (“early”) involution before age 5, 38% had “imperfect” cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant (“late”) involution by 5 years of age, 80% had imperfect cosmetic outcomes, he noted. Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion.

All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

Lesion Myths And Realities

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. “This is very low-tech surgery,” Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that although these myths don't apply to hemangiomas, they may sometimes apply to malformations like port wine stains.

LAS VEGAS — Telling parents that an infant's facial hemangioma will go away and doesn't need follow-up is no longer acceptable, Dr. Edward D. Buckingham said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Older studies that support the leave-it-alone approach defined “acceptable” cosmetic outcomes in ways that don't meet today's higher standards, said Dr. Buckingham of Austin, Tex.

Hemangiomas are benign tumors that evolve from an initial proliferative phase to a second phase of involution, in which the tumor gradually disappears. Complications can include scars from ulcerations, epidermal atrophy from thinning of the skin as the tumor grows, cosmetic distortion of facial features, residual telangiectasias, redundant skin after involution, or cartilage destruction by some hemangiomas around the ear or nose.

In the half of children with hemangiomas who show significant (“early”) involution before age 5, 38% had “imperfect” cosmetic outcomes, one 1983 study found. In the other half of children whose hemangiomas did not show significant (“late”) involution by 5 years of age, 80% had imperfect cosmetic outcomes, he noted. Once the hemangioma stops proliferating, the rate of involution can give a sense of the likelihood of an acceptable cosmetic outcome without medical or surgical treatment.

Observation alone may be adequate management for small hemangiomas in clinically insignificant cosmetic areas, but this does not mean forgetting about the lesion.

All birthmarks that develop during the first month of life should be evaluated by a specialist and followed through serial evaluations, Dr. Buckingham said.

There are reasons to treat many hemangiomas during the proliferative or involution phases with the goals of preventing the lesion from getting larger than it needs to be and achieving the best cosmetic results by age 2 or 3 years, when children begin to form a self-image, he said.

Evaluation by a specialist also is key to proper diagnosis of hemangiomas, which commonly are confused with port wine stains, said Dr. Marcelo Hochman. Port wine stains are venous malformations, not tumors, and require different and more difficult treatment.

Hemangiomas occur in 4%–10% of white newborns, with girls four times more likely than boys to develop the lesions. Most hemangiomas develop on the head or neck. Diagnosis is made by history and physical exam; ultrasound imaging should be performed if more than three hemangiomas are present to check for involvement of the liver or spleen, said Dr. Hochman of Charleston, S.C.

Dr. Buckingham warned that hemangiomas on the upper or lower eyelid can endanger vision permanently and deserve referral to a pediatric ophthalmologist.

There is no consensus on treating hemangiomas. Photodynamic therapy (PDT), steroids, and surgery are the main treatment options. Treat superficial or rapidly proliferating hemangiomas every 4–8 weeks with PDT, a safe option with very little risk of scarring, he said.

PDT on the area around an ulcerated hemangioma can help heal the ulcer, data show. Retreat every 4–6 weeks if needed, Dr. Buckingham suggested. PDT also cleans up residual telangiectasias.

For deep hemangiomas, inject steroids into the lesion or try a 10-week course of oral steroids during proliferation; expect a 30%–90% response. Combine steroids and photodynamic therapy for compound lesions. Refer children on oral steroids to an endocrinologist for weekly evaluation.

Reserve surgical debulking for cleanup during involution, or during the proliferative phase for hemangiomas that don't respond to steroids or that threaten vision.

Lesion Myths And Realities

Confusion about the differences between vascular malformations and hemangiomas abound. Many physicians entertain the following common misconceptions about hemangiomas, Dr. Hochman said:

Myth: Hemangiomas are big bags of blood, so surgical resection carries a big risk of bleeding.

Reality: Hemangiomas are solid tumors. Surgical removal is relatively simple.

Myth: There are numerous and tortuous feeder vessels in hemangiomas that require embolization.

Reality: Hemangiomas typically have one feeder vessel that's easily isolated. “This is very low-tech surgery,” Dr. Hochman said.

Myth: Hemangiomas infiltrate surrounding tissues and are difficult to remove.

Reality: Hemangiomas can push tissue out of the way, giving the impression of infiltration, but there is always a plane between the tumor and surrounding normal tissues. Dissection is relatively easy in discrete planes that occur naturally and can be created between the superficial and deep components of the hemangioma, or in the deep component, or within the fibrofatty residuum of skin and scar tissue.

