Sherry Boschert

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates. It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers.

Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding in the diabetic mothers, and higher education levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

There were trends toward less success in long-term breast-feeding among diabetic mothers who smoked of who had a nonvaginal delivery, but these did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates. It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers.

Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding in the diabetic mothers, and higher education levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

There were trends toward less success in long-term breast-feeding among diabetic mothers who smoked of who had a nonvaginal delivery, but these did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Offering women with type 1 diabetes support to breast-feed their newborns led to similar rates of breast-feeding among diabetic and nondiabetic women at 4 months after delivery despite high rates of morbidity in infants born to diabetic mothers, a Danish study found.

Exclusive breast-feeding is recommended for the first 4–6 months of life for all infants. Some previous reports have suggested that diabetic women may resort to early weaning because of fluctuating maternal blood glucose values and frequent episodes of symptomatic hypoglycemia.

In the current study, 86% of 102 diabetic mothers were breast-feeding 5 days after delivery, despite anticipated difficulties in initiating breast-feeding because of infant morbidities, reported Edna Stage, R.N., and her associates. It is the largest prospective study of nursing mothers with type 1 diabetes.

Four months after delivery, 54% of the diabetic mothers were exclusively breast-feeding, compared with 50% of 9,654 randomly selected Danish women interviewed in a separate study on lactation. Among the diabetic mothers, 14% were partly breast-feeding 4 months after delivery and 32% were not breast-feeding, compared with 26% and 24%, respectively, of the control group of mothers.

Neonatal morbidity occurred in 25 (45%) of 55 infants who were still exclusively breast-feeding at 4 months and in 30 (73%) of 47 infants who were not exclusively breast-feeding by 4 months, said Ms. Stage of Copenhagen University Hospital and her associates (Diabetes Care 2006;29:771–4).

Neonatal morbidity was defined as a need for continuous positive airway pressure for more than 1 hour, antibiotic treatment, IV glucose, or phototherapy.

Previous experience breast-feeding increased sixfold the likelihood of long-term exclusive breast-feeding in the diabetic mothers, and higher education levels (more than 10 years of school) increased the likelihood sevenfold, the investigators said.

There were trends toward less success in long-term breast-feeding among diabetic mothers who smoked of who had a nonvaginal delivery, but these did not hold up as independent predictors after multiple logistic regression analysis. The small number of smokers in the study may have reduced the odds of finding an association between smoking and lactation, an association identified in previous studies.

The investigators studied all women with type 1 diabetes delivering consecutively at the hospital from May 2001 to February 2003. The results did not include two women who did not want to participate, two who were not invited to participate because of an investigator's vacation, and one woman who could not be identified 4 months after delivery.

During pregnancy, the diabetic women were offered prenatal classes with information on breast-feeding and a visit to the neonatal intensive care unit. In addition, a diabetes nurse specialist offered individual counseling on the benefits of breast feeding and described the possibility of using a breast pump if the infant's ability to suck was impaired.

Neonates stayed with their mothers for the first 2 hours of life, and 47% first nursed during this time. They then were admitted to the neonatal intensive care unit for 24 hours, where they received artificial feedings of mother's milk or low-immunogen formula milk, mainly by nasogastric tube, every 3 hours to prevent hypoglycemia. During that time, they also averaged two breast-feedings. Severe hypoglycemia in 30% of infants was treated with IV glucose.

The rate of breast-feeding during this early period might have been improved if the mothers had been allowed to sleep near the infants in the neonatal ICU, the investigators suggested.

“We believe that the [prenatal] classes and individual counseling about benefits and difficulties in initiating breast-feeding offered to the women were valuable,” Ms. Stage and her associates wrote.

Imagine losing access to telephones, the Internet, and fax lines during a disaster and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, such as ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and associates had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Imagine losing access to telephones, the Internet, and fax lines during a disaster and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, such as ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and associates had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

Imagine losing access to telephones, the Internet, and fax lines during a disaster and trying to treat patients with nothing but a scratchy two-way radio to connect you with people and institutions outside your office.

It's so last century, and so avoidable, yet that's what happens after natural or man-made disasters, said Dr. Ronald C. Merrell. Physicians should plan ahead to maintain telecommunications so that they can practice medicine independently of emergency operation centers in such situations, he advised.

After terrorists destroyed the World Trade Center in New York in 2001, the dust was so thick that it interfered with satellite communications and cell phones. After a tsunami decimated parts of Southeast Asia in 2004, and after Hurricane Katrina hit the U.S. Gulf Coast in 2005, many physicians lost phone lines and were stuck with more primitive modes of communication, such as ham radios.

“That's technology we've had since the Second World War. It's fine, but we need to find a way to access the Internet. It's hard to practice medicine over a radio,” said Dr. Merrell, director of the Medical Informatics and Technology Applications Consortium (MITAC) at Virginia Commonwealth University, Richmond. MITAC is a research center sponsored by the National Aeronautic and Space Administration (NASA).

The medical needs of refugees from a disaster aren't necessarily what you might expect. Dr. Merrell and two colleagues from MITAC responded to a call from NASA after Hurricane Katrina to help an occupational medicine office at a NASA facility about 34 miles from the Mississippi coast. The office and its one physician had lost most communication with the outside world. Hundreds of people needed medical care, and within days the numbers grew to 4,000.

Many patients were on complex regimens of medicine, but their pills had washed away in the storm. One group of mentally ill patients from an assisted living facility had lost antipsychotic medication. Others had lost refrigeration and no longer had insulin.

Telemedicine teams in other parts of the country were eager to help, but the Mississippi facility had no good way to let them know what to send. Dr. Merrell and his team set up a satellite telephone, a computer satellite dish, and other equipment that gave them 65 kilobytes of transmission speed. Phone calls were transmitted via a French satellite to Paris and back to the United States. The team even brought solar panels to provide power if needed, but they were able to use electricity from the NASA facility.

The system allowed them to order medications, connect with other medical facilities, and coordinate transfers of patients to more stable environments.

Because telemedicine isn't part of the usual disaster preparedness infrastructure, deploying the specialized equipment and then training people to practice telemedicine is time consuming, which limits the amount of help it can provide, Dr. Merrell noted.

Physicians would be wise to assess the disaster plans for their clinics or hospitals and advocate for redundant telecommunications capabilities. “Medicine has to have a fairly independent and broadband interface” separate from acute emergency response efforts to serve patients well in a crisis, he said.

Having equipment and trained personnel in place made a huge difference when a devastating earthquake struck Pakistan in October 2005, Dr. Merrell said, noting that it may have been the first time that telemedicine formed the core of a successful medical response to a tragedy.

Under a grant from the U.S. Agency for International Development, Dr. Merrell and associates had traveled to Pakistan about a month before the earthquake to help establish two telemedicine training facilities in Rawalpindi, just outside the capital of Islamabad. The telemedicine facilities were to enable communications with two primary care clinics in the rural Punjab area for a more integrated health system.

When the earthquake hit, “We were in touch with them within 12 hours” thanks to the telemedicine programs, he said. The Rawalpindi medical facility was the first fully intact medical site encountered by people fleeing the mountainous areas, where the earthquake had leveled brick hospitals and killed almost all of the medical workers. Soon Rawalpindi's 1,500 beds were in demand for 6,000 patients.

Telecommunications kept the facility from being overwhelmed. Medical students volunteered for brief training in telemedicine and hiked into the mountains with backpacks containing satellite phones, digital cameras, laptop computers, and mobile power sources. From the mountains they informed the hospital at Rawalpindi and other facilities about which patients were headed their way and what would be needed. The students also transmitted medical records and photographs.

After reconstructive surgery at the Rawalpindi medical facility, patients were sent back to tent facilities in the mountains to recover. Surgeons were even able to send patients with complex orthopedic repairs to the mountains, knowing that staff would be able to telecommunicate about the patients' status and any postsurgical problems that arose.

