Betsy Bates

Diagnosis: Disseminated Mycobacterium marinum

SAN DIEGO — The differential diagnosis in this immunocompromised patient pointed to infection, likely complicated by an underlying process related to Crohn's disease and/or pyoderma gangrenosum.

Bacterial infection, Mycobacterium tuberculosis, atypical mycobacterium, Treponema pallidum, deep fungal infection, and viral infection were considered, as were potential contributors such as pyoderma gangrenosum, metastatic Crohn's disease, cutaneous lymphoma, and/or vasculitis.

A blood culture was negative. Skin biopsies revealed ulceration, fibrinous inflammation, necrosis, and mixed cell infiltrate. A Fite stain was positive for acid-fast bacteria. Biochemical analysis of tissue cultures revealed Mycobacterium marinum, "of fish tank granuloma fame," said Dr. Jeffrey Vallee at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient was asked whether she had an aquarium. She replied, "Well, I don't have any fish, but they call me the Chameleon Lady," Dr. Vallee recalled.

The patient's pets included African water frogs, tortoises, newts, geckos, and chameleons, "one of which she had eaten with, slept with, and showered with for the last few weeks of his life," said Dr. Vallee, a dermatology resident at the University of California, Irvine, who worked on the case with Dr. Tanya Kormeili, Dr. Kenneth G. Linden, and Dr. Ronald J. Barr.

The incidence of M. marinum is 0.27 per 100,000, with about 85% of cases associated with contact with aquariums. Disseminated M. marinum is rare, with fewer than 10 reported cases in the literature, and this case is believed to be the first involving infliximab.

The patient spent 7 weeks in the burn unit, undergoing daily hydrotherapy and repeated surgeries for debridement and application of split-thickness skin grafts.

She was treated with a triad of antibiotics: clarithromycin, doxycycline, and ethambutol. By discharge, her prednisone dose had been tapered to 7.5 mg.

"The antibiotics essentially cleared her and she's had no skin lesions since," Dr. Vallee reported.

A Fite stain was positive for acid-fast bacteria, and biochemical analysis of tissue cultures revealed Mycobacterium marinum. Courtesy Dr. Jeffrey Vallee

Diagnosis: Disseminated Mycobacterium marinum

SAN DIEGO — The differential diagnosis in this immunocompromised patient pointed to infection, likely complicated by an underlying process related to Crohn's disease and/or pyoderma gangrenosum.

Bacterial infection, Mycobacterium tuberculosis, atypical mycobacterium, Treponema pallidum, deep fungal infection, and viral infection were considered, as were potential contributors such as pyoderma gangrenosum, metastatic Crohn's disease, cutaneous lymphoma, and/or vasculitis.

A blood culture was negative. Skin biopsies revealed ulceration, fibrinous inflammation, necrosis, and mixed cell infiltrate. A Fite stain was positive for acid-fast bacteria. Biochemical analysis of tissue cultures revealed Mycobacterium marinum, "of fish tank granuloma fame," said Dr. Jeffrey Vallee at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient was asked whether she had an aquarium. She replied, "Well, I don't have any fish, but they call me the Chameleon Lady," Dr. Vallee recalled.

The patient's pets included African water frogs, tortoises, newts, geckos, and chameleons, "one of which she had eaten with, slept with, and showered with for the last few weeks of his life," said Dr. Vallee, a dermatology resident at the University of California, Irvine, who worked on the case with Dr. Tanya Kormeili, Dr. Kenneth G. Linden, and Dr. Ronald J. Barr.

The incidence of M. marinum is 0.27 per 100,000, with about 85% of cases associated with contact with aquariums. Disseminated M. marinum is rare, with fewer than 10 reported cases in the literature, and this case is believed to be the first involving infliximab.

The patient spent 7 weeks in the burn unit, undergoing daily hydrotherapy and repeated surgeries for debridement and application of split-thickness skin grafts.

She was treated with a triad of antibiotics: clarithromycin, doxycycline, and ethambutol. By discharge, her prednisone dose had been tapered to 7.5 mg.

"The antibiotics essentially cleared her and she's had no skin lesions since," Dr. Vallee reported.

A Fite stain was positive for acid-fast bacteria, and biochemical analysis of tissue cultures revealed Mycobacterium marinum. Courtesy Dr. Jeffrey Vallee

Diagnosis: Disseminated Mycobacterium marinum

SAN DIEGO — The differential diagnosis in this immunocompromised patient pointed to infection, likely complicated by an underlying process related to Crohn's disease and/or pyoderma gangrenosum.

Bacterial infection, Mycobacterium tuberculosis, atypical mycobacterium, Treponema pallidum, deep fungal infection, and viral infection were considered, as were potential contributors such as pyoderma gangrenosum, metastatic Crohn's disease, cutaneous lymphoma, and/or vasculitis.

A blood culture was negative. Skin biopsies revealed ulceration, fibrinous inflammation, necrosis, and mixed cell infiltrate. A Fite stain was positive for acid-fast bacteria. Biochemical analysis of tissue cultures revealed Mycobacterium marinum, "of fish tank granuloma fame," said Dr. Jeffrey Vallee at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The patient was asked whether she had an aquarium. She replied, "Well, I don't have any fish, but they call me the Chameleon Lady," Dr. Vallee recalled.

The patient's pets included African water frogs, tortoises, newts, geckos, and chameleons, "one of which she had eaten with, slept with, and showered with for the last few weeks of his life," said Dr. Vallee, a dermatology resident at the University of California, Irvine, who worked on the case with Dr. Tanya Kormeili, Dr. Kenneth G. Linden, and Dr. Ronald J. Barr.

The incidence of M. marinum is 0.27 per 100,000, with about 85% of cases associated with contact with aquariums. Disseminated M. marinum is rare, with fewer than 10 reported cases in the literature, and this case is believed to be the first involving infliximab.

The patient spent 7 weeks in the burn unit, undergoing daily hydrotherapy and repeated surgeries for debridement and application of split-thickness skin grafts.

She was treated with a triad of antibiotics: clarithromycin, doxycycline, and ethambutol. By discharge, her prednisone dose had been tapered to 7.5 mg.

"The antibiotics essentially cleared her and she's had no skin lesions since," Dr. Vallee reported.

A Fite stain was positive for acid-fast bacteria, and biochemical analysis of tissue cultures revealed Mycobacterium marinum. Courtesy Dr. Jeffrey Vallee

SAN DIEGO — The "vast majority" of dermatologic office visits qualify for a CPT code of 99213, so long as they are properly documented, Dr. Allan S. Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"Most dermatologists tend to undercode for their services," asserted Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., who also chairs the American Academy of Dermatology task force on coding and reimbursement.

Quite simply, he said, a 99213 requires two of three major criteria, which can be fulfilled by properly examining and treating an established patient whose acne is flaring, for example.

To illustrate the point, Dr. Wirtzer detailed how a hypothetical patient visit would meet all three required elements for a hypothetical patient visit—more than are required for a 99213.

1. Expanded, problem-focused history, including a brief history of present illness (one to three elements that can include body site, duration, quality, severity, timing, context, modifying factors, or associated signs and symptoms): Acne check, flaring for 2 months. Problem-pertinent review of systems (integumentary system, constitutional system): No other skin complaints; patient reports good general overall health.

2. Expanded, problem-focused physical examination, including limited exam of the affected body area or organ system and other symptomatic or related organ systems (requires 6–11 areas): Multiple papulocystic lesions on cheeks. Chest, back, and neck are clear. Patient appears generally well, is alert, well oriented, and pleasant.

3. Low level of decision making (two stable problems or one worsening problem or new problem): Worsening problem (flaring for 2 months).