Dr. Hochman cautioned that although these myths don't apply to hemangiomas, they may sometimes apply to malformations like port wine stains.

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

LAS VEGAS — Periocular fat injections in thin patients are more likely to capsulize and create unsightly "hot dog" rods in the tear trough that require multiple surgeries to remove, Dr. Cynthia Boxrud said at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Injected adipocytes behave differently in thin, muscular patients than in patients with more fat in their bodies, explained Dr. Boxrud of the University of California, Los Angeles. Be cautious with periorbital fillers in thinner patients, and warn them of the added risk.

Dr. Boxrud shared other pearls for successful periorbital volume replacement at the symposium. Tear-trough augmentation is an off-label indication for injectable fillers.

The first step is to obtain photos of the patient at a younger age to get a sense of the desired look. "Our faces age like a balloon deflates," she said.

Harvest fat from another body area using a small 10-cc syringe and let the tube of fat sit upright for 10 minutes before reinjecting. It settles into three layers: a top layer of oil, a middle layer of usable fat, and a bottom layer of blood. Studies have shown that centrifuging harvested fat makes no difference for these purposes, "so you don't have to spin it," Dr. Boxrud said.

Reinject the fat into the periocular area in a vertical direction using a blunt cannula pointing away from the eye. Dr. Boxrud prefers a 1.2-mm cannula instead of a 0.9-mm because she has seen some of the smaller cannulas bend during this procedure.

Inject small amounts of fat at a time, giving 20–25 injections, and be conservative, she advised. Insert the syringe deep below the surface and only release the fat when pulling the syringe back out. "Don't inject directly into muscles. I've seen muscle wasting from this," Dr. Boxrud added.

Document everything with photos and record the volume of fat injected.

Injectable collagen filler (Restylane) is another option for periorbital volume replacement. Results usually are more subtle than with fat injections, especially in younger patients.

"Young people aren't going to see great changes," Dr. Boxrud said.

Inject minimally, placing 0.2–0.3 cc under each eye via many small injections.

Results with Restylane are less successful in patients who have malar hypoplasia or translucent or thin skin. The product can cause temporary color changes in thin skin. "For the thinnest skin, use fat transplantation, not Restylane," she said.

Fat injection in the tear trough of this patient capsulized into a "hot dog" formation that necessitated surgical removal. Courtesy Dr. Cynthia Boxrud

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.

LAS VEGAS — Treatment of keloids or hypertrophic scars with surgery alone is almost guaranteed to fail, but there are theories as to which of the many potential adjunctive therapies might be best, and how best to combine treatments, Dr. Jimmy J. Brown said.

Dr. Brown and two other experts described their preferred treatment regimens at an international symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

Developing a strong bond between the physician and patient is paramount for successful management of these challenging lesions, especially for giant keloids, said Dr. Brown of Charles R. Drew University of Medicine and Science, Los Angeles.

Dr. Brian J. F. Wong said that most current treatment regimens use some combination of surgery, pressure, silicone gels or sheeting, and steroid injections, based mainly on ad hoc and anecdotal reports. "It's a very confusing body of literature," said Dr. Wong of the University of California, Irvine.

Even with combination therapy, 50% of keloids and hypertrophic scars recur, he noted.

Prevention is the best strategy, Dr. R. James Koch emphasized. Studies show that African Americans and possibly people of Chinese ancestry are at higher risk to develop keloids, compared with whites. Many things can cause keloids, including surgery, burns, skin piercing, lacerations, abrasions, and tattoos. Patient who may be predisposed to keloids should avoid nonessential surgery, said Dr. Koch of Palo Alto, Calif.

After surgery alone, keloids recur in 45%–100% of cases. Adding radiation therapy may reduce the recurrence rate to 10%–20%, the literature suggests, but its use is not standardized. No one knows when best to use it, how much to use, or whether fractionated protocols are beneficial, he pointed out.

Some physicians use a single postoperative dose of radiation in some patients. Dr. Brown cautioned that most radiologists prefer to use low-dose radiation for patients with keloids because it is a benign disease, but this may increase the risk for later development of radiation-related malignancy. He knows of three patients who developed squamous cell carcinoma in a keloid site after postoperative radiation therapy.

His immediate postoperative care comprises topical imiquimod (Aldara) cream 5% once a day and a pressure dressing; the wound is kept tension free. The jury is still out on imiquimod's usefulness for keloids, Dr. Brown said. His anecdotal experience suggests that using positive pressure splints once the surgical wound is healed is important to prevent keloid recurrence. It may be necessary to create pressure devices, such as a clothespin on an earlobe, after keloid removal, he suggested.