“They never did overwhelm the hospital,” Dr. Merrell said. “They were able to use telecommunications to move patients down out of the mountains for definitive care and get them out and back to the mountains in a fraction of the usual time—in about 48 hours.”

SAN FRANCISCO — Suffocating head lice with a benzyl alcohol product appears to be a safe and effective alternative to current therapies, industry-sponsored studies suggest.

Unlike many other lice therapies, the “lice asphyxiator” product does not contain pesticides. Therefore it shouldn't carry the potential for the lice to develop resistance, Terri Meinking wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The increasing incidence of head lice in the past 8 years has been largely a result of lice becoming more tolerant or resistant to conventional treatments. “For this reason, children are being overtreated with pesticide-containing products as well as unconventional treatments,” noted Ms. Meinking of Global Health Associates of Miami Inc. and her associates. Global Health Associates is a contract research organization.

The active ingredient in Summers Nonpesticide Lice Asphyxiator, benzyl alcohol, works by stunning the louse's respiratory spiracles open, thereby allowing the product to mechanically block the respiratory system. Ms. Meinking, also of the department of dermatology and cutaneous surgery at the University of Miami, and her associates tested the safety and efficacy of this product in three randomized, observer-blinded studies sponsored by Summers Laboratories Inc., which makes the product.

Patients came from an area of high lice infestation in South Florida and had a high probability of being reinfested after treatment. They ranged in age from 2 to 70 years and had at least 3 live head lice and 10 eggs at study entry.

In the first study, 81 patients enrolled and 79 completed the study, which involved two applications for 10 minutes, 1 week apart, of a 5% or 10% concentration of the asphyxiator product, vehicle alone, or RID shampoo. Patients who were treated with the asphyxiator or RID who still had live lice 1 week after the initial treatment (day 8), were re-treated with the same product. Those who initially had been given placebo and had live lice on day 8 were treated with the 5% asphyxiator.

At day 1 after the first treatment, the kill rate was more than 80% among the 20 patients who had applied a 5% solution of the asphyxiator and among the 20 patients who had applied a 10% solution of the product. This was the same kill rate seen among the 20 patients who had applied RID shampoo, a pyrethrin-piperonyl-butoxide pediculicide. In comparison, the kill rate was less than 20% among the 19 patients who applied vehicle alone (placebo).

At day 15, all three active treatment groups had achieved a 70% success rate in eradicating live lice. The success rate was 53% among those in the placebo group. Only one adverse event, a mild burning on the scalp experienced by a patient in the RID group, was thought to possibly be treatment related.

Investigators noted that some of the scalps probably were insufficiently saturated to fully suffocate the lice and hypothesized that this may have been why success rates in the treatment groups were not higher.

In the second study, Ms. Meinking and her associates corrected for this and looked at duration of application. They compared 10− and 30-minute applications of the 5% concentration of the asphyxiator product on fully saturated hair in 44 patients, 43 of whom completed two applications, 1 week apart, and returned for follow-up on day 15. At follow-up, the success rate was 100% for all 21 patients randomized to apply the solution for 10 minutes and for all 22 who had applied it for 30 minutes. No treatment-related adverse events were noted.

The investigators then evaluated whether a 5% concentration of the asphyxiator was more effective than a 2.5% solution. At day 15, the overall treatment success was 91% among the 18 patients given the higher dose and 81% of the 21 given the lower dose. The 5% concentration is the dose of choice, they concluded.

SAN FRANCISCO — Suffocating head lice with a benzyl alcohol product appears to be a safe and effective alternative to current therapies, industry-sponsored studies suggest.

Unlike many other lice therapies, the “lice asphyxiator” product does not contain pesticides. Therefore it shouldn't carry the potential for the lice to develop resistance, Terri Meinking wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The increasing incidence of head lice in the past 8 years has been largely a result of lice becoming more tolerant or resistant to conventional treatments. “For this reason, children are being overtreated with pesticide-containing products as well as unconventional treatments,” noted Ms. Meinking of Global Health Associates of Miami Inc. and her associates. Global Health Associates is a contract research organization.

The active ingredient in Summers Nonpesticide Lice Asphyxiator, benzyl alcohol, works by stunning the louse's respiratory spiracles open, thereby allowing the product to mechanically block the respiratory system. Ms. Meinking, also of the department of dermatology and cutaneous surgery at the University of Miami, and her associates tested the safety and efficacy of this product in three randomized, observer-blinded studies sponsored by Summers Laboratories Inc., which makes the product.

Patients came from an area of high lice infestation in South Florida and had a high probability of being reinfested after treatment. They ranged in age from 2 to 70 years and had at least 3 live head lice and 10 eggs at study entry.

In the first study, 81 patients enrolled and 79 completed the study, which involved two applications for 10 minutes, 1 week apart, of a 5% or 10% concentration of the asphyxiator product, vehicle alone, or RID shampoo. Patients who were treated with the asphyxiator or RID who still had live lice 1 week after the initial treatment (day 8), were re-treated with the same product. Those who initially had been given placebo and had live lice on day 8 were treated with the 5% asphyxiator.

At day 1 after the first treatment, the kill rate was more than 80% among the 20 patients who had applied a 5% solution of the asphyxiator and among the 20 patients who had applied a 10% solution of the product. This was the same kill rate seen among the 20 patients who had applied RID shampoo, a pyrethrin-piperonyl-butoxide pediculicide. In comparison, the kill rate was less than 20% among the 19 patients who applied vehicle alone (placebo).

At day 15, all three active treatment groups had achieved a 70% success rate in eradicating live lice. The success rate was 53% among those in the placebo group. Only one adverse event, a mild burning on the scalp experienced by a patient in the RID group, was thought to possibly be treatment related.

Investigators noted that some of the scalps probably were insufficiently saturated to fully suffocate the lice and hypothesized that this may have been why success rates in the treatment groups were not higher.

In the second study, Ms. Meinking and her associates corrected for this and looked at duration of application. They compared 10− and 30-minute applications of the 5% concentration of the asphyxiator product on fully saturated hair in 44 patients, 43 of whom completed two applications, 1 week apart, and returned for follow-up on day 15. At follow-up, the success rate was 100% for all 21 patients randomized to apply the solution for 10 minutes and for all 22 who had applied it for 30 minutes. No treatment-related adverse events were noted.

The investigators then evaluated whether a 5% concentration of the asphyxiator was more effective than a 2.5% solution. At day 15, the overall treatment success was 91% among the 18 patients given the higher dose and 81% of the 21 given the lower dose. The 5% concentration is the dose of choice, they concluded.

SAN FRANCISCO — Suffocating head lice with a benzyl alcohol product appears to be a safe and effective alternative to current therapies, industry-sponsored studies suggest.

Unlike many other lice therapies, the “lice asphyxiator” product does not contain pesticides. Therefore it shouldn't carry the potential for the lice to develop resistance, Terri Meinking wrote in a poster presentation at the annual meeting of the American Academy of Dermatology.

The increasing incidence of head lice in the past 8 years has been largely a result of lice becoming more tolerant or resistant to conventional treatments. “For this reason, children are being overtreated with pesticide-containing products as well as unconventional treatments,” noted Ms. Meinking of Global Health Associates of Miami Inc. and her associates. Global Health Associates is a contract research organization.

The active ingredient in Summers Nonpesticide Lice Asphyxiator, benzyl alcohol, works by stunning the louse's respiratory spiracles open, thereby allowing the product to mechanically block the respiratory system. Ms. Meinking, also of the department of dermatology and cutaneous surgery at the University of Miami, and her associates tested the safety and efficacy of this product in three randomized, observer-blinded studies sponsored by Summers Laboratories Inc., which makes the product.

Patients came from an area of high lice infestation in South Florida and had a high probability of being reinfested after treatment. They ranged in age from 2 to 70 years and had at least 3 live head lice and 10 eggs at study entry.

In the first study, 81 patients enrolled and 79 completed the study, which involved two applications for 10 minutes, 1 week apart, of a 5% or 10% concentration of the asphyxiator product, vehicle alone, or RID shampoo. Patients who were treated with the asphyxiator or RID who still had live lice 1 week after the initial treatment (day 8), were re-treated with the same product. Those who initially had been given placebo and had live lice on day 8 were treated with the 5% asphyxiator.