Dermatologists generally perform the necessary tasks required for a 99213 in visits with established patients, but they fail to provide the necessary detail in their charts when describing what they've done, Dr. Wirtzer said.

Many elements of the history can be completed using patient intake forms filled out in the waiting room, reviewed by the physician, and placed in the chart. Without this simple step, a visit that would have easily qualified for a 99213 can be billed only as a 99212, he said.

For established patients, history taking and documentation assume a special importance since they can fulfill two of the three elements that are required for a 99213 visit.

Make sure patients are asked about the number and types of problems they have on each visit, and any other related symptoms they may be suffering, Dr. Wirtzer suggested.

For example, an acne patient's upset stomach may be caused by the antibiotics that were prescribed for his or her skin condition. This finding is important to document, and contributes both to the problem-pertinent review of systems in criterion 1 and to criterion 3 since it speaks to the level of decision making. This "new problem" requires consideration of various alternative dosing strategies or therapies.

An expanded, problem-focused physical examination documenting 6–11 elements constitutes one of two elements justifying a billing level of 99213. A detailed physical examination that contributes to a billing code of 99214 requires more than 12 elements. (See box.)

The thresholds may sound hard to fulfill in a dermatologic examination, but they actually aren't, Dr. Wirtzer said at the meeting.

Each body site counts as one element, so a thorough skin examination of the head, neck, chest, back, abdomen, and each extremity totals nine elements, he pointed out.

Often overlooked are constitutional and neurologic/psychological systems, including the general appearance of the patient (one element) and orientation as to time, place, and person (one element).

Although most patient visits do justify a 99213 billing code, Dr. Wirtzer cautioned against overusing the code for very brief, routine follow-up visits in which detailed histories and examinations would be superfluous.

Billing every routine acne visit as a 99213 "sticks out on a computer as an aberration," he said.

If auditors see overreaching for codes, they may assess a penalty on a large proportion of all 99213 visits a physician has billed.

Furthermore, using a 99203 code for a new patient visit is not automatic. As with a 99213, billing for a 99203 requires very specific and proper documentation, he said.

A full-body examination, which Dr. Wirtzer believes should be conducted on every new patient, easily fulfills the requirements for a detailed physical examination, but the patient's chart must include at least 12 of the bullet items that are included in the skin examination. (See box.)

Furthermore, the "low level of decision making" required for a 99213 is automatically fulfilled in any new patient, since any problem that he or she describes is new, he said.

But billing for a 99203 also requires documentation of a more extended history of the present illness (four or more elements or three active or inactive problems) and an extended review of systems (two to nine systems, which may be captured in a form filled out by the patient and reviewed by the physician).

The 99203 code also requires documentation of "pertinent past personal, family, and social history" (such as illnesses, operations, treatments, smoking history, occupation).

SAN DIEGO — The "vast majority" of dermatologic office visits qualify for a CPT code of 99213, so long as they are properly documented, Dr. Allan S. Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"Most dermatologists tend to undercode for their services," asserted Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., who also chairs the American Academy of Dermatology task force on coding and reimbursement.

Quite simply, he said, a 99213 requires two of three major criteria, which can be fulfilled by properly examining and treating an established patient whose acne is flaring, for example.

To illustrate the point, Dr. Wirtzer detailed how a hypothetical patient visit would meet all three required elements for a hypothetical patient visit—more than are required for a 99213.

1. Expanded, problem-focused history, including a brief history of present illness (one to three elements that can include body site, duration, quality, severity, timing, context, modifying factors, or associated signs and symptoms): Acne check, flaring for 2 months. Problem-pertinent review of systems (integumentary system, constitutional system): No other skin complaints; patient reports good general overall health.

2. Expanded, problem-focused physical examination, including limited exam of the affected body area or organ system and other symptomatic or related organ systems (requires 6–11 areas): Multiple papulocystic lesions on cheeks. Chest, back, and neck are clear. Patient appears generally well, is alert, well oriented, and pleasant.

3. Low level of decision making (two stable problems or one worsening problem or new problem): Worsening problem (flaring for 2 months).

Dermatologists generally perform the necessary tasks required for a 99213 in visits with established patients, but they fail to provide the necessary detail in their charts when describing what they've done, Dr. Wirtzer said.

Many elements of the history can be completed using patient intake forms filled out in the waiting room, reviewed by the physician, and placed in the chart. Without this simple step, a visit that would have easily qualified for a 99213 can be billed only as a 99212, he said.

For established patients, history taking and documentation assume a special importance since they can fulfill two of the three elements that are required for a 99213 visit.

Make sure patients are asked about the number and types of problems they have on each visit, and any other related symptoms they may be suffering, Dr. Wirtzer suggested.

For example, an acne patient's upset stomach may be caused by the antibiotics that were prescribed for his or her skin condition. This finding is important to document, and contributes both to the problem-pertinent review of systems in criterion 1 and to criterion 3 since it speaks to the level of decision making. This "new problem" requires consideration of various alternative dosing strategies or therapies.

An expanded, problem-focused physical examination documenting 6–11 elements constitutes one of two elements justifying a billing level of 99213. A detailed physical examination that contributes to a billing code of 99214 requires more than 12 elements. (See box.)

The thresholds may sound hard to fulfill in a dermatologic examination, but they actually aren't, Dr. Wirtzer said at the meeting.

Each body site counts as one element, so a thorough skin examination of the head, neck, chest, back, abdomen, and each extremity totals nine elements, he pointed out.

Often overlooked are constitutional and neurologic/psychological systems, including the general appearance of the patient (one element) and orientation as to time, place, and person (one element).

Although most patient visits do justify a 99213 billing code, Dr. Wirtzer cautioned against overusing the code for very brief, routine follow-up visits in which detailed histories and examinations would be superfluous.

Billing every routine acne visit as a 99213 "sticks out on a computer as an aberration," he said.

If auditors see overreaching for codes, they may assess a penalty on a large proportion of all 99213 visits a physician has billed.

Furthermore, using a 99203 code for a new patient visit is not automatic. As with a 99213, billing for a 99203 requires very specific and proper documentation, he said.

A full-body examination, which Dr. Wirtzer believes should be conducted on every new patient, easily fulfills the requirements for a detailed physical examination, but the patient's chart must include at least 12 of the bullet items that are included in the skin examination. (See box.)

Furthermore, the "low level of decision making" required for a 99213 is automatically fulfilled in any new patient, since any problem that he or she describes is new, he said.

But billing for a 99203 also requires documentation of a more extended history of the present illness (four or more elements or three active or inactive problems) and an extended review of systems (two to nine systems, which may be captured in a form filled out by the patient and reviewed by the physician).

The 99203 code also requires documentation of "pertinent past personal, family, and social history" (such as illnesses, operations, treatments, smoking history, occupation).

SAN DIEGO — The "vast majority" of dermatologic office visits qualify for a CPT code of 99213, so long as they are properly documented, Dr. Allan S. Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"Most dermatologists tend to undercode for their services," asserted Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., who also chairs the American Academy of Dermatology task force on coding and reimbursement.

Quite simply, he said, a 99213 requires two of three major criteria, which can be fulfilled by properly examining and treating an established patient whose acne is flaring, for example.

To illustrate the point, Dr. Wirtzer detailed how a hypothetical patient visit would meet all three required elements for a hypothetical patient visit—more than are required for a 99213.

1. Expanded, problem-focused history, including a brief history of present illness (one to three elements that can include body site, duration, quality, severity, timing, context, modifying factors, or associated signs and symptoms): Acne check, flaring for 2 months. Problem-pertinent review of systems (integumentary system, constitutional system): No other skin complaints; patient reports good general overall health.