"If we can get away with excision, Aldara, and pressure therapy, we may not need radiation," he said.

He generally stops imiquimod after 8 weeks, although he will interrupt therapy earlier if the wound starts to break down where it was applied. This is not a debilitating problem, and the drug can be restarted after the wound heals, he said.

Intralesional corticosteroid injections should be a key part of treatment, Dr. Koch and Dr. Brown agreed.

Dr. Koch typically treats keloids with excision, but one shouldn't compromise anatomic structures to remove all of the keloid at once, he said. It may be done in stages. He avoids wound tension and may add pressure therapy. Intralesional steroids begin at least 2–3 weeks after surgery, and he also may use silicone gel.

For hypertrophic scars, Dr. Koch performs scar revision surgery and will start intralesional steroids at the first sign of hypertrophic scar recurrence. He also said he may use compression or silicone gel.

The most promising upcoming therapies for keloids and hypertrophic scars may be pulsed dye laser and photodynamic therapy (PDT), Dr. Wong said. Keloids are hypervascular lesions, and the pulsed dye laser disrupts blood supply, using a very narrow, local heat effect to trigger apoptotic mechanisms. When he removes a keloid, he sends the patient to a dermatologist for targeted pulsed dye laser therapy.

Studies of PDT for cancer have shown that it does not successfully treat malignancies but seems to decrease scar formation. Since PDT has no ionizing radiation, it can treat the keloid while preserving the normal tissue matrix. Dr. Wong plans to begin using PDT in patients with refractory keloids soon. "It's like a neutron bomb—you can kill the occupants but leave the house intact," he said. "There's no downside in the correct patient."

Dr. Koch was less enthusiastic about flashlamp and pumped pulsed dye laser therapy for keloids. This strategy mainly helps take the red out of the lesions, he said.

A combination of surgery, topical imiquimod, and pressure therapy may stave off the need for radiation. Courtesy Dr. R. James Koch

Metaanalysis Yields Mixed Results in Keloid, Hypertrophic Scar Treatment

Most of the available treatments for keloids or hypertrophic scars offer a minimal likelihood of improvement, a metaanalysis suggests.

The metaanalysis of results from 70 trials found a 70% chance of improvement from treatment. The management regimens improved lesions by a mean of 60%, compared with baseline, and a few therapies were no better than observation alone, Dr. Douglas Leventhal reported in a poster presentation at the international symposium.

There is no universally accepted treatment regimen for keloids or hypertrophic scars and no evidence-based literature to help clinicians choose from among the many treatment options that have already been tried. Management has evolved over the years from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that work on a cellular level, wrote Dr. Leventhal of Jefferson Medical College, Philadelphia.

Some current treatments for keloids or hypertrophic scars may provide clinically significant improvements, but results fall far short of a cure, he concluded.

SAN FRANCISCO — Skin striae are at least twice as common in women with pelvic organ prolapse as in women without prolapse, a survey of 116 women found.

Hormonal status alone didn't explain the association. Women with prolapse were less likely to be postmenopausal than women without prolapse. The association may indicate a common defect in connective tissue for prolapse and striae (stretch marks), Dr. Sharon Salter wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The surveys were completed by urogynecology patients and by a control group of women undergoing Mohs surgery for skin cancer in 2005. Just over half of the women with prolapse reported striae, compared with a quarter of women without prolapse. A majority of women with striae said the marks developed during pregnancy, reported Dr. Salter of Brigham and Women's Hospital, Boston.

Women were considered to have prolapse if they had a prior diagnosis of pelvic relaxation and prolapse or reported symptoms of pelvic pressure, urinary incontinence, or pelvic organ protrusion through the vagina.

Women with striae were significantly heavier (averaging 161 pounds vs. 144 pounds in the nonstriae group) and were more likely to have varicose veins.

Previous studies have noted decreased collagen and elastin content in women with prolapse. There are no reliable methods of predicting which women will develop pelvic organ prolapse.

Future studies might explore the possibility of stretch marks as a predictor of prolapse. If there is a definitive link, it may lead to a better understanding of the pathophysiology of both prolapse and striae, and potential treatments, Dr. Salter wrote.

SAN FRANCISCO — Skin striae are at least twice as common in women with pelvic organ prolapse as in women without prolapse, a survey of 116 women found.