At day 1 after the first treatment, the kill rate was more than 80% among the 20 patients who had applied a 5% solution of the asphyxiator and among the 20 patients who had applied a 10% solution of the product. This was the same kill rate seen among the 20 patients who had applied RID shampoo, a pyrethrin-piperonyl-butoxide pediculicide. In comparison, the kill rate was less than 20% among the 19 patients who applied vehicle alone (placebo).

At day 15, all three active treatment groups had achieved a 70% success rate in eradicating live lice. The success rate was 53% among those in the placebo group. Only one adverse event, a mild burning on the scalp experienced by a patient in the RID group, was thought to possibly be treatment related.

Investigators noted that some of the scalps probably were insufficiently saturated to fully suffocate the lice and hypothesized that this may have been why success rates in the treatment groups were not higher.

In the second study, Ms. Meinking and her associates corrected for this and looked at duration of application. They compared 10− and 30-minute applications of the 5% concentration of the asphyxiator product on fully saturated hair in 44 patients, 43 of whom completed two applications, 1 week apart, and returned for follow-up on day 15. At follow-up, the success rate was 100% for all 21 patients randomized to apply the solution for 10 minutes and for all 22 who had applied it for 30 minutes. No treatment-related adverse events were noted.

The investigators then evaluated whether a 5% concentration of the asphyxiator was more effective than a 2.5% solution. At day 15, the overall treatment success was 91% among the 18 patients given the higher dose and 81% of the 21 given the lower dose. The 5% concentration is the dose of choice, they concluded.

SAN FRANCISCO — Adalimumab is effective in treating both mild to moderate and moderate to severe skin disease in patients with psoriatic arthritis, Dr. Dafna D. Gladman reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

Adalimumab, a tumor necrosis factor blocker, was approved in 2005 for the treatment of rheumatoid arthritis and psoriatic arthritis. To assess whether the level of skin disease affected the response of psoriasis to the drug, Dr. Gladman and her associates performed a post-hoc analysis of a 24-week, placebo-controlled phase III trial of patients with moderately active to severely active psoriatic arthritis.

Among those in the adalimumab-treated group, 53 patients had mild to moderate skin disease, with a Psoriasis Area and Severity Index (PASI) score of less than 10 at baseline; 16 patients had moderate to severe skin disease, with a PASI score of 10 or more.

PASI responses occurred quickly and were maintained. After 24 weeks of drug treatment, the two subgroups had similar response rates. Comparing the mild/moderate and moderate/severe groups, a PASI 50 score (a 50% reduction from baseline) was achieved by 39 (74%) and 13 (81%), respectively; a PASI 90 score was achieved by 23 (43%) and 6 (38%) in the respective groups, reported Dr. Gladman of the University of Toronto.

Dr. Gladman is a primary investigator for Abbott Laboratories, which makes adalimumab (Humira).

Both subgroups, she said, achieved “meaningful improvements” in quality of life, compared with baseline, as measured by the Dermatology Life Quality Index.

SAN FRANCISCO — Adalimumab is effective in treating both mild to moderate and moderate to severe skin disease in patients with psoriatic arthritis, Dr. Dafna D. Gladman reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

Adalimumab, a tumor necrosis factor blocker, was approved in 2005 for the treatment of rheumatoid arthritis and psoriatic arthritis. To assess whether the level of skin disease affected the response of psoriasis to the drug, Dr. Gladman and her associates performed a post-hoc analysis of a 24-week, placebo-controlled phase III trial of patients with moderately active to severely active psoriatic arthritis.

Among those in the adalimumab-treated group, 53 patients had mild to moderate skin disease, with a Psoriasis Area and Severity Index (PASI) score of less than 10 at baseline; 16 patients had moderate to severe skin disease, with a PASI score of 10 or more.

PASI responses occurred quickly and were maintained. After 24 weeks of drug treatment, the two subgroups had similar response rates. Comparing the mild/moderate and moderate/severe groups, a PASI 50 score (a 50% reduction from baseline) was achieved by 39 (74%) and 13 (81%), respectively; a PASI 90 score was achieved by 23 (43%) and 6 (38%) in the respective groups, reported Dr. Gladman of the University of Toronto.

Dr. Gladman is a primary investigator for Abbott Laboratories, which makes adalimumab (Humira).

Both subgroups, she said, achieved “meaningful improvements” in quality of life, compared with baseline, as measured by the Dermatology Life Quality Index.

SAN FRANCISCO — Adalimumab is effective in treating both mild to moderate and moderate to severe skin disease in patients with psoriatic arthritis, Dr. Dafna D. Gladman reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

Adalimumab, a tumor necrosis factor blocker, was approved in 2005 for the treatment of rheumatoid arthritis and psoriatic arthritis. To assess whether the level of skin disease affected the response of psoriasis to the drug, Dr. Gladman and her associates performed a post-hoc analysis of a 24-week, placebo-controlled phase III trial of patients with moderately active to severely active psoriatic arthritis.

Among those in the adalimumab-treated group, 53 patients had mild to moderate skin disease, with a Psoriasis Area and Severity Index (PASI) score of less than 10 at baseline; 16 patients had moderate to severe skin disease, with a PASI score of 10 or more.

PASI responses occurred quickly and were maintained. After 24 weeks of drug treatment, the two subgroups had similar response rates. Comparing the mild/moderate and moderate/severe groups, a PASI 50 score (a 50% reduction from baseline) was achieved by 39 (74%) and 13 (81%), respectively; a PASI 90 score was achieved by 23 (43%) and 6 (38%) in the respective groups, reported Dr. Gladman of the University of Toronto.

Dr. Gladman is a primary investigator for Abbott Laboratories, which makes adalimumab (Humira).

Both subgroups, she said, achieved “meaningful improvements” in quality of life, compared with baseline, as measured by the Dermatology Life Quality Index.

SAN FRANCISCO — Efalizumab appears to be well tolerated over the course of up to 60 weeks of treatment, according to a combined analysis of more than 1,000 patients with moderate to severe chronic plaque psoriasis.

Common adverse events were similar to those seen in shorter trials; no new category of common adverse event appeared during extended therapy periods, Dr. Alice B. Gottlieb reported in a poster session at the annual meeting of the American Academy of Dermatology.

The risk of serious adverse events did not increase over time, added Dr. Gottlieb of the University of Medicine and Dentistry of New Jersey, New Brunswick, N.J. Dr. Gottlieb is a paid consultant for Genentech Inc., which makes efalizumab (Raptiva). The Food and Drug Administration approved the biologic agent for the treatment of moderate to severe psoriasis in October 2003.

The analysis appears to be the largest compilation of psoriasis patients studied through 60 weeks of treatment with a biologic therapy.

Dr. Gottlieb and her associates evaluated the long-term safety of efalizumab, injected subcutaneously at weekly intervals, by pooling the 60-week data from two multicenter phase III studies of adults with moderate to severe chronic plaque psoriasis. The Psoriasis Area and Severity Index (PASI) of the patients was at least 12 at baseline; their mean PASI was 19. At least 10% of their body surface area was affected; the mean was 29%.

One study was a 60-week randomized, double-blind, parallel-group, placebo-controlled trial. Included in the pooled analysis were 450 patients who had been randomized to receive efalizumab during the 12-week placebo-controlled portion of the trial and 218 who were randomized to receive placebo. Both groups entered an open-label extended-treatment phase for up to 48 weeks of active treatment, and then were eligible to continue to receive the drug for another 12 weeks or until the drug became commercially available.

The second study included in the pooled analysis was an open-label 36-month trial. The investigators evaluated safety data for up to 60 weeks of therapy for 339 of the patients.