2. Expanded, problem-focused physical examination, including limited exam of the affected body area or organ system and other symptomatic or related organ systems (requires 6–11 areas): Multiple papulocystic lesions on cheeks. Chest, back, and neck are clear. Patient appears generally well, is alert, well oriented, and pleasant.

3. Low level of decision making (two stable problems or one worsening problem or new problem): Worsening problem (flaring for 2 months).

Dermatologists generally perform the necessary tasks required for a 99213 in visits with established patients, but they fail to provide the necessary detail in their charts when describing what they've done, Dr. Wirtzer said.

Many elements of the history can be completed using patient intake forms filled out in the waiting room, reviewed by the physician, and placed in the chart. Without this simple step, a visit that would have easily qualified for a 99213 can be billed only as a 99212, he said.

For established patients, history taking and documentation assume a special importance since they can fulfill two of the three elements that are required for a 99213 visit.

Make sure patients are asked about the number and types of problems they have on each visit, and any other related symptoms they may be suffering, Dr. Wirtzer suggested.

For example, an acne patient's upset stomach may be caused by the antibiotics that were prescribed for his or her skin condition. This finding is important to document, and contributes both to the problem-pertinent review of systems in criterion 1 and to criterion 3 since it speaks to the level of decision making. This "new problem" requires consideration of various alternative dosing strategies or therapies.

An expanded, problem-focused physical examination documenting 6–11 elements constitutes one of two elements justifying a billing level of 99213. A detailed physical examination that contributes to a billing code of 99214 requires more than 12 elements. (See box.)

The thresholds may sound hard to fulfill in a dermatologic examination, but they actually aren't, Dr. Wirtzer said at the meeting.

Each body site counts as one element, so a thorough skin examination of the head, neck, chest, back, abdomen, and each extremity totals nine elements, he pointed out.

Often overlooked are constitutional and neurologic/psychological systems, including the general appearance of the patient (one element) and orientation as to time, place, and person (one element).

Although most patient visits do justify a 99213 billing code, Dr. Wirtzer cautioned against overusing the code for very brief, routine follow-up visits in which detailed histories and examinations would be superfluous.

Billing every routine acne visit as a 99213 "sticks out on a computer as an aberration," he said.

If auditors see overreaching for codes, they may assess a penalty on a large proportion of all 99213 visits a physician has billed.

Furthermore, using a 99203 code for a new patient visit is not automatic. As with a 99213, billing for a 99203 requires very specific and proper documentation, he said.

A full-body examination, which Dr. Wirtzer believes should be conducted on every new patient, easily fulfills the requirements for a detailed physical examination, but the patient's chart must include at least 12 of the bullet items that are included in the skin examination. (See box.)

Furthermore, the "low level of decision making" required for a 99213 is automatically fulfilled in any new patient, since any problem that he or she describes is new, he said.

But billing for a 99203 also requires documentation of a more extended history of the present illness (four or more elements or three active or inactive problems) and an extended review of systems (two to nine systems, which may be captured in a form filled out by the patient and reviewed by the physician).

The 99203 code also requires documentation of "pertinent past personal, family, and social history" (such as illnesses, operations, treatments, smoking history, occupation).

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the "golden rules" of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by "unwelcome conduct," she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

"You can hide things in a resume," Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an "at will" clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee "at will." The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

"There are huge exceptions" to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with "posturing princesses" or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow "soft" evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, "I thought if I gave her positive feedback it might cause her to change," Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff, Ms. Peck advised. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get "into trouble with employment law," she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a "clean" reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the "golden rules" of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by "unwelcome conduct," she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

"You can hide things in a resume," Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an "at will" clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee "at will." The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

"There are huge exceptions" to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with "posturing princesses" or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow "soft" evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, "I thought if I gave her positive feedback it might cause her to change," Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff, Ms. Peck advised. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get "into trouble with employment law," she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a "clean" reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

PORTLAND, ORE. — As if it weren't aggravating enough to worry about frivolous lawsuits filed by patients, physicians, like all employers, also need to consider their legal liability with regard to their employees.

Fortunately, most employment lawsuits are eminently avoidable, said employment attorney Kathy A. Peck at the annual meeting of the Pacific Northwest Dermatological Society.

Supervisors should follow the "golden rules" of discipline, said Ms. Peck, a partner in the law firm of Williams, Zografos, and Peck in Lake Oswego, Ore.

These include immediacy, consistency, impersonality (targeting the behavior, not the person), and positivism, always remembering that the goal is to rehabilitate employees whenever possible, rather than to punish or ostracize them.

Physicians and office managers also need to watch their language. Ms. Peck said many cases may turn on remarks, perhaps unintentional, that might be interpreted as being derogatory or stereotypical with regard to a protected class of workers, such as older employees, women, or members of a racial or ethnic group.

Work environment harassment claims are on the rise, so practices should respond promptly and definitively to complaints of sexual, racial, ethnic, religious, age, and disability-related harassment. Just as physicians should monitor their own remarks and behavior, they are responsible for their office environment and should take immediate corrective action if that atmosphere is tainted by "unwelcome conduct," she said.

Require applicants to fill out an application form. Great interview skills do not necessarily reflect a solid employment history.

"You can hide things in a resume," Ms. Peck said.

All employees (established and newly hired) should sign an employee handbook documenting policies and procedures. Include within the handbook an "at will" clause stating that the employee is free to resign at any time and that the practice is free to terminate the employee "at will." The manual also should state that this policy remains in effect unless it is changed in writing by the physician or another designated individual at the office.

"There are huge exceptions" to when an employee can be discharged and why—because of pregnancy, for example—but the clause protects employers from being sued by those who assert they were hired until they retired, or some other vague point in time, said Ms. Peck.

Another issue that needs to be addressed is when an employee has a bad attitude. It's a huge mistake to put up with "posturing princesses" or passive-aggressive manipulators who stir up trouble. These employees can sour morale very quickly, leading to turnover problems, excessive time off, stress claims, and grievances, she said.

Offenders should be reminded of policies that require polite and cooperative behavior, and their behaviors should be documented.

When it comes to employee performance, it is important to not allow "soft" evaluations. It will be very difficult to justify in court the dismissal of an employee who received above-average evaluations for the past 6 years.

Many times a supervisor will say, "I thought if I gave her positive feedback it might cause her to change," Ms. Peck explained.

Although every evaluation should fairly point out positive performance examples, inflated praise generally does not compel an employee to work harder. Address shortcomings, establish goals for improvement, and then follow up, she advised.

Any decisions that are made regarding personnel must be documented. An employer who can present a record of fair, reasonable, and consistent evaluations and decisions will fare much better if an employment discrimination case makes it to court.

If something does happen that requires action, always listen to the employee's side of the story. Not only is this fair, it might change your perception of an event, and it also helps to establish an accurate line of documentation right away, said Ms. Peck.

A dismissed employee later may come up with a multitude of supposed claims against you, but if someone listened to and documented his or her initial story, it establishes these facts on the record.

When an employee needs to be discharged, do not call it a layoff, Ms. Peck advised. Softening the blow to an employee by falsely implying that their dismissal was a result of a reduction in the workforce is a good way to get "into trouble with employment law," she said. An incompetent 55-year-old employee who is laid off and immediately replaced with a 36-year-old employee has the makings of a successful age-discrimination suit, she explained.

It is also important to provide a "clean" reason when an employee is discharged. If an employee was caught embezzling money, that's a firing offense and it's enough. Piling on other minor offenses is unnecessary and may clutter up any resulting employment claim against the practice, particularly if other employees had also committed minor infractions without losing their jobs, Ms. Peck said.