Hormonal status alone didn't explain the association. Women with prolapse were less likely to be postmenopausal than women without prolapse. The association may indicate a common defect in connective tissue for prolapse and striae (stretch marks), Dr. Sharon Salter wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The surveys were completed by urogynecology patients and by a control group of women undergoing Mohs surgery for skin cancer in 2005. Just over half of the women with prolapse reported striae, compared with a quarter of women without prolapse. A majority of women with striae said the marks developed during pregnancy, reported Dr. Salter of Brigham and Women's Hospital, Boston.

Women were considered to have prolapse if they had a prior diagnosis of pelvic relaxation and prolapse or reported symptoms of pelvic pressure, urinary incontinence, or pelvic organ protrusion through the vagina.

Women with striae were significantly heavier (averaging 161 pounds vs. 144 pounds in the nonstriae group) and were more likely to have varicose veins.

Previous studies have noted decreased collagen and elastin content in women with prolapse. There are no reliable methods of predicting which women will develop pelvic organ prolapse.

Future studies might explore the possibility of stretch marks as a predictor of prolapse. If there is a definitive link, it may lead to a better understanding of the pathophysiology of both prolapse and striae, and potential treatments, Dr. Salter wrote.

SAN FRANCISCO — Skin striae are at least twice as common in women with pelvic organ prolapse as in women without prolapse, a survey of 116 women found.

Hormonal status alone didn't explain the association. Women with prolapse were less likely to be postmenopausal than women without prolapse. The association may indicate a common defect in connective tissue for prolapse and striae (stretch marks), Dr. Sharon Salter wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The surveys were completed by urogynecology patients and by a control group of women undergoing Mohs surgery for skin cancer in 2005. Just over half of the women with prolapse reported striae, compared with a quarter of women without prolapse. A majority of women with striae said the marks developed during pregnancy, reported Dr. Salter of Brigham and Women's Hospital, Boston.

Women were considered to have prolapse if they had a prior diagnosis of pelvic relaxation and prolapse or reported symptoms of pelvic pressure, urinary incontinence, or pelvic organ protrusion through the vagina.

Women with striae were significantly heavier (averaging 161 pounds vs. 144 pounds in the nonstriae group) and were more likely to have varicose veins.

Previous studies have noted decreased collagen and elastin content in women with prolapse. There are no reliable methods of predicting which women will develop pelvic organ prolapse.

Future studies might explore the possibility of stretch marks as a predictor of prolapse. If there is a definitive link, it may lead to a better understanding of the pathophysiology of both prolapse and striae, and potential treatments, Dr. Salter wrote.

SAN FRANCISCO — Prescribing has been gradually moving away from antimicrobial agents and toward increased use of retinoids in the treatment of acne vulgaris.

The shift toward nonantibiotics, reported in an analysis of national prescription habits between 1990 and 2002, may in part be explained by a growing awareness of antibiotic-resistant Propionibacterium acnes, wrote Dr. Suganthi Thevarajah and her associates in a poster presentation at the annual meeting of the American Academy of Dermatology.

The first report of antibiotic resistance to cutaneous P. acnes appeared in the late 1970s. The study showed that one in five U.S. patients treated with either topical erythromycin or clindamycin had resistant strains within their pilosebaceous follicles, noted Dr. Thevarajah of Hospital Kuala Lumpur, Malaysia. Dr. Thevarajah led the study while at the Center for Dermatology Research, Wake Forest University, Winston-Salem, N.C. The center is supported by a grant from Galderma Laboratories, which makes acne treatments.

She and her associates retrospectively analyzed data from all 4,922 acne visits from 1990 to 2002 in the National Ambulatory Medical Care Survey. The survey consists of outpatient information obtained from U.S. non-federally employed physicians.

During the 13-year period, there were significant declines in the likelihood of prescribing agents that relied on antimicrobial mechanisms for controlling acne. Included among these were benzoyl peroxide, topical clindamycin, oral erythromycin, and tetracycline-group antibiotics. In the same time period, there were significant increases in the likelihood of prescribing agents that were not dependent on antimicrobial mechanisms, such as topical retinoids and oral isotretinoin.

“Cross-resistance between erythromycin and clindamycin is increasing. This knowledge may have resulted in a decline in prescriptions for topical antibiotics as seen in our study,” Dr. Thevarajah wrote.

While use of tetracycline-group antibiotics decreased overall, their use actually increased among dermatologists. This may be because dermatologists are increasingly prescribing them for their anti-inflammatory effects rather than their antimicrobial properties, she added. Dermatologists were more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographics did not change the utilization findings. Older patients were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin. Men were less likely to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. Whites were more likely than nonwhites to get isotretinoin but less likely to be given benzoyl peroxide.