Concomitant use of topical psoriasis therapy or phototherapy was permitted at various periods in both studies. For analysis, the investigators divided treatment phases into five consecutive 12-week segments. During the first 12-week exposure period, 80% of 1,004 patients experienced at least one adverse event. These occurred most often within 48 hours of efalizumab injection, and consisted primarily of headache, fever, chills, nausea, pharyngitis, and a flulike syndrome. The percentage of patients experiencing an adverse event then gradually decreased to 48% among the 537 patients followed for 49–60 weeks, Dr. Gottlieb wrote.

Infections occurred in 20%–30% of patients during each of the five evaluation periods. Arthritis occurred in 1%–3% of patients throughout the five periods.

Serious adverse events were noted in 2%–3% of patients during each 12-week segment. The incidence of each serious event was less than 1%, except for serious skin-related problems, which peaked at 1% during the 37–48 week exposure period. There was one case of hemolytic anemia that occurred with 25–36 weeks of exposure. Eight cases of thrombocytopenia were reported; two occurred during the first 12 weeks of exposure, three with 13–24 weeks, two with 25–36 weeks, and one with 37–48 weeks of exposure.

The incidence of malignancy remained at less than 1% throughout. The most common malignancy was nonmelanoma skin cancer, of which there were 18 cases, Dr. Gottlieb reported.

SAN FRANCISCO — Efalizumab appears to be well tolerated over the course of up to 60 weeks of treatment, according to a combined analysis of more than 1,000 patients with moderate to severe chronic plaque psoriasis.

Common adverse events were similar to those seen in shorter trials; no new category of common adverse event appeared during extended therapy periods, Dr. Alice B. Gottlieb reported in a poster session at the annual meeting of the American Academy of Dermatology.

The risk of serious adverse events did not increase over time, added Dr. Gottlieb of the University of Medicine and Dentistry of New Jersey, New Brunswick, N.J. Dr. Gottlieb is a paid consultant for Genentech Inc., which makes efalizumab (Raptiva). The Food and Drug Administration approved the biologic agent for the treatment of moderate to severe psoriasis in October 2003.

The analysis appears to be the largest compilation of psoriasis patients studied through 60 weeks of treatment with a biologic therapy.

Dr. Gottlieb and her associates evaluated the long-term safety of efalizumab, injected subcutaneously at weekly intervals, by pooling the 60-week data from two multicenter phase III studies of adults with moderate to severe chronic plaque psoriasis. The Psoriasis Area and Severity Index (PASI) of the patients was at least 12 at baseline; their mean PASI was 19. At least 10% of their body surface area was affected; the mean was 29%.

One study was a 60-week randomized, double-blind, parallel-group, placebo-controlled trial. Included in the pooled analysis were 450 patients who had been randomized to receive efalizumab during the 12-week placebo-controlled portion of the trial and 218 who were randomized to receive placebo. Both groups entered an open-label extended-treatment phase for up to 48 weeks of active treatment, and then were eligible to continue to receive the drug for another 12 weeks or until the drug became commercially available.

The second study included in the pooled analysis was an open-label 36-month trial. The investigators evaluated safety data for up to 60 weeks of therapy for 339 of the patients.

Concomitant use of topical psoriasis therapy or phototherapy was permitted at various periods in both studies. For analysis, the investigators divided treatment phases into five consecutive 12-week segments. During the first 12-week exposure period, 80% of 1,004 patients experienced at least one adverse event. These occurred most often within 48 hours of efalizumab injection, and consisted primarily of headache, fever, chills, nausea, pharyngitis, and a flulike syndrome. The percentage of patients experiencing an adverse event then gradually decreased to 48% among the 537 patients followed for 49–60 weeks, Dr. Gottlieb wrote.

Infections occurred in 20%–30% of patients during each of the five evaluation periods. Arthritis occurred in 1%–3% of patients throughout the five periods.

Serious adverse events were noted in 2%–3% of patients during each 12-week segment. The incidence of each serious event was less than 1%, except for serious skin-related problems, which peaked at 1% during the 37–48 week exposure period. There was one case of hemolytic anemia that occurred with 25–36 weeks of exposure. Eight cases of thrombocytopenia were reported; two occurred during the first 12 weeks of exposure, three with 13–24 weeks, two with 25–36 weeks, and one with 37–48 weeks of exposure.

The incidence of malignancy remained at less than 1% throughout. The most common malignancy was nonmelanoma skin cancer, of which there were 18 cases, Dr. Gottlieb reported.

SAN FRANCISCO — Efalizumab appears to be well tolerated over the course of up to 60 weeks of treatment, according to a combined analysis of more than 1,000 patients with moderate to severe chronic plaque psoriasis.

Common adverse events were similar to those seen in shorter trials; no new category of common adverse event appeared during extended therapy periods, Dr. Alice B. Gottlieb reported in a poster session at the annual meeting of the American Academy of Dermatology.

The risk of serious adverse events did not increase over time, added Dr. Gottlieb of the University of Medicine and Dentistry of New Jersey, New Brunswick, N.J. Dr. Gottlieb is a paid consultant for Genentech Inc., which makes efalizumab (Raptiva). The Food and Drug Administration approved the biologic agent for the treatment of moderate to severe psoriasis in October 2003.

The analysis appears to be the largest compilation of psoriasis patients studied through 60 weeks of treatment with a biologic therapy.

Dr. Gottlieb and her associates evaluated the long-term safety of efalizumab, injected subcutaneously at weekly intervals, by pooling the 60-week data from two multicenter phase III studies of adults with moderate to severe chronic plaque psoriasis. The Psoriasis Area and Severity Index (PASI) of the patients was at least 12 at baseline; their mean PASI was 19. At least 10% of their body surface area was affected; the mean was 29%.

One study was a 60-week randomized, double-blind, parallel-group, placebo-controlled trial. Included in the pooled analysis were 450 patients who had been randomized to receive efalizumab during the 12-week placebo-controlled portion of the trial and 218 who were randomized to receive placebo. Both groups entered an open-label extended-treatment phase for up to 48 weeks of active treatment, and then were eligible to continue to receive the drug for another 12 weeks or until the drug became commercially available.

The second study included in the pooled analysis was an open-label 36-month trial. The investigators evaluated safety data for up to 60 weeks of therapy for 339 of the patients.

Concomitant use of topical psoriasis therapy or phototherapy was permitted at various periods in both studies. For analysis, the investigators divided treatment phases into five consecutive 12-week segments. During the first 12-week exposure period, 80% of 1,004 patients experienced at least one adverse event. These occurred most often within 48 hours of efalizumab injection, and consisted primarily of headache, fever, chills, nausea, pharyngitis, and a flulike syndrome. The percentage of patients experiencing an adverse event then gradually decreased to 48% among the 537 patients followed for 49–60 weeks, Dr. Gottlieb wrote.

Infections occurred in 20%–30% of patients during each of the five evaluation periods. Arthritis occurred in 1%–3% of patients throughout the five periods.

Serious adverse events were noted in 2%–3% of patients during each 12-week segment. The incidence of each serious event was less than 1%, except for serious skin-related problems, which peaked at 1% during the 37–48 week exposure period. There was one case of hemolytic anemia that occurred with 25–36 weeks of exposure. Eight cases of thrombocytopenia were reported; two occurred during the first 12 weeks of exposure, three with 13–24 weeks, two with 25–36 weeks, and one with 37–48 weeks of exposure.

The incidence of malignancy remained at less than 1% throughout. The most common malignancy was nonmelanoma skin cancer, of which there were 18 cases, Dr. Gottlieb reported.

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.

Although the use of tetracycline-group antibiotics, including tetracycline, doxycycline and minocycline, 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.

There was also a trend for dermatologists to have been more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographic factors in the analysis did not change the findings about drug utilization.

A few demographic factors appeared to influence prescribing behavior. Older patients, for example, were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin than younger patients. Men were less likely than women to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. White patients were more likely to receive a prescription for isotretinoin but less apt to be given benzoyl peroxide, compared with nonwhite patients.

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.

Although the use of tetracycline-group antibiotics, including tetracycline, doxycycline and minocycline, 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.