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — Physicians should think outside the liposuction box when it comes to using tumescent anesthesia in dermatologic surgery practices, Dr. Jeffrey A. Klein said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Excisions, Mohs surgery, lipoma removal, breast reduction, and intravascular vein ablation all lend themselves well to the use of tumescent anesthesia, according to the discoverer of the technique.

Besides providing long-lasting and profound local anesthesia, bactericidal protection, and elevation of tissues for delicate procedures, the tumescent technique offers "exquisite hemostasis," said Dr. Klein, a dermatologic surgeon in San Juan Capistrano, Calif., who is credited with revolutionizing the safety of liposuction anesthesia by pioneering the use of dilute concentrations of lidocaine and epinephrine in saline with sodium bicarbonate.

"I'm really impressed at how little blood loss there is," he said.

In laser and radiofrequency procedures, tumescent liposuction acts as a heat sink. For excisions or Mohs surgery on the neck or face, it can lift lesions safely away from superficial nerve branches, he pointed out.

It can be used in conjunction with dissection with blunt liposuction cannulas to separate fibrous, multilobular lipomas from surrounding tissue so they can be easily excised. In Germany, it is being used to perform sentinel lymph node biopsies on melanoma patients.

Dr. Klein outlined examples of numerous dermatologic procedures he has performed with tumescent liposuction, from the extraction of excess glandular tissue through the nipple of a patient with male gynecomastia to the excision of a large melanoma down to fascia.

Mohs surgery of a large, recurrent basal cell carcinoma can be accomplished as "essentially a painless procedure" during which the patient remains awake, he said.

The lack of infections seen following liposuction—just 1 in more than 6,000 procedures performed by Dr. Klein—suggests that "there must be a very substantial bacteriocidal effect" of tumescent solution, he said.

Obviously, much smaller volumes of tumescent fluid are utilized in these other procedures than are needed in large liposuction cases, but the ratio of the ingredients in the formula remains the same. (See box.)

Once the area is infiltrated, "you need to allow time for detumescence to occur," said Dr. Klein.

In large abdominal liposuction cases, this process ideally should occur over the course of an hour. For smaller dermatologic surgery cases, the procedure should be delayed for at least 15–30 minutes for fluids to drain away and the architecture of the lesion to be restored.

Recovery following cases in which tumescent anesthesia is used is remarkably quick, with patients most likely able to return to work within a day, even following large excisions.

Dr. Klein noted that tumescent anesthesia has been widely adopted by other specialties and is commonly used in stem cell harvesting and vein, breast, burn, craniofacial, and rectal surgery.

Small-Volume Tumescent Recipe

A 100-mL formulation of tumescent local anesthesia (TLA) consists of approximately 0.25% lidocaine and epinephrine 1:400,000. To prepare this formulation, use:

▸ 100-mL bag of sodium chloride 0.9%.

▸ 300 mg lidocaine and 0.3 mg epinephrine (30 mL of 1% lidocaine with epinephrine 1:100,000).

▸ 3 mEq sodium bicarbonate (3 mL of 8.4% sodium bicarbonate).

On the day of surgery, a nurse prepares and labels the bag of TLA immediately after the patient arrives. For safety reasons, TLA should never be mixed 1 or more days before the day of surgery. Every bag of TLA should be well labeled at the time of its preparation.

Source: Dr. Klein

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY

SAN DIEGO — A novel pneumatic skin-flattening device may reduce the pain associated with laser or light-source hair removal treatments, although comprehensive data are not yet available to verify the results, said Dr. Gary Lask at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

The device generates negative pressure of 600 mm Hg when the skin surface is elevated using compression and suction, which flattens the skin surface and causes expulsion of blood into surrounding tissues. This allows for less absorption of laser or light energy by competing chromophores during hair removal procedures, as well as the potential for less erythema, he explained. It appears to reduce pain "by way of the gate theory: afferent inhibition of sensory nerves of the dorsal horn," said Dr. Lask, director of dermatologic surgery and the dermatology laser center at the University of California, Los Angeles.

Patients treated with various hair removal sources and the adjunctive skin-flattening device had "no pain whatsoever" in Dr. Lask's practice, even though no topical anesthetic was used, he said. Early results from Israeli researchers suggest that the device may produce "a little more efficacious" reduction of hair growth, less pain, and less erythema than hair removal devices can achieve on their own, he said.

Other surgeons at the conference expressed interest in the device's mechanism of action, which they said makes more scientific sense than some explanations for how various light and energy sources and devices can supposedly plump, compress, and tighten skin; erase wrinkles; and remove cellulite. In a general overview of such devices, Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, scoffed, "There is far too much sucking and blowing going on here."

Dr. Lask good-naturedly encouraged Dr. Zachary to keep an open mind about the pneumatic skin-flattening device: "Just because a machine sucks doesn't mean it doesn't work."

Dr. Lask disclosed that he has a commercial interest in the device's manufacturer, Inolase Ltd. of Netanya, Israel. He chairs the company's advisory board.

Hair removal remains a highly popular in-office cosmetic procedure, but it is not without drawbacks, including pain that can be considerable. Despite a generally safe track record, hair removal procedures constitute a sizable proportion of the medicolegal cases Dr. Lask reviews each year. "Most of your complications are at higher energy levels. If you can theoretically get the same results with lower power, you should minimize your complications," he said.

The pneumatic device, by better targeting hair follicles, might have the potential to accomplish this goal, he said.

'There is far too much sucking and blowing going on' with the various light and energy devices. DR. ZACHARY

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer

PORTLAND, ORE. — Dysplastic nevi, also known as nevi with architectural disorder, are “overbiopsied and overtreated” in what has become a money-making “nevi-melanocytic industrial complex,” Dr. Terry Barrett asserted at the annual meeting of the Pacific Northwest Dermatological Society.

Nevi with architectural disorder do not generally need to be excised unless severe cytologic atypia is present in a lesion that has been incompletely excised or if severe atypia extends to the margins, said Dr. Barrett, clinical professor of pathology and dermatology at the University of Texas Southwestern Medical Center in Dallas.

Confusion has reigned since 1978 when Dr. Wallace Clark first described what has become known as the dysplastic nevus, an entity clearly distinct from melanoma at one end of the spectrum and common acquired nevus at the other, he said. By 1992, a National Institutes of Health Consensus Statement tried to banish the term “atypical nevus,” preferring that clinicians and pathologists use the term “nevus with architectural disorder,” followed by a statement about the degree of cytologic atypia present.

Today, both terms are used, often with little agreement on their definitions or even what constitutes atypia, said Dr. Barrett, who is also director for the dermatopathology division of Dallas-based ProPath pathology services. “It has been a quagmire.” Physicians were confused. The general pathologist had difficulty, and “even the dermatopathologists fought with one another. The histology became an incredible mess.”

Because the clinical significance of the lesions was unclear, patients were overtreated with biopsies, excisions, and reexcisions of numerous nevi as they evolved.

Dr. Barrett said he believes there is room for moderation in managing nevi with architectural disorder, based on increasing evidence that the lesions represent markers for the development of melanoma, rather than precursors leading to the disease. In other words, they share the same risk factors, such as intermittent sun exposure.

“A marker tells us that this patient has received the same assault that they need to develop melanoma. It's absolutely clear that these patients need to be followed,” he said, adding that it is unclear whether melanoma arises from nevi, but it is doubtful.

About 40% of patients who develop melanoma have a history of dysplastic nevi, but 70%–80% of melanomas arise on normal-appearing skin. About 10% of the U.S. population has dysplastic nevi.

Further complicating the biopsy issue is the dynamic nature of nevi with architectural disorder.