SAN FRANCISCO — Prescribing has been gradually moving away from antimicrobial agents and toward increased use of retinoids in the treatment of acne vulgaris.

The shift toward nonantibiotics, reported in an analysis of national prescription habits between 1990 and 2002, may in part be explained by a growing awareness of antibiotic-resistant Propionibacterium acnes, wrote Dr. Suganthi Thevarajah and her associates in a poster presentation at the annual meeting of the American Academy of Dermatology.

The first report of antibiotic resistance to cutaneous P. acnes appeared in the late 1970s. The study showed that one in five U.S. patients treated with either topical erythromycin or clindamycin had resistant strains within their pilosebaceous follicles, noted Dr. Thevarajah of Hospital Kuala Lumpur, Malaysia. Dr. Thevarajah led the study while at the Center for Dermatology Research, Wake Forest University, Winston-Salem, N.C. The center is supported by a grant from Galderma Laboratories, which makes acne treatments.

She and her associates retrospectively analyzed data from all 4,922 acne visits from 1990 to 2002 in the National Ambulatory Medical Care Survey. The survey consists of outpatient information obtained from U.S. non-federally employed physicians.

During the 13-year period, there were significant declines in the likelihood of prescribing agents that relied on antimicrobial mechanisms for controlling acne. Included among these were benzoyl peroxide, topical clindamycin, oral erythromycin, and tetracycline-group antibiotics. In the same time period, there were significant increases in the likelihood of prescribing agents that were not dependent on antimicrobial mechanisms, such as topical retinoids and oral isotretinoin.

“Cross-resistance between erythromycin and clindamycin is increasing. This knowledge may have resulted in a decline in prescriptions for topical antibiotics as seen in our study,” Dr. Thevarajah wrote.

While use of tetracycline-group antibiotics decreased overall, their use actually increased among dermatologists. This may be because dermatologists are increasingly prescribing them for their anti-inflammatory effects rather than their antimicrobial properties, she added. Dermatologists were more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographics did not change the utilization findings. Older patients were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin. Men were less likely to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. Whites were more likely than nonwhites to get isotretinoin but less likely to be given benzoyl peroxide.

SAN FRANCISCO — Prescribing has been gradually moving away from antimicrobial agents and toward increased use of retinoids in the treatment of acne vulgaris.

The shift toward nonantibiotics, reported in an analysis of national prescription habits between 1990 and 2002, may in part be explained by a growing awareness of antibiotic-resistant Propionibacterium acnes, wrote Dr. Suganthi Thevarajah and her associates in a poster presentation at the annual meeting of the American Academy of Dermatology.

The first report of antibiotic resistance to cutaneous P. acnes appeared in the late 1970s. The study showed that one in five U.S. patients treated with either topical erythromycin or clindamycin had resistant strains within their pilosebaceous follicles, noted Dr. Thevarajah of Hospital Kuala Lumpur, Malaysia. Dr. Thevarajah led the study while at the Center for Dermatology Research, Wake Forest University, Winston-Salem, N.C. The center is supported by a grant from Galderma Laboratories, which makes acne treatments.

She and her associates retrospectively analyzed data from all 4,922 acne visits from 1990 to 2002 in the National Ambulatory Medical Care Survey. The survey consists of outpatient information obtained from U.S. non-federally employed physicians.

During the 13-year period, there were significant declines in the likelihood of prescribing agents that relied on antimicrobial mechanisms for controlling acne. Included among these were benzoyl peroxide, topical clindamycin, oral erythromycin, and tetracycline-group antibiotics. In the same time period, there were significant increases in the likelihood of prescribing agents that were not dependent on antimicrobial mechanisms, such as topical retinoids and oral isotretinoin.

“Cross-resistance between erythromycin and clindamycin is increasing. This knowledge may have resulted in a decline in prescriptions for topical antibiotics as seen in our study,” Dr. Thevarajah wrote.

While use of tetracycline-group antibiotics decreased overall, their use actually increased among dermatologists. This may be because dermatologists are increasingly prescribing them for their anti-inflammatory effects rather than their antimicrobial properties, she added. Dermatologists were more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographics did not change the utilization findings. Older patients were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin. Men were less likely to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. Whites were more likely than nonwhites to get isotretinoin but less likely to be given benzoyl peroxide.