There was also a trend for dermatologists to have been more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographic factors in the analysis did not change the findings about drug utilization.

A few demographic factors appeared to influence prescribing behavior. Older patients, for example, were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin than younger patients. Men were less likely than women to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. White patients were more likely to receive a prescription for isotretinoin but less apt to be given benzoyl peroxide, compared with nonwhite patients.

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.

Although the use of tetracycline-group antibiotics, including tetracycline, doxycycline and minocycline, 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.

There was also a trend for dermatologists to have been more likely than nondermatologists to prescribe benzoyl peroxide, clindamycin, isotretinoin, topical retinoids, and tetracycline-group antibiotics.

Controls for demographic factors in the analysis did not change the findings about drug utilization.

A few demographic factors appeared to influence prescribing behavior. Older patients, for example, were less likely to receive clindamycin, topical retinoids, benzoyl peroxide, tetracycline-group antibiotics, and isotretinoin than younger patients. Men were less likely than women to receive clindamycin and topical retinoids and more likely to receive tetracycline-group antibiotics and oral isotretinoin. White patients were more likely to receive a prescription for isotretinoin but less apt to be given benzoyl peroxide, compared with nonwhite patients.

SAN FRANCISCO — Shunt revisions are necessary in a “startlingly high rate” in patients with hydrocephalus diagnosed in infancy or childhood, Dr. Nalin Gupta said at the annual meeting of the American Association of Neurological Surgeons.

Like the need for shunt revision, infections and functional problems continued into adulthood, judging from the findings that a retrospective study of 1,459 patients found.

“By focusing on surgical complications, we underestimate the impact of hydrocephalus. Lifelong medical treatment and complications are to be expected,” said Dr. Gupta.

He and his associates studied survey responses collected by the Hydrocephalus Association from 1,459 people with pediatric diagnoses of hydrocephalus. The data included 10-year follow-up information for 718 respondents, and 403 of these were at least 20 years of age at the time of the survey.

Most respondents developed hydrocephalus during gestation or in infancy, with 16% diagnosed before birth and 42% diagnosed before 18 months of age, said Dr. Gupta, chief of pediatric neurological surgery at the University of California, San Francisco.

Shunts to treat hydrocephalus were placed in 97% of cases. Approximately 31% of respondents had between 1 and 10 shunt revisions. Among 581 people diagnosed with hydrocephalus before 18 months of age, only 8% reported no shunt revisions; another 25% underwent more than 10 shunt revisions, he said. People who reported more than 10 shunt revisions had a median age of 21 years; most were in their 20s.

Hydrocephalus diagnosed later in childhood also was associated with a high rate of shunt revisions. Among 137 people diagnosed after 18 months of age, 15% needed no shunt revisions, 23% underwent more than 10 revisions, and the rest fell in between.

Shunt-related infections were common as well. One or two infections were reported by 29% of respondents; among a subset of patients diagnosed before 18 months of age, at least a third reported one or two infections, and a small percentage reported many more infections, Dr. Gupta said.

The proportions of shunt revisions exceeds what is reported in the literature for hydrocephalus diagnosed in childhood, and the proportion of infections is higher than what physicians usually describe to families contemplating shunt placement, said Dr. Timothy B. Mapstone, who discussed the study at the meeting. The true extent of revisions and infections probably is even worse, he added.

The data emphasize the need to be sure that a shunt is needed before placing one, said Dr. Mapstone, the Harry Wilkins Chair in neurosurgery at the University of Oklahoma, Oklahoma City.

Other complications, including shunt breakage, overdrainage, and subjective symptoms, were reported by 36% of respondents. “To me, this was an unacceptable rate of complications associated with this disease,” Dr. Gupta said, noting the study's design limits its usefulness.

Respondents who were diagnosed with hydrocephalus during infancy were more likely to report being depressed or to have used special assistance in school, and were less likely to be married, have children, be employed, or have a driver's license, compared with those diagnosed after 18 months of age.

Among a subset of 403 respondents currently aged 19–45 years who were diagnosed with hydrocephalus before age 19 years, a majority reported being depressed and 37%–45% reported receiving treatment for depression, depending on their age at diagnosis. Fewer than 25% had completed a college education.

The respondents were 53% male, and 85% were white.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Shunt revisions are necessary in a “startlingly high rate” in patients with hydrocephalus diagnosed in infancy or childhood, Dr. Nalin Gupta said at the annual meeting of the American Association of Neurological Surgeons.

Like the need for shunt revision, infections and functional problems continued into adulthood, judging from the findings that a retrospective study of 1,459 patients found.

“By focusing on surgical complications, we underestimate the impact of hydrocephalus. Lifelong medical treatment and complications are to be expected,” said Dr. Gupta.

He and his associates studied survey responses collected by the Hydrocephalus Association from 1,459 people with pediatric diagnoses of hydrocephalus. The data included 10-year follow-up information for 718 respondents, and 403 of these were at least 20 years of age at the time of the survey.

Most respondents developed hydrocephalus during gestation or in infancy, with 16% diagnosed before birth and 42% diagnosed before 18 months of age, said Dr. Gupta, chief of pediatric neurological surgery at the University of California, San Francisco.

Shunts to treat hydrocephalus were placed in 97% of cases. Approximately 31% of respondents had between 1 and 10 shunt revisions. Among 581 people diagnosed with hydrocephalus before 18 months of age, only 8% reported no shunt revisions; another 25% underwent more than 10 shunt revisions, he said. People who reported more than 10 shunt revisions had a median age of 21 years; most were in their 20s.

Hydrocephalus diagnosed later in childhood also was associated with a high rate of shunt revisions. Among 137 people diagnosed after 18 months of age, 15% needed no shunt revisions, 23% underwent more than 10 revisions, and the rest fell in between.

Shunt-related infections were common as well. One or two infections were reported by 29% of respondents; among a subset of patients diagnosed before 18 months of age, at least a third reported one or two infections, and a small percentage reported many more infections, Dr. Gupta said.

The proportions of shunt revisions exceeds what is reported in the literature for hydrocephalus diagnosed in childhood, and the proportion of infections is higher than what physicians usually describe to families contemplating shunt placement, said Dr. Timothy B. Mapstone, who discussed the study at the meeting. The true extent of revisions and infections probably is even worse, he added.

The data emphasize the need to be sure that a shunt is needed before placing one, said Dr. Mapstone, the Harry Wilkins Chair in neurosurgery at the University of Oklahoma, Oklahoma City.

Other complications, including shunt breakage, overdrainage, and subjective symptoms, were reported by 36% of respondents. “To me, this was an unacceptable rate of complications associated with this disease,” Dr. Gupta said, noting the study's design limits its usefulness.

Respondents who were diagnosed with hydrocephalus during infancy were more likely to report being depressed or to have used special assistance in school, and were less likely to be married, have children, be employed, or have a driver's license, compared with those diagnosed after 18 months of age.

Among a subset of 403 respondents currently aged 19–45 years who were diagnosed with hydrocephalus before age 19 years, a majority reported being depressed and 37%–45% reported receiving treatment for depression, depending on their age at diagnosis. Fewer than 25% had completed a college education.

The respondents were 53% male, and 85% were white.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Shunt revisions are necessary in a “startlingly high rate” in patients with hydrocephalus diagnosed in infancy or childhood, Dr. Nalin Gupta said at the annual meeting of the American Association of Neurological Surgeons.

Like the need for shunt revision, infections and functional problems continued into adulthood, judging from the findings that a retrospective study of 1,459 patients found.

“By focusing on surgical complications, we underestimate the impact of hydrocephalus. Lifelong medical treatment and complications are to be expected,” said Dr. Gupta.

He and his associates studied survey responses collected by the Hydrocephalus Association from 1,459 people with pediatric diagnoses of hydrocephalus. The data included 10-year follow-up information for 718 respondents, and 403 of these were at least 20 years of age at the time of the survey.