The lesions change histologically as well as clinically, displaying cellular activity (atypia) if biopsied at a particular point in time, but looking quiescent at another, raising serious questions about whether any important information can be gained by the knowledge that they show atypical features.

If they are biopsied, Dr. Barrett said, he believes that the degree of their atypia must be spelled out in a straightforward way and characterized as either “mild” or “severe” with an explanation of their significance attached.

His laboratory currently uses a modified version of Dr. Arthur R. Rhodes' atypia grading system from Massachusetts General Hospital (Mod. Pathol. 1989;2:306–19), using the following definitions:

▸ Mild atypia. The nucleus is 1.5–2 times the diameter of the nucleus of the basilar keratinocyte. The nucleolus is not visible, or if visible, there is only one per cell.

▸ Severe atypia. The nucleus is more than twice the size of the nucleus of the basilar keratinocyte; there are multiple nucleoli per cell; or there is chromatin clumping or nuclear membrane notching. “It's very simple. It's reproducible,” Dr. Barrett said.

Excision is rarely necessary, and not justified in patients with absent or mild atypia, he asserted.

Patients should be followed up according to their degree of risk at 3- to 12-month intervals.

They should be taught how to perform skin self-examination and sun protection strategies, and their blood relatives should be screened.

As always, any lesion suspected to be melanoma should be excised, and reexcision should be considered when a lesion appears to be becoming more atypical, he said.

The degree of atypia must be spelled out in a straightforward way and labeled as either 'mild'or 'severe.' DR. BARRETT

Dysplastic nevi seem to represent a marker for melanoma risk, rather than precursors to the disease.

Lack of clarity in describing the histology of dysplastic nevi, shown here, has resulted in overtreatment. Photos courtesy Dr. Terry Barrett

What to Look Out for, Clinically and Histologically

In clinical appearance, nevi with architectural disorder tend to be macules, with or without a papule. If a papule is present, it is usually in the center of the macule. These nevi are generally symmetrical with regular, but fuzzy borders. Sharp angulations and prominent notching should not be present. Color includes variations of tans and browns, but rarely black. Grey suggests regression and should not be present. Erythema may be present. Histologically, the cellular components include lentiginous junctional melanocytic proliferation, with lateral fusion of nests and shouldering, and epidermal hyperplasia with elongation of the rete ridges. The stromal reaction involves fibrosis (concentric eosinophilic, lamellar) and inflammation. The cytologic atypia has large nuclei with variation of nuclear size, irregular nuclear membrane, variably stained chromatin, large eosinophilic nucleoli, and fine dusty melanin pigment in cytoplasm.

Source: Dr. Barrett

PORTLAND, ORE. — Dysplastic nevi, also known as nevi with architectural disorder, are “overbiopsied and overtreated” in what has become a money-making “nevi-melanocytic industrial complex,” Dr. Terry Barrett asserted at the annual meeting of the Pacific Northwest Dermatological Society.

Nevi with architectural disorder do not generally need to be excised unless severe cytologic atypia is present in a lesion that has been incompletely excised or if severe atypia extends to the margins, said Dr. Barrett, clinical professor of pathology and dermatology at the University of Texas Southwestern Medical Center in Dallas.

Confusion has reigned since 1978 when Dr. Wallace Clark first described what has become known as the dysplastic nevus, an entity clearly distinct from melanoma at one end of the spectrum and common acquired nevus at the other, he said. By 1992, a National Institutes of Health Consensus Statement tried to banish the term “atypical nevus,” preferring that clinicians and pathologists use the term “nevus with architectural disorder,” followed by a statement about the degree of cytologic atypia present.

Today, both terms are used, often with little agreement on their definitions or even what constitutes atypia, said Dr. Barrett, who is also director for the dermatopathology division of Dallas-based ProPath pathology services. “It has been a quagmire.” Physicians were confused. The general pathologist had difficulty, and “even the dermatopathologists fought with one another. The histology became an incredible mess.”

Because the clinical significance of the lesions was unclear, patients were overtreated with biopsies, excisions, and reexcisions of numerous nevi as they evolved.

Dr. Barrett said he believes there is room for moderation in managing nevi with architectural disorder, based on increasing evidence that the lesions represent markers for the development of melanoma, rather than precursors leading to the disease. In other words, they share the same risk factors, such as intermittent sun exposure.

“A marker tells us that this patient has received the same assault that they need to develop melanoma. It's absolutely clear that these patients need to be followed,” he said, adding that it is unclear whether melanoma arises from nevi, but it is doubtful.

About 40% of patients who develop melanoma have a history of dysplastic nevi, but 70%–80% of melanomas arise on normal-appearing skin. About 10% of the U.S. population has dysplastic nevi.

Further complicating the biopsy issue is the dynamic nature of nevi with architectural disorder.

The lesions change histologically as well as clinically, displaying cellular activity (atypia) if biopsied at a particular point in time, but looking quiescent at another, raising serious questions about whether any important information can be gained by the knowledge that they show atypical features.

If they are biopsied, Dr. Barrett said, he believes that the degree of their atypia must be spelled out in a straightforward way and characterized as either “mild” or “severe” with an explanation of their significance attached.

His laboratory currently uses a modified version of Dr. Arthur R. Rhodes' atypia grading system from Massachusetts General Hospital (Mod. Pathol. 1989;2:306–19), using the following definitions:

▸ Mild atypia. The nucleus is 1.5–2 times the diameter of the nucleus of the basilar keratinocyte. The nucleolus is not visible, or if visible, there is only one per cell.

▸ Severe atypia. The nucleus is more than twice the size of the nucleus of the basilar keratinocyte; there are multiple nucleoli per cell; or there is chromatin clumping or nuclear membrane notching. “It's very simple. It's reproducible,” Dr. Barrett said.

Excision is rarely necessary, and not justified in patients with absent or mild atypia, he asserted.

Patients should be followed up according to their degree of risk at 3- to 12-month intervals.

They should be taught how to perform skin self-examination and sun protection strategies, and their blood relatives should be screened.

As always, any lesion suspected to be melanoma should be excised, and reexcision should be considered when a lesion appears to be becoming more atypical, he said.

The degree of atypia must be spelled out in a straightforward way and labeled as either 'mild'or 'severe.' DR. BARRETT

Dysplastic nevi seem to represent a marker for melanoma risk, rather than precursors to the disease.

Lack of clarity in describing the histology of dysplastic nevi, shown here, has resulted in overtreatment. Photos courtesy Dr. Terry Barrett

What to Look Out for, Clinically and Histologically

In clinical appearance, nevi with architectural disorder tend to be macules, with or without a papule. If a papule is present, it is usually in the center of the macule. These nevi are generally symmetrical with regular, but fuzzy borders. Sharp angulations and prominent notching should not be present. Color includes variations of tans and browns, but rarely black. Grey suggests regression and should not be present. Erythema may be present. Histologically, the cellular components include lentiginous junctional melanocytic proliferation, with lateral fusion of nests and shouldering, and epidermal hyperplasia with elongation of the rete ridges. The stromal reaction involves fibrosis (concentric eosinophilic, lamellar) and inflammation. The cytologic atypia has large nuclei with variation of nuclear size, irregular nuclear membrane, variably stained chromatin, large eosinophilic nucleoli, and fine dusty melanin pigment in cytoplasm.

Source: Dr. Barrett

PORTLAND, ORE. — Dysplastic nevi, also known as nevi with architectural disorder, are “overbiopsied and overtreated” in what has become a money-making “nevi-melanocytic industrial complex,” Dr. Terry Barrett asserted at the annual meeting of the Pacific Northwest Dermatological Society.

Nevi with architectural disorder do not generally need to be excised unless severe cytologic atypia is present in a lesion that has been incompletely excised or if severe atypia extends to the margins, said Dr. Barrett, clinical professor of pathology and dermatology at the University of Texas Southwestern Medical Center in Dallas.

Confusion has reigned since 1978 when Dr. Wallace Clark first described what has become known as the dysplastic nevus, an entity clearly distinct from melanoma at one end of the spectrum and common acquired nevus at the other, he said. By 1992, a National Institutes of Health Consensus Statement tried to banish the term “atypical nevus,” preferring that clinicians and pathologists use the term “nevus with architectural disorder,” followed by a statement about the degree of cytologic atypia present.

Today, both terms are used, often with little agreement on their definitions or even what constitutes atypia, said Dr. Barrett, who is also director for the dermatopathology division of Dallas-based ProPath pathology services. “It has been a quagmire.” Physicians were confused. The general pathologist had difficulty, and “even the dermatopathologists fought with one another. The histology became an incredible mess.”

Because the clinical significance of the lesions was unclear, patients were overtreated with biopsies, excisions, and reexcisions of numerous nevi as they evolved.

Dr. Barrett said he believes there is room for moderation in managing nevi with architectural disorder, based on increasing evidence that the lesions represent markers for the development of melanoma, rather than precursors leading to the disease. In other words, they share the same risk factors, such as intermittent sun exposure.

“A marker tells us that this patient has received the same assault that they need to develop melanoma. It's absolutely clear that these patients need to be followed,” he said, adding that it is unclear whether melanoma arises from nevi, but it is doubtful.

About 40% of patients who develop melanoma have a history of dysplastic nevi, but 70%–80% of melanomas arise on normal-appearing skin. About 10% of the U.S. population has dysplastic nevi.

Further complicating the biopsy issue is the dynamic nature of nevi with architectural disorder.

The lesions change histologically as well as clinically, displaying cellular activity (atypia) if biopsied at a particular point in time, but looking quiescent at another, raising serious questions about whether any important information can be gained by the knowledge that they show atypical features.

If they are biopsied, Dr. Barrett said, he believes that the degree of their atypia must be spelled out in a straightforward way and characterized as either “mild” or “severe” with an explanation of their significance attached.

His laboratory currently uses a modified version of Dr. Arthur R. Rhodes' atypia grading system from Massachusetts General Hospital (Mod. Pathol. 1989;2:306–19), using the following definitions:

▸ Mild atypia. The nucleus is 1.5–2 times the diameter of the nucleus of the basilar keratinocyte. The nucleolus is not visible, or if visible, there is only one per cell.

▸ Severe atypia. The nucleus is more than twice the size of the nucleus of the basilar keratinocyte; there are multiple nucleoli per cell; or there is chromatin clumping or nuclear membrane notching. “It's very simple. It's reproducible,” Dr. Barrett said.

Excision is rarely necessary, and not justified in patients with absent or mild atypia, he asserted.

Patients should be followed up according to their degree of risk at 3- to 12-month intervals.

They should be taught how to perform skin self-examination and sun protection strategies, and their blood relatives should be screened.

As always, any lesion suspected to be melanoma should be excised, and reexcision should be considered when a lesion appears to be becoming more atypical, he said.

The degree of atypia must be spelled out in a straightforward way and labeled as either 'mild'or 'severe.' DR. BARRETT

Dysplastic nevi seem to represent a marker for melanoma risk, rather than precursors to the disease.

Lack of clarity in describing the histology of dysplastic nevi, shown here, has resulted in overtreatment. Photos courtesy Dr. Terry Barrett

What to Look Out for, Clinically and Histologically

In clinical appearance, nevi with architectural disorder tend to be macules, with or without a papule. If a papule is present, it is usually in the center of the macule. These nevi are generally symmetrical with regular, but fuzzy borders. Sharp angulations and prominent notching should not be present. Color includes variations of tans and browns, but rarely black. Grey suggests regression and should not be present. Erythema may be present. Histologically, the cellular components include lentiginous junctional melanocytic proliferation, with lateral fusion of nests and shouldering, and epidermal hyperplasia with elongation of the rete ridges. The stromal reaction involves fibrosis (concentric eosinophilic, lamellar) and inflammation. The cytologic atypia has large nuclei with variation of nuclear size, irregular nuclear membrane, variably stained chromatin, large eosinophilic nucleoli, and fine dusty melanin pigment in cytoplasm.

Source: Dr. Barrett

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large study presented by Dr. Seth L. Feigenbaum at the annual meeting of the Pacific Coast Reproductive Society.

Dr. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group, and associates at the Kaiser Permanente Health Plan of Northern California compared 6,671 women aged 16–44 years who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

Two-thirds of women with a diagnosis of PCOS were obese (a body mass index of 30 kg/m

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks. A multivariate regression analysis adjusting for variables showed distinct patterns:

▸ Asians had a twofold increased risk of diabetes, compared with whites.

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension.

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites (OR1.33 and 0.68, respectively).

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large study presented by Dr. Seth L. Feigenbaum at the annual meeting of the Pacific Coast Reproductive Society.

Dr. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group, and associates at the Kaiser Permanente Health Plan of Northern California compared 6,671 women aged 16–44 years who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

Two-thirds of women with a diagnosis of PCOS were obese (a body mass index of 30 kg/m

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks. A multivariate regression analysis adjusting for variables showed distinct patterns:

▸ Asians had a twofold increased risk of diabetes, compared with whites.

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension.

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites (OR1.33 and 0.68, respectively).

RANCHO MIRAGE, CALIF. — Cardiovascular risk factors varied considerably by race and ethnicity in women with polycystic ovary syndrome in a large study presented by Dr. Seth L. Feigenbaum at the annual meeting of the Pacific Coast Reproductive Society.

Dr. Feigenbaum, a reproductive endocrinologist in the San Francisco office of the Permanente Medical Group, and associates at the Kaiser Permanente Health Plan of Northern California compared 6,671 women aged 16–44 years who were diagnosed with polycystic ovary syndrome (PCOS) with 26,662 age-matched women in terms of three cardiovascular risk factors: obesity, diabetes, and hypertension.

Two-thirds of women with a diagnosis of PCOS were obese (a body mass index of 30 kg/m

Blacks were far more likely than Asians or Hispanics, and somewhat more likely than whites, to be hypertensive. Diabetes was most prevalent in Asians and Hispanics, followed by whites, then blacks. A multivariate regression analysis adjusting for variables showed distinct patterns:

▸ Asians had a twofold increased risk of diabetes, compared with whites.

▸ Blacks, by an odds ratio of 1.32, were considerably more likely than whites to have hypertension.

▸ Hispanics had higher rates of diabetes, but lower rates of hypertension than whites (OR1.33 and 0.68, respectively).

LOS ANGELES — Many behaviors that raise the risk of diabetes also act as stress relievers in patients demoralized by lifelong hardship, Dr. Ann K. Bullock said at the annual meeting of the American Association of Diabetes Educators.

Overeating, alcohol and drug use, cigarette smoking—even the numbing effect of watching TV rather than exercising—all can be seen as adaptive responses to profound stress.

“The problem isn't that we do dumb things to help calm stress. The problem is that we have so much stress,” said Dr. Bullock, medical director of the Eastern Band of Cherokee Indians in Cherokee, N.C.

Evidence is mounting that even early childhood stressors impact adult coping behaviors that undermine health, she said. Nicotine, for example, “perks you up but calms you down.”

Dr. Bullock noted that researchers from Kaiser Permanente and the Centers for Disease Control and Prevention showed in the late 1990s a strong dose-dependent relationship between “adverse childhood experiences,” such as physical or emotional abuse, and smoking in adulthood (JAMA 1999;282:1652).