Most respondents developed hydrocephalus during gestation or in infancy, with 16% diagnosed before birth and 42% diagnosed before 18 months of age, said Dr. Gupta, chief of pediatric neurological surgery at the University of California, San Francisco.

Shunts to treat hydrocephalus were placed in 97% of cases. Approximately 31% of respondents had between 1 and 10 shunt revisions. Among 581 people diagnosed with hydrocephalus before 18 months of age, only 8% reported no shunt revisions; another 25% underwent more than 10 shunt revisions, he said. People who reported more than 10 shunt revisions had a median age of 21 years; most were in their 20s.

Hydrocephalus diagnosed later in childhood also was associated with a high rate of shunt revisions. Among 137 people diagnosed after 18 months of age, 15% needed no shunt revisions, 23% underwent more than 10 revisions, and the rest fell in between.

Shunt-related infections were common as well. One or two infections were reported by 29% of respondents; among a subset of patients diagnosed before 18 months of age, at least a third reported one or two infections, and a small percentage reported many more infections, Dr. Gupta said.

The proportions of shunt revisions exceeds what is reported in the literature for hydrocephalus diagnosed in childhood, and the proportion of infections is higher than what physicians usually describe to families contemplating shunt placement, said Dr. Timothy B. Mapstone, who discussed the study at the meeting. The true extent of revisions and infections probably is even worse, he added.

The data emphasize the need to be sure that a shunt is needed before placing one, said Dr. Mapstone, the Harry Wilkins Chair in neurosurgery at the University of Oklahoma, Oklahoma City.

Other complications, including shunt breakage, overdrainage, and subjective symptoms, were reported by 36% of respondents. “To me, this was an unacceptable rate of complications associated with this disease,” Dr. Gupta said, noting the study's design limits its usefulness.

Respondents who were diagnosed with hydrocephalus during infancy were more likely to report being depressed or to have used special assistance in school, and were less likely to be married, have children, be employed, or have a driver's license, compared with those diagnosed after 18 months of age.

Among a subset of 403 respondents currently aged 19–45 years who were diagnosed with hydrocephalus before age 19 years, a majority reported being depressed and 37%–45% reported receiving treatment for depression, depending on their age at diagnosis. Fewer than 25% had completed a college education.

The respondents were 53% male, and 85% were white.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Ulcerated skin lesions in three patients with refractory pyoderma gangrenosum shrank and reepithelialized after 10–11 weekly treatments with granulocyte and monocyte adsorption apheresis, Dr. Mariko Seishima and her associates reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

All three patients were being treated concurrently with prednisolone and cyclosporine, sulfasalazine, or cyclophosphamide, so it's difficult to sort out the exact benefit of granulocyte and monocyte adsorption apheresis (GCAP). It's significant, however, that the lesions had not healed with prior treatment with these medications and others, and clinicians were able to discontinue the drugs or reduce the dosages after GCAP, wrote Dr. Seishima and her associates at Ogaki (Japan) Municipal Hospital.

Pyoderma gangrenosum often is associated with other diseases, including Crohn's disease, ulcerative colitis, or rheumatoid arthritis. One of the three patients treated had rheumatoid arthritis. Recent studies of GCAP for ulcerative colitis have produced impressive results, the investigators noted.

Pyoderma gangrenosum is a chronic skin disorder characterized by intractable ulcers. Histology typically reveals dense cellular infiltration consisting of dominant neutrophils throughout the dermis. After the GCAP treatments, neutrophil counts and leukocyte counts decreased in all patients.

Dr. Seishima and her associates used the column design of GCAP to remove pathogenic granulocytes. The column is a device filled with 220 g of cellulose acetate beads, each 2 mm in diameter. The procedure draws peripheral blood from the cubital vein of one of the patient's arms, perfuses it through the column to remove pathogenic granulocytes, and returns the blood to the cubital vein of the opposite arm. The consecutive weekly sessions each lasted 60 minutes, with a flow rate of 30 mL/min.

No side effects were seen during 8 months of follow-up after completing the GCAP treatments.

For patients with pyoderma gangrenosum who do not respond to treatment with corticosteroids, sulfonamides, and immunosuppressive agents, GCAP may be a useful alternative, according to Dr. Seishima and her colleagues.

A double-blind clinical study is needed to confirm the effects of GCAP, they wrote. Future research also should examine GCAP alone or combined with drug therapy and try to identify the optimal frequency and number of treatments.

SAN FRANCISCO — Ulcerated skin lesions in three patients with refractory pyoderma gangrenosum shrank and reepithelialized after 10–11 weekly treatments with granulocyte and monocyte adsorption apheresis, Dr. Mariko Seishima and her associates reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

All three patients were being treated concurrently with prednisolone and cyclosporine, sulfasalazine, or cyclophosphamide, so it's difficult to sort out the exact benefit of granulocyte and monocyte adsorption apheresis (GCAP). It's significant, however, that the lesions had not healed with prior treatment with these medications and others, and clinicians were able to discontinue the drugs or reduce the dosages after GCAP, wrote Dr. Seishima and her associates at Ogaki (Japan) Municipal Hospital.

Pyoderma gangrenosum often is associated with other diseases, including Crohn's disease, ulcerative colitis, or rheumatoid arthritis. One of the three patients treated had rheumatoid arthritis. Recent studies of GCAP for ulcerative colitis have produced impressive results, the investigators noted.

Pyoderma gangrenosum is a chronic skin disorder characterized by intractable ulcers. Histology typically reveals dense cellular infiltration consisting of dominant neutrophils throughout the dermis. After the GCAP treatments, neutrophil counts and leukocyte counts decreased in all patients.

Dr. Seishima and her associates used the column design of GCAP to remove pathogenic granulocytes. The column is a device filled with 220 g of cellulose acetate beads, each 2 mm in diameter. The procedure draws peripheral blood from the cubital vein of one of the patient's arms, perfuses it through the column to remove pathogenic granulocytes, and returns the blood to the cubital vein of the opposite arm. The consecutive weekly sessions each lasted 60 minutes, with a flow rate of 30 mL/min.

No side effects were seen during 8 months of follow-up after completing the GCAP treatments.

For patients with pyoderma gangrenosum who do not respond to treatment with corticosteroids, sulfonamides, and immunosuppressive agents, GCAP may be a useful alternative, according to Dr. Seishima and her colleagues.

A double-blind clinical study is needed to confirm the effects of GCAP, they wrote. Future research also should examine GCAP alone or combined with drug therapy and try to identify the optimal frequency and number of treatments.

SAN FRANCISCO — Ulcerated skin lesions in three patients with refractory pyoderma gangrenosum shrank and reepithelialized after 10–11 weekly treatments with granulocyte and monocyte adsorption apheresis, Dr. Mariko Seishima and her associates reported in a poster presentation at the annual meeting of the American Academy of Dermatology.

All three patients were being treated concurrently with prednisolone and cyclosporine, sulfasalazine, or cyclophosphamide, so it's difficult to sort out the exact benefit of granulocyte and monocyte adsorption apheresis (GCAP). It's significant, however, that the lesions had not healed with prior treatment with these medications and others, and clinicians were able to discontinue the drugs or reduce the dosages after GCAP, wrote Dr. Seishima and her associates at Ogaki (Japan) Municipal Hospital.

Pyoderma gangrenosum often is associated with other diseases, including Crohn's disease, ulcerative colitis, or rheumatoid arthritis. One of the three patients treated had rheumatoid arthritis. Recent studies of GCAP for ulcerative colitis have produced impressive results, the investigators noted.

Pyoderma gangrenosum is a chronic skin disorder characterized by intractable ulcers. Histology typically reveals dense cellular infiltration consisting of dominant neutrophils throughout the dermis. After the GCAP treatments, neutrophil counts and leukocyte counts decreased in all patients.

Dr. Seishima and her associates used the column design of GCAP to remove pathogenic granulocytes. The column is a device filled with 220 g of cellulose acetate beads, each 2 mm in diameter. The procedure draws peripheral blood from the cubital vein of one of the patient's arms, perfuses it through the column to remove pathogenic granulocytes, and returns the blood to the cubital vein of the opposite arm. The consecutive weekly sessions each lasted 60 minutes, with a flow rate of 30 mL/min.

No side effects were seen during 8 months of follow-up after completing the GCAP treatments.

For patients with pyoderma gangrenosum who do not respond to treatment with corticosteroids, sulfonamides, and immunosuppressive agents, GCAP may be a useful alternative, according to Dr. Seishima and her colleagues.

A double-blind clinical study is needed to confirm the effects of GCAP, they wrote. Future research also should examine GCAP alone or combined with drug therapy and try to identify the optimal frequency and number of treatments.

SALT LAKE CITY – Watch for signs of depression in adolescents with inflammatory bowel disease, especially if they are older, have more severe disease, are on steroids, or report family conflict, Dr. Eva Szigethy said.

A study of 141 adolescents with Crohn's disease and 52 with ulcerative colitis seen in a pediatric gastroenterology clinic used a slew of assessment tools to measure disease severity, screen for depression, and assess psychosocial factors in the patients' lives. A total of 43 patients with a Child Depression Inventory score of 9 or greater (suggesting increased risk for depression) underwent a comprehensive psychiatric evaluation using the Kiddie Schedule for Affective Disorders and Schizophrenia.

Of the 43, 2 had major depression, 14 had minor depression, and 27 had depressive symptoms, Dr. Szigethy said at a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Patients who self-reported poor family functioning, poor personal health, or poor physical functioning were more likely to be depressed. The patients on steroids–especially higher doses–had more depression. Disease severity and older age were risk factors for depression, she and her associates reported.

“The whole idea is to pick up depression before it becomes a full-blown, clinical, major depression and becomes functionally incapacitating,” Dr. Szigethy, a pediatric psychiatrist at the University of Pittsburgh who is also in the university medical center's inflammatory bowel disease program, said in an interview.

Risk factors for depression need to be assessed routinely in outpatient pediatric clinics to enhance comprehensive care for these patients, the investigators concluded.

Untreated depression increases the likelihood that patients with inflammatory bowel disease will not adhere to medication regimens, leading to treatment failure, other studies have shown.

Unlike some other studies that suggested an association between parental psychopathology and depression risk in adolescents with inflammatory bowel disease, the current study found no significant effect of parental history of depression, parental psychopathology, or life stressors on the youth's risk for depression.

The investigators also plan to study patients who are younger than the 11− to 17-year-olds in the current study.

SALT LAKE CITY – Watch for signs of depression in adolescents with inflammatory bowel disease, especially if they are older, have more severe disease, are on steroids, or report family conflict, Dr. Eva Szigethy said.

A study of 141 adolescents with Crohn's disease and 52 with ulcerative colitis seen in a pediatric gastroenterology clinic used a slew of assessment tools to measure disease severity, screen for depression, and assess psychosocial factors in the patients' lives. A total of 43 patients with a Child Depression Inventory score of 9 or greater (suggesting increased risk for depression) underwent a comprehensive psychiatric evaluation using the Kiddie Schedule for Affective Disorders and Schizophrenia.

Of the 43, 2 had major depression, 14 had minor depression, and 27 had depressive symptoms, Dr. Szigethy said at a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Patients who self-reported poor family functioning, poor personal health, or poor physical functioning were more likely to be depressed. The patients on steroids–especially higher doses–had more depression. Disease severity and older age were risk factors for depression, she and her associates reported.

“The whole idea is to pick up depression before it becomes a full-blown, clinical, major depression and becomes functionally incapacitating,” Dr. Szigethy, a pediatric psychiatrist at the University of Pittsburgh who is also in the university medical center's inflammatory bowel disease program, said in an interview.

Risk factors for depression need to be assessed routinely in outpatient pediatric clinics to enhance comprehensive care for these patients, the investigators concluded.

Untreated depression increases the likelihood that patients with inflammatory bowel disease will not adhere to medication regimens, leading to treatment failure, other studies have shown.

Unlike some other studies that suggested an association between parental psychopathology and depression risk in adolescents with inflammatory bowel disease, the current study found no significant effect of parental history of depression, parental psychopathology, or life stressors on the youth's risk for depression.

The investigators also plan to study patients who are younger than the 11− to 17-year-olds in the current study.

SALT LAKE CITY – Watch for signs of depression in adolescents with inflammatory bowel disease, especially if they are older, have more severe disease, are on steroids, or report family conflict, Dr. Eva Szigethy said.

A study of 141 adolescents with Crohn's disease and 52 with ulcerative colitis seen in a pediatric gastroenterology clinic used a slew of assessment tools to measure disease severity, screen for depression, and assess psychosocial factors in the patients' lives. A total of 43 patients with a Child Depression Inventory score of 9 or greater (suggesting increased risk for depression) underwent a comprehensive psychiatric evaluation using the Kiddie Schedule for Affective Disorders and Schizophrenia.

Of the 43, 2 had major depression, 14 had minor depression, and 27 had depressive symptoms, Dr. Szigethy said at a poster presentation at the annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

Patients who self-reported poor family functioning, poor personal health, or poor physical functioning were more likely to be depressed. The patients on steroids–especially higher doses–had more depression. Disease severity and older age were risk factors for depression, she and her associates reported.

“The whole idea is to pick up depression before it becomes a full-blown, clinical, major depression and becomes functionally incapacitating,” Dr. Szigethy, a pediatric psychiatrist at the University of Pittsburgh who is also in the university medical center's inflammatory bowel disease program, said in an interview.

Risk factors for depression need to be assessed routinely in outpatient pediatric clinics to enhance comprehensive care for these patients, the investigators concluded.

Untreated depression increases the likelihood that patients with inflammatory bowel disease will not adhere to medication regimens, leading to treatment failure, other studies have shown.

Unlike some other studies that suggested an association between parental psychopathology and depression risk in adolescents with inflammatory bowel disease, the current study found no significant effect of parental history of depression, parental psychopathology, or life stressors on the youth's risk for depression.

The investigators also plan to study patients who are younger than the 11− to 17-year-olds in the current study.

SAN FRANCISCO — Allergy to the materials in an implanted cardioverter defibrillator can cause a contact dermatitis over the implantation site that may be mistaken for infection, Dr. Margaret Lee-Bellantoni said.

Although allergic reactions to implantable cardioverter defibrillators (ICDs) are rare, the rapidly increasing number of patients being given ICDs probably will mean more cases of defibrillator dermatitis. “We do expect to see more,” she said at the annual meeting of the American Contact Dermatitis Society.

During 1996–2001, the number of patients with ICDs increased by 24% annually, noted Dr. Lee-Bellantoni of Tufts-New England Medical Center, Boston.

She described the case of a 57-year-old man with a history of coronary artery disease and MI who received an ICD to manage ventricular tachycardia. His first ICD, implanted in 1991, was replaced in 1994 and again in 1997 and 2004. One week after the 2004 ICD was placed in the extraperitoneal space of the man's abdomen, he developed a wound dehiscence near the center of the incision site. He had no fever, chills, or leukocytosis but developed erythema over the ICD area. The dehiscence healed, but the erythema persisted, so he was treated with oral antibiotics for presumed infection. The erythema expanded over the ICD implantation, still with no pain, pruritus, or fever. The patient was hospitalized twice with a diagnosis of infection of the left lower abdomen and was given IV antibiotics, including vancomycin.

In the second hospitalization, the patient came to the attention of dermatologists, who took a tissue biopsy. The results were nondiagnostic but consistent with possible hypersensitivity. Culture was negative for bacteria and fungi.

“Although the cardiologists knew there was something weird going on, they were still essentially worried about infection. But the dermatologists were worried about hypersensitivity reaction,” Dr. Lee-Bellantoni said.

The dermatologists obtained an ICD materials test kit from the ICD manufacturer containing materials from the 11 components that come into contact with patient tissue. They patch-tested the patient to the plastics, silicones, epoxies, and other materials in the kit, as well as to a standard group of preservatives, fragrances, and other potential allergens.

The results showed evidence of contact hypersensitivity to polyurethane 75D and peroxide-cured silicone rubber, which were present in the patient's ICD. This information helped cardiologists choose a different ICD for him. After replacement of the offending ICD with the new one in a different location, the erythema gradually resolved.

The cost of the patient's two hospitalizations and antibiotic treatment totalled $9,544. The patch test, which cost $1,286, was “really cost effective,” Dr. Lee-Bellantoni said. Plus, “you really can't overestimate the emotional cost to the patient in terms of stress over the possibility of resistant infection, nosocomial infection, and work time lost.”

Suspect contact allergy in the absence of proven infection in a patient with erythema at the ICD site, she advised.

Amine catalysts used in polyurethanes and epoxy systems as hardeners and curing agents are very strong sensitizers. Polyurethanes and epoxies may be used for surface coatings of various manufactured items in general.

The patient had a history of exposure to these and other potential sensitizers in his work as a motorcycle shop manager and in previous woodworking environments. Regardless, multiple ICD placements could, by themselves, be enough to sensitize someone to these agents, she said.

So far there are only 30 cases in the literature of hypersensitivity to ICDs or to pacemakers. If a hypersensitivity reaction is suspected in patients with these devices, a negative patch test does not necessarily rule out sensitization because it is difficult to get a response to the tiny piece of material used in the tests, she cautioned.

SAN FRANCISCO — Allergy to the materials in an implanted cardioverter defibrillator can cause a contact dermatitis over the implantation site that may be mistaken for infection, Dr. Margaret Lee-Bellantoni said.

Although allergic reactions to implantable cardioverter defibrillators (ICDs) are rare, the rapidly increasing number of patients being given ICDs probably will mean more cases of defibrillator dermatitis. “We do expect to see more,” she said at the annual meeting of the American Contact Dermatitis Society.

During 1996–2001, the number of patients with ICDs increased by 24% annually, noted Dr. Lee-Bellantoni of Tufts-New England Medical Center, Boston.

She described the case of a 57-year-old man with a history of coronary artery disease and MI who received an ICD to manage ventricular tachycardia. His first ICD, implanted in 1991, was replaced in 1994 and again in 1997 and 2004. One week after the 2004 ICD was placed in the extraperitoneal space of the man's abdomen, he developed a wound dehiscence near the center of the incision site. He had no fever, chills, or leukocytosis but developed erythema over the ICD area. The dehiscence healed, but the erythema persisted, so he was treated with oral antibiotics for presumed infection. The erythema expanded over the ICD implantation, still with no pain, pruritus, or fever. The patient was hospitalized twice with a diagnosis of infection of the left lower abdomen and was given IV antibiotics, including vancomycin.

In the second hospitalization, the patient came to the attention of dermatologists, who took a tissue biopsy. The results were nondiagnostic but consistent with possible hypersensitivity. Culture was negative for bacteria and fungi.

“Although the cardiologists knew there was something weird going on, they were still essentially worried about infection. But the dermatologists were worried about hypersensitivity reaction,” Dr. Lee-Bellantoni said.

The dermatologists obtained an ICD materials test kit from the ICD manufacturer containing materials from the 11 components that come into contact with patient tissue. They patch-tested the patient to the plastics, silicones, epoxies, and other materials in the kit, as well as to a standard group of preservatives, fragrances, and other potential allergens.

The results showed evidence of contact hypersensitivity to polyurethane 75D and peroxide-cured silicone rubber, which were present in the patient's ICD. This information helped cardiologists choose a different ICD for him. After replacement of the offending ICD with the new one in a different location, the erythema gradually resolved.

The cost of the patient's two hospitalizations and antibiotic treatment totalled $9,544. The patch test, which cost $1,286, was “really cost effective,” Dr. Lee-Bellantoni said. Plus, “you really can't overestimate the emotional cost to the patient in terms of stress over the possibility of resistant infection, nosocomial infection, and work time lost.”

Suspect contact allergy in the absence of proven infection in a patient with erythema at the ICD site, she advised.

Amine catalysts used in polyurethanes and epoxy systems as hardeners and curing agents are very strong sensitizers. Polyurethanes and epoxies may be used for surface coatings of various manufactured items in general.

The patient had a history of exposure to these and other potential sensitizers in his work as a motorcycle shop manager and in previous woodworking environments. Regardless, multiple ICD placements could, by themselves, be enough to sensitize someone to these agents, she said.

So far there are only 30 cases in the literature of hypersensitivity to ICDs or to pacemakers. If a hypersensitivity reaction is suspected in patients with these devices, a negative patch test does not necessarily rule out sensitization because it is difficult to get a response to the tiny piece of material used in the tests, she cautioned.

SAN FRANCISCO — Allergy to the materials in an implanted cardioverter defibrillator can cause a contact dermatitis over the implantation site that may be mistaken for infection, Dr. Margaret Lee-Bellantoni said.

Although allergic reactions to implantable cardioverter defibrillators (ICDs) are rare, the rapidly increasing number of patients being given ICDs probably will mean more cases of defibrillator dermatitis. “We do expect to see more,” she said at the annual meeting of the American Contact Dermatitis Society.

During 1996–2001, the number of patients with ICDs increased by 24% annually, noted Dr. Lee-Bellantoni of Tufts-New England Medical Center, Boston.

She described the case of a 57-year-old man with a history of coronary artery disease and MI who received an ICD to manage ventricular tachycardia. His first ICD, implanted in 1991, was replaced in 1994 and again in 1997 and 2004. One week after the 2004 ICD was placed in the extraperitoneal space of the man's abdomen, he developed a wound dehiscence near the center of the incision site. He had no fever, chills, or leukocytosis but developed erythema over the ICD area. The dehiscence healed, but the erythema persisted, so he was treated with oral antibiotics for presumed infection. The erythema expanded over the ICD implantation, still with no pain, pruritus, or fever. The patient was hospitalized twice with a diagnosis of infection of the left lower abdomen and was given IV antibiotics, including vancomycin.

In the second hospitalization, the patient came to the attention of dermatologists, who took a tissue biopsy. The results were nondiagnostic but consistent with possible hypersensitivity. Culture was negative for bacteria and fungi.

“Although the cardiologists knew there was something weird going on, they were still essentially worried about infection. But the dermatologists were worried about hypersensitivity reaction,” Dr. Lee-Bellantoni said.

The dermatologists obtained an ICD materials test kit from the ICD manufacturer containing materials from the 11 components that come into contact with patient tissue. They patch-tested the patient to the plastics, silicones, epoxies, and other materials in the kit, as well as to a standard group of preservatives, fragrances, and other potential allergens.

The results showed evidence of contact hypersensitivity to polyurethane 75D and peroxide-cured silicone rubber, which were present in the patient's ICD. This information helped cardiologists choose a different ICD for him. After replacement of the offending ICD with the new one in a different location, the erythema gradually resolved.

The cost of the patient's two hospitalizations and antibiotic treatment totalled $9,544. The patch test, which cost $1,286, was “really cost effective,” Dr. Lee-Bellantoni said. Plus, “you really can't overestimate the emotional cost to the patient in terms of stress over the possibility of resistant infection, nosocomial infection, and work time lost.”

Suspect contact allergy in the absence of proven infection in a patient with erythema at the ICD site, she advised.

Amine catalysts used in polyurethanes and epoxy systems as hardeners and curing agents are very strong sensitizers. Polyurethanes and epoxies may be used for surface coatings of various manufactured items in general.

The patient had a history of exposure to these and other potential sensitizers in his work as a motorcycle shop manager and in previous woodworking environments. Regardless, multiple ICD placements could, by themselves, be enough to sensitize someone to these agents, she said.

So far there are only 30 cases in the literature of hypersensitivity to ICDs or to pacemakers. If a hypersensitivity reaction is suspected in patients with these devices, a negative patch test does not necessarily rule out sensitization because it is difficult to get a response to the tiny piece of material used in the tests, she cautioned.