Carbohydrates help to modulate brain serotonin level, and high-fat, high-calorie “comfort foods” appear to help turn off the hypothalamic-pituitary-adrenal axis (Proc. Natl. Acad. Sci. USA 2003; 100:11696–701).

“There's a little mini Prozac in that mac and cheese,” she quipped. Standing “in our nice white coats” lecturing people to give up cigarettes and comfort foods just won't work, according to Dr. Bullock.

“You want me to give up the stuff that helps me get through the day so I don't get a bad disease or a complication that might take me out of this painful life a little sooner? Hmmm,” she said.

The key to reducing diabetes risk may lie in the amygdala, not the pancreas.

That primitive brain center is where stress takes root early in life, establishing autonomic nervous system hyperreactivity and potentially setting off a cortisol-and-epinephrine-driven cascade that increases hepatic glucose level, blood pressure, and heart rate while elevating insulin resistance in adipose tissue.

“We're running away from lions all the time,” she said, which primes the body to ignite an exaggerated physiologic response to family conflict, job insecurity, and the “hugely traumatizing” lifelong effects of poverty and racism.

The pattern becomes magnified with each generation of children raised by traumatized parents, who not only pass on genetic stress responses but create stressful home environments as well.

Meaningful interventions address the stress, not the unhealthy behaviors, she said. For individual patients, progressive muscle relaxation, breathing exercises, biofeedback, guided imagery, and practices such as qi gong can relay to the amygdala the message that “in the present moment, I am okay.”

Group medical visits, 12-step programs, and support groups can foster emotional healing through shared experiences.

Spirituality and a connection to one's ethnic identity can provide deep comfort to some. Dr. Bullock recounted an early study performed on the Pima Indians in which those randomized to a control group that spent time learning the history and culture of their tribe outperformed those involved in an active weight-management program on nearly every biologic parameter (Diabet. Med. 1998;15:66–72).

Health professionals can help by advocating in the community for programs that improve the conditions of early life for disadvantaged patients, from prenatal support to parenting classes, excellent day care, and strong schools, she said.

On a personal basis, “we can be a wonderful support for our patients,” she said. “Understand that there is lot going on that is bigger than their diabetes.”

As many diabetes researchers have learned, there may be no point in discussing a patient's body mass index, hemoglobin A_1c, or neuropathy before sitting down to hear about their alcoholic spouse or troubled kids.

“If nothing else—and this is profound—have a sense of compassion for your patients,” said Dr. Bullock. “For some patients, we are the one place in their lives where they get nonjudgmental attention and listening. Can you imagine that?”

LOS ANGELES — Many behaviors that raise the risk of diabetes also act as stress relievers in patients demoralized by lifelong hardship, Dr. Ann K. Bullock said at the annual meeting of the American Association of Diabetes Educators.

Overeating, alcohol and drug use, cigarette smoking—even the numbing effect of watching TV rather than exercising—all can be seen as adaptive responses to profound stress.

“The problem isn't that we do dumb things to help calm stress. The problem is that we have so much stress,” said Dr. Bullock, medical director of the Eastern Band of Cherokee Indians in Cherokee, N.C.

Evidence is mounting that even early childhood stressors impact adult coping behaviors that undermine health, she said. Nicotine, for example, “perks you up but calms you down.”

Dr. Bullock noted that researchers from Kaiser Permanente and the Centers for Disease Control and Prevention showed in the late 1990s a strong dose-dependent relationship between “adverse childhood experiences,” such as physical or emotional abuse, and smoking in adulthood (JAMA 1999;282:1652).

Carbohydrates help to modulate brain serotonin level, and high-fat, high-calorie “comfort foods” appear to help turn off the hypothalamic-pituitary-adrenal axis (Proc. Natl. Acad. Sci. USA 2003; 100:11696–701).

“There's a little mini Prozac in that mac and cheese,” she quipped. Standing “in our nice white coats” lecturing people to give up cigarettes and comfort foods just won't work, according to Dr. Bullock.

“You want me to give up the stuff that helps me get through the day so I don't get a bad disease or a complication that might take me out of this painful life a little sooner? Hmmm,” she said.

The key to reducing diabetes risk may lie in the amygdala, not the pancreas.

That primitive brain center is where stress takes root early in life, establishing autonomic nervous system hyperreactivity and potentially setting off a cortisol-and-epinephrine-driven cascade that increases hepatic glucose level, blood pressure, and heart rate while elevating insulin resistance in adipose tissue.

“We're running away from lions all the time,” she said, which primes the body to ignite an exaggerated physiologic response to family conflict, job insecurity, and the “hugely traumatizing” lifelong effects of poverty and racism.

The pattern becomes magnified with each generation of children raised by traumatized parents, who not only pass on genetic stress responses but create stressful home environments as well.

Meaningful interventions address the stress, not the unhealthy behaviors, she said. For individual patients, progressive muscle relaxation, breathing exercises, biofeedback, guided imagery, and practices such as qi gong can relay to the amygdala the message that “in the present moment, I am okay.”

Group medical visits, 12-step programs, and support groups can foster emotional healing through shared experiences.

Spirituality and a connection to one's ethnic identity can provide deep comfort to some. Dr. Bullock recounted an early study performed on the Pima Indians in which those randomized to a control group that spent time learning the history and culture of their tribe outperformed those involved in an active weight-management program on nearly every biologic parameter (Diabet. Med. 1998;15:66–72).

Health professionals can help by advocating in the community for programs that improve the conditions of early life for disadvantaged patients, from prenatal support to parenting classes, excellent day care, and strong schools, she said.

On a personal basis, “we can be a wonderful support for our patients,” she said. “Understand that there is lot going on that is bigger than their diabetes.”

As many diabetes researchers have learned, there may be no point in discussing a patient's body mass index, hemoglobin A_1c, or neuropathy before sitting down to hear about their alcoholic spouse or troubled kids.

“If nothing else—and this is profound—have a sense of compassion for your patients,” said Dr. Bullock. “For some patients, we are the one place in their lives where they get nonjudgmental attention and listening. Can you imagine that?”

LOS ANGELES — Many behaviors that raise the risk of diabetes also act as stress relievers in patients demoralized by lifelong hardship, Dr. Ann K. Bullock said at the annual meeting of the American Association of Diabetes Educators.

Overeating, alcohol and drug use, cigarette smoking—even the numbing effect of watching TV rather than exercising—all can be seen as adaptive responses to profound stress.

“The problem isn't that we do dumb things to help calm stress. The problem is that we have so much stress,” said Dr. Bullock, medical director of the Eastern Band of Cherokee Indians in Cherokee, N.C.

Evidence is mounting that even early childhood stressors impact adult coping behaviors that undermine health, she said. Nicotine, for example, “perks you up but calms you down.”

Dr. Bullock noted that researchers from Kaiser Permanente and the Centers for Disease Control and Prevention showed in the late 1990s a strong dose-dependent relationship between “adverse childhood experiences,” such as physical or emotional abuse, and smoking in adulthood (JAMA 1999;282:1652).

Carbohydrates help to modulate brain serotonin level, and high-fat, high-calorie “comfort foods” appear to help turn off the hypothalamic-pituitary-adrenal axis (Proc. Natl. Acad. Sci. USA 2003; 100:11696–701).

“There's a little mini Prozac in that mac and cheese,” she quipped. Standing “in our nice white coats” lecturing people to give up cigarettes and comfort foods just won't work, according to Dr. Bullock.

“You want me to give up the stuff that helps me get through the day so I don't get a bad disease or a complication that might take me out of this painful life a little sooner? Hmmm,” she said.

The key to reducing diabetes risk may lie in the amygdala, not the pancreas.

That primitive brain center is where stress takes root early in life, establishing autonomic nervous system hyperreactivity and potentially setting off a cortisol-and-epinephrine-driven cascade that increases hepatic glucose level, blood pressure, and heart rate while elevating insulin resistance in adipose tissue.

“We're running away from lions all the time,” she said, which primes the body to ignite an exaggerated physiologic response to family conflict, job insecurity, and the “hugely traumatizing” lifelong effects of poverty and racism.

The pattern becomes magnified with each generation of children raised by traumatized parents, who not only pass on genetic stress responses but create stressful home environments as well.

Meaningful interventions address the stress, not the unhealthy behaviors, she said. For individual patients, progressive muscle relaxation, breathing exercises, biofeedback, guided imagery, and practices such as qi gong can relay to the amygdala the message that “in the present moment, I am okay.”

Group medical visits, 12-step programs, and support groups can foster emotional healing through shared experiences.

Spirituality and a connection to one's ethnic identity can provide deep comfort to some. Dr. Bullock recounted an early study performed on the Pima Indians in which those randomized to a control group that spent time learning the history and culture of their tribe outperformed those involved in an active weight-management program on nearly every biologic parameter (Diabet. Med. 1998;15:66–72).

Health professionals can help by advocating in the community for programs that improve the conditions of early life for disadvantaged patients, from prenatal support to parenting classes, excellent day care, and strong schools, she said.

On a personal basis, “we can be a wonderful support for our patients,” she said. “Understand that there is lot going on that is bigger than their diabetes.”

As many diabetes researchers have learned, there may be no point in discussing a patient's body mass index, hemoglobin A_1c, or neuropathy before sitting down to hear about their alcoholic spouse or troubled kids.

“If nothing else—and this is profound—have a sense of compassion for your patients,” said Dr. Bullock. “For some patients, we are the one place in their lives where they get nonjudgmental attention and listening. Can you imagine that?”

LOS ANGELES — Patients with hereditary pancreatitis face an 87-fold elevated risk of being diagnosed with pancreatic adenocarcinoma, and if they smoke, the risk is even greater, according to a national cohort study of 78 affected families in France.

Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene (PRSS1) that is inherited in an autosomal dominant pattern. Whether inherited or not, chronic pancreatitis is known to be associated with pancreatic cancer.

To determine the incidence and risk factors for pancreatic cancer in patients with the hereditary form of pancreatitis, French investigators, led by Dr. Vinciane Rebours, studied 200 patients representing 6,673 person-years who either carried the gene mutation or had a strong family history of pancreatitis in relatives who did not have other notable risk factors for chronic pancreatitis, such as alcoholism (two or more first-degree relatives or at least three second-degree relatives).

Dr. Rebours, of the gastroenterology service at Beaujon Hospital in Clichy, reported the results at the annual Digestive Disease Week.

At enrollment, the median age of the cohort was 30 years, with a range of 1–84 years; about one-third of the cohort smoked.

Of these patients, 10 were diagnosed with pancreatic adenocarcinoma at a median age of 55 years, with a range of 39–78 years, Dr. Rebours reported.

By comparing the cohort with the general population, the researchers determined that individuals with hereditary pancreatitis had an 87-fold elevated risk of pancreatic cancer. Among all patients with chronic pancreatitis, there is a historically quoted 27-fold increase in pancreatic cancer incidence.

The chance of being diagnosed with pancreatic adenocarcinoma increased with age, for a cumulative risk of 11%, 16%, and 49% for males at ages 50, 60, and 70 years. The cumulative risk for females was 8%, 22%, and 55% at ages 50, 60, and 70 years. Smokers faced even worse odds, with a risk of pancreatic adenocarcinoma at age 75 of 61% for males and 70% for females.

Other important risk factors were diabetes mellitus and the absence of acute pancreatitis, Dr. Rebours said.

LOS ANGELES — Patients with hereditary pancreatitis face an 87-fold elevated risk of being diagnosed with pancreatic adenocarcinoma, and if they smoke, the risk is even greater, according to a national cohort study of 78 affected families in France.

Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene (PRSS1) that is inherited in an autosomal dominant pattern. Whether inherited or not, chronic pancreatitis is known to be associated with pancreatic cancer.

To determine the incidence and risk factors for pancreatic cancer in patients with the hereditary form of pancreatitis, French investigators, led by Dr. Vinciane Rebours, studied 200 patients representing 6,673 person-years who either carried the gene mutation or had a strong family history of pancreatitis in relatives who did not have other notable risk factors for chronic pancreatitis, such as alcoholism (two or more first-degree relatives or at least three second-degree relatives).

Dr. Rebours, of the gastroenterology service at Beaujon Hospital in Clichy, reported the results at the annual Digestive Disease Week.

At enrollment, the median age of the cohort was 30 years, with a range of 1–84 years; about one-third of the cohort smoked.

Of these patients, 10 were diagnosed with pancreatic adenocarcinoma at a median age of 55 years, with a range of 39–78 years, Dr. Rebours reported.

By comparing the cohort with the general population, the researchers determined that individuals with hereditary pancreatitis had an 87-fold elevated risk of pancreatic cancer. Among all patients with chronic pancreatitis, there is a historically quoted 27-fold increase in pancreatic cancer incidence.

The chance of being diagnosed with pancreatic adenocarcinoma increased with age, for a cumulative risk of 11%, 16%, and 49% for males at ages 50, 60, and 70 years. The cumulative risk for females was 8%, 22%, and 55% at ages 50, 60, and 70 years. Smokers faced even worse odds, with a risk of pancreatic adenocarcinoma at age 75 of 61% for males and 70% for females.

Other important risk factors were diabetes mellitus and the absence of acute pancreatitis, Dr. Rebours said.

LOS ANGELES — Patients with hereditary pancreatitis face an 87-fold elevated risk of being diagnosed with pancreatic adenocarcinoma, and if they smoke, the risk is even greater, according to a national cohort study of 78 affected families in France.

Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene (PRSS1) that is inherited in an autosomal dominant pattern. Whether inherited or not, chronic pancreatitis is known to be associated with pancreatic cancer.

To determine the incidence and risk factors for pancreatic cancer in patients with the hereditary form of pancreatitis, French investigators, led by Dr. Vinciane Rebours, studied 200 patients representing 6,673 person-years who either carried the gene mutation or had a strong family history of pancreatitis in relatives who did not have other notable risk factors for chronic pancreatitis, such as alcoholism (two or more first-degree relatives or at least three second-degree relatives).

Dr. Rebours, of the gastroenterology service at Beaujon Hospital in Clichy, reported the results at the annual Digestive Disease Week.

At enrollment, the median age of the cohort was 30 years, with a range of 1–84 years; about one-third of the cohort smoked.

Of these patients, 10 were diagnosed with pancreatic adenocarcinoma at a median age of 55 years, with a range of 39–78 years, Dr. Rebours reported.

By comparing the cohort with the general population, the researchers determined that individuals with hereditary pancreatitis had an 87-fold elevated risk of pancreatic cancer. Among all patients with chronic pancreatitis, there is a historically quoted 27-fold increase in pancreatic cancer incidence.

The chance of being diagnosed with pancreatic adenocarcinoma increased with age, for a cumulative risk of 11%, 16%, and 49% for males at ages 50, 60, and 70 years. The cumulative risk for females was 8%, 22%, and 55% at ages 50, 60, and 70 years. Smokers faced even worse odds, with a risk of pancreatic adenocarcinoma at age 75 of 61% for males and 70% for females.

Other important risk factors were diabetes mellitus and the absence of acute pancreatitis, Dr. Rebours